Every finding on record at Hill View Skilled Nursing and Rehabilitation Cente

Based on record review, observation, staff interview, and policy review, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent the development of avoidable pressure ulcers, failed to thoroughly assess a resident's skin, and failed to timely identify pressure ulcers until they had reached an advanced stage. Actual Harm occurred on 10/13/25 when Resident #61, who was cognitively impaired and dependent on staff for bed mobility, developed an unstageable pressure ulcer to the left heel (a full thickness wound where damage depth is hidden by slough or eschar making an accurate stage assessment impossible.) This affected one (Resident #61) of two residents reviewed for pressure ulcers. The facility census was 69. Findings include:Review of the medical record for Resident #61 revealed an admission date of 09/19/25 with diagnoses including displaced subtrochanteric fracture of left femur, Alzheimer's disease, chronic kidney disease, congestive heart failure, and depression. Review of the admission nursing assessment dated [DATE] revealed Resident #61was admitted to the facility without pressure ulcers following surgical repair of a displaced fracture of the left femur. Review of the pressure ulcer risk assessment (Braden scale) for Resident #61 dated 09/19/26 revealed a score of 16 (on a scale of zero to 23) indicating the resident was at mild risk for the development of skin breakdown. Review of the care plan for Resident #61 dated 09/19/25 revealed the resident had the potential for pressure ulcer development related to immobility. Interventions included the following: cushion to wheelchair/chair, encourage resident to elevate lower extremities as tolerated, encourage to turn and reposition every two hours and as needed for comfort, barrier cream to peri-anal area every shift and as needed, gel overlay to bed, inform resident/family/caregivers of any new area of skin breakdown, may follow local wound care if skin issues occur. Review of the admission pressure ulcer/skin assessment for Resident #61 dated 09/25/26 revealed the resident had no skin issues. Review of the Minimum Data Set (MDS) assessment for Resident #61 dated 09/26/25 revealed the resident was severely cognitively impaired, was dependent on staff for bed mobility and transfers, was at risk for skin breakdown and had no pressure ulcers. Review of the Treatment Administration Record (TAR) for Resident #61 dated October 2025 revealed the staff documented the application and removal of thrombo-embolic deterrent (TED) hose daily. Review of the body check form dated 10/08/25 revealed Resident #61 had no skin issues. Review of the progress note dated 10/13/25 at 8:00 A.M. revealed Resident #61 had an area to the left heel which measured five centimeters (cm) in diameter. Review of the physician's orders for Resident #61 revealed an order dated 10/13/25 to cleanse the left heel with normal saline (NS), pat dry, apply betadine and wrap with Kerlix gauze every other day and as needed and an order for offloading boots to the resident's bilateral heels while in bed and in the recliner chair as tolerated. Review of the body check form dated 10/14/25 revealed Resident #61 had an unstageable pressure ulcer to the left heel which measured four cm in length by four cm in width. Review of the weekly pressure ulcer assessment dated [DATE] revealed Resident #61 had an unstageable pressure injury to the left heel which measured four cm in length by four cm in width. There was no documentation regarding the presence or absence of drainage.Review of the care plan dated 10/14/25 revealed Resident #61 had impaired skin integrity as evidenced by an unstageable pressure ulcer to left heel due to immobility. Interventions included the following: cushion to wheelchair/chair, encourage resident to elevate lower extremities as tolerated, encourage to turn and reposition every two hours and as needed for comfort, barrier cream to peri-anal area every shift and as needed, gel overlay to bed, inform resident/family/caregivers of any new area of skin breakdown, may follow local wound care if skin issues occur, monitor open area every shift for signs/symptoms of infection, pain, surrounding tissue changes, and dressing intact, notify the physician of any changes, offloading boots to bilateral heels, treatment to skin impairment as ordered by physician. Review of the body check form dated 10/21/25 revealed Resident #61had an unstageable blister to the left heel measuring four cm in length by four cm in width. Review of the pressure ulcer weekly assessment dated [DATE] revealed the unstageable pressure injury to Resident #61's left heel measured four cm in length by four cm in width and was dark and hardening. Review of the pressure ulcer evaluation dated 05/26/26 revealed the unstageable pressure ulcer to Resident #61's left heel measured 1.2 cm in length by 0.3 cm in width by 0.2 cm in depth and had a scant amount of exudate. The facility determined the wound was improving and the physician ordered the facility to continue the wound treatment to cleanse the left heel with normal saline, apply calcium alginate, cover with gauze and secure with Kerlix. During an observation on 06/02/26 at 2:39 P.M., Licensed Practical Nurse (LPN) #135 provided wound care to Resident #61. The wound to the left heel was dime-sized with a scant amount of yellow slough present to the wound bed. During an interview on 06/03/26 at 9:49 A.M., the Director of Nursing (DON) verified the facility did not develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent the development of an avoidable pressure ulcer to Resident 61's left heel. The DON also verified Resident #61 was admitted on [DATE] without pressure ulcers and developed an unstageable pressure ulcer to the left heel which was not identified until 10/13/25 despite staff application and removal of TED hose daily to the resident's lower extremities and weekly skin checks. Review of the facility policy titled Preventative Skin Care, dated 05/20/26, revealed residents who are admitted to the facility without pressure sores will not develop pressure sores unless the individual clinical record demonstrates the sores were unavoidable. The licensed nurse would ensure a weekly and as needed body check was completed on all residents.

Based on observation, staff interview and review of the facility policy, the facility failed to properly store food items to avoid possible contamination. This had the potential to affect all of the residents residing in the facility. The facility census was 69 residents. Findings include: Observation on 06/01/26 at 9:12 A.M. of the kitchen dry storage area revealed there was a large 102 ounce can of vanilla pudding on the shelf with visible dents along the rim of the can. Interview on 06/01/26 at 9:12 A.M. with Director of Dietary Services (DDS) #932 verified the dented can of vanilla pudding should have been sent back as the contents were not suitable for use. Observation on 06/04/26 at 09:45 A.M. of the kitchen dry storage area revealed there were two 102 ounce cans of ketchup both of which were dented along the top seam of the can. Interview on 06/04/26 at 9:45 A.M. with DDS #932 verified the cans should have been returned to the supplier since the cans were dented and should not have been put on the shelf for use. Review of the facility policy titled Food and Supply Purchasing undated revealed the facility staff were to check deliveries carefully and return to the supplier any food items which were damaged which included dented or rusted canned goods.

Based on observation and staff interview, the facility failed to ensure all kitchen garbage receptacles including outdoor dumpsters were equipped with proper fitting lids to deter animals and pests. This had the potential to affect all of the residents residing in the facility. The facility census was 69 residents. Findings include: Observations on 06/01/26 at 10:20 A.M. and at 2:20 P.M. revealed there were two outside dumpsters near the loading dock which were not covered with lids. Observation on 06/02/26 at 10:51 A.M. with the Administrator revealed the outside dumpsters near the loading dock were not covered with lids. Interview on 06/02/26 at 10:51 A.M. with the Administrator verified the dumpsters did not have lids. The Administrator stated the city had delivered the two dumpsters without lids last week and he had notified the city officials the facility had food service and required lids on all outdoor trash bins. The Administrated stated the lids would be brought out on 06/02/26 or 06/03/26. Observations on 06/03/26 at 09:20 A.M. and at 3:20 P.M. revealed the outside dumpsters were not covered with lids. Observations on 06/04/26 at 07:26 A.M. and at 12:49 P.M. revealed the outside dumpsters were not covered with lids.

Based on medical record review, staff interview, and review of online medication resources, the facility failed to ensure antipsychotic medications were only ordered for an appropriate indication. This affected one (Resident #23) of five residents reviewed for unnecessary medications. The facility census was 69 residents. Findings include: Review of the medical record for Resident #23 revealed an admission date of 06/23/25 with diagnoses including Alzheimer's disease, osteoporosis, and depression. Review of the physician's orders for Resident #23 revealed an order dated 02/24/26 for Zyprexa 2.5 milligrams (mg) one tablet by mouth daily at bedtime for unspecified dementia and an order dated 06/03/26 for Risperdal 0.5 mg three tablets by mouth every morning and every night for a diagnosis of dementia. Review of the Minimum Data Set (MDS) assessment for Resident #23 dated 04/02/26 revealed the resident had severely impaired cognition. Interview on 06/03/26 at 1:13 P.M. with the Director of Nursing (DON) confirmed the facility had administered Zyprexa and Risperdal to Resident #23 without an appropriate indication/diagnosis for use. Review of an online resource on 06/10/26 at Zyprexa, Zyprexa Relprevv (olanzapine) dosing, indications, interactions, adverse effects, and more and at Risperdal, Risperdal Consta (risperidone) dosing, indications, interactions, adverse effects, and more revealed Zyprexa and Risperdal carried black box warnings which indicated the medication was not approved for dementia-related psychosis. Elderly patients with dementia-related psychosis who are treated with antipsychotic drugs are at increased risk of death, as shown in short-term controlled trials. In these trials, deaths appeared to be either cardiovascular (e.g. heart failure, sudden death) or infectious (e.g. pneumonia) in nature.

Based on medical record review, observation, and staff interview, the facility failed to ensure a resident with a contracture received care and services to prevent a decline in the contracture. This affected one (Resident #17) of two residents reviewed for limited range of motion. The facility census was 69 residents. Findings include:Review of the medical record for Resident #17 revealed an admission date of 06/20/25 with diagnoses including contracture of the right hand, chronic pain, and dementia. Review of the Minimum Data Set (MDS) assessment for Resident #17 dated 03/30/26 revealed the resident had impaired cognition and had functional limitation in range of motion to one side of the upper extremities. Review of the active care plan for Resident #17 revealed it did not include interventions to prevent a further decline in range of motion or to treat the resident's contractures. Observation on 06/02/26 at 12:52 P.M. revealed Resident #17 was sitting in her room in a wheelchair at her dining table with her right hand closed up in a pinching position. Resident #17 was picking at a fidget blanket in her lap and did not open her right hand during the observation and was unable to open her hand when asked to do so. Observation on 06/03/26 at 10:20 A.M. with Director of Rehabilitation (DOR) #126 revealed Resident #17 was sitting in the activity room in her wheelchair with her right hand resting in her lap in a pinched position. DOR #126 lifted the fingers on Resident #17's right hand and pulled them out revealing slight contractures at the knuckles. Interview on 06/03/26 at 10:45 A.M. with DOR #126 confirmed Resident #17 had a slight contracture of the right hand which did not appear to have worsened since admitting to the facility. DOR #126 confirmed Resident #17's right hand contractures had not been addressed by therapy services since her admission to the facility and was unsure of any interventions implemented to prevent a further decline in the resident's range of motion. Interview on 06/04/26 at 11:35 A.M. with Assistant Director of Nursing (ADON) #133 confirmed the facility had not implement a care plan or interventions to prevent the worsening of Resident #17's right hand contractures and/or to prevent a further decline in the resident's range of motion.

Based on medical record review, staff interview, review of the facility's fall investigation, review of the hospital notes, review of the Medscape guidance, and review of the facility's pain management policy, the facility failed to provide adequate pain management for one resident. This result in Actual Harm for Resident #64 who screamed out in pain at multiple staff, receiving a delay and appropriate treatment of pain beginning 10/30/25 at 6:30 P.M. to 10/31/25 at 12:40 A.M. This resulted in an emergency room visit for acute pain and reporting a severe pain level of nine (pain scale from zero indicating no pain to ten being worst pain). This affected one (Resident #64) of three residents reviewed for pain control. The facility census was 72.Findings include:Review of the closed medical record revealed Resident #64 was re-admitted to the facility on [DATE] and discharged to another facility on 11/10/25. Diagnoses included osteoporosis, osteopenia, atherosclerosis, and a history of bone demineralization. The quarterly Minimum data Set (MDS) assessment dated [DATE] revealed Resident #64 had moderate cognitive impairment and required extensive assistance of two persons with bed mobility and transfers.Review of the care plan dated 02/22/24 revealed Resident #64 was at risk for pain related to osteoarthritis, recent fractures, and to be able to voice a level of comfort. Interventions included pain medications half hour before treatments, turning and repositioning, evaluating effectiveness every shift, notify the physician of any significant change in comfort, and offering non-pharmacological interventions first. Review of the late entry nursing note dated10/30/25 at 7:45 P.M. revealed Resident #64 was complaining of pain to her left arm. No redness or edema noted. Acetaminophen (Tylenol, treats mild to moderate pain) provided per resident request. Resident repositioned in bed, and call light in place. The Medication Administration Record (MAR) for 10/30/25 revealed Acetaminophen 325 milligrams (mg) two tablets by mouth every eight hours as needed for pain. This resident was administered this medication as documented at approximately 7:45 P.M. for a pain level of nine (pain scale from zero indicating no pain to ten being worse pain ever.) The post administration assessment pain level was seven out of 10. There was no time documented as to when the post assessment pain was assessed. There were no documented interventions attempted to relieve Resident #64's pain after 7:45 P.M. on 10/30/25. The late entry nursing note dated 10/30/25 at 10:30 P.M. revealed the nurse was summoned to resident's room still complaining of pain in left arm. Physician made aware. The nursing note dated 10/30/25 at 11:00 P.M. revealed Resident #64 complained of pain in her left arm and elbow. The evening shift nurse messaged physician about the pain. No redness or swelling currently. The nursing note dated 10/31/25 at 12:00 A.M. revealed the physician responded to a text and provided an order to send Resident #64 to the emergency room (ER) for evaluation. The nursing note dated 10/31/25 at 12:42 A.M. revealed emergency medical services (EMS) arrived at the facility at approximately 12:40 A.M. to transport Resident #64 to the hospital. Family members were waiting at the hospital for the resident's arrival. Review of the hospital encounter report dated 10/30/25 revealed Resident #64 resided in a long-term-care facility. Resident #64 was brought in complaining of left elbow pain and was brought to the ER by EMS. Resident #64 was assessed to have a pain level of nine out of 10 upon her arrival at the hospital. Work-up in the ER revealed a previous shoulder fracture and a new acute displaced transcondylar humerus fracture (serious break at the lower end of the upper arm near the elbow joint, where bone fragments have significantly shifted out of alignment) to her left elbow. Resident #64 was treated with nonsurgical interventions with a sling/immobilizer to her left arm. Resident #64 was discharged back to the facility on [DATE], with orthopedic follow up on 11/06/25 and a medication order for Norco 5-325 (narcotic pain medication to treat severe pain) mg by mouth every four hours as needed for pain control.The nursing note dated 10/31/25 at 3:30 A.M. revealed Resident #64 returned from the ER and records sent with no new orders for the right shoulder, with the right elbow showing the appearance of an acute displaced transcondylar humerus fracture and joint effusion. Recommend orthopedic consult. Review of the facility's fall investigation report dated 10/31/25 completed by the Director of Nursing (DON) revealed Resident #64 began complaining of pain to the left arm on 10/30/25 at approximately 7:30 P.M. The report revealed Resident #64 sustained an acute left displaced transcondylar humerus fracture to her left elbow and complained of left elbow pain after being sent to the hospital and returning on 10/31/25 around 4:00 A.M. Review of the e-mail statement provided by Certified Nursing Assistant (CNA) #590 dated 10/31/25 revealed CNA #590 had entered the resident's room to feed her dinner around 5:45 P.M. with the resident reporting no complaints of pain at that time. She stated she had returned to the resident's room around 6:30 P.M. to get her ready for bed. When she was hooking up the lift pad under the resident, she began screaming that her arm was hurting, with Resident #64 stating It was broken again. CNA #590 then finished hooking up the resident to the lift and moving her over to bed with Resident #64 still screaming in pain. CNA #590 then began rolling and changing the resident. Two additional CNAs entered Resident #64's room to respond to Resident #64's screaming during care provided by CNA #590. During an interview on 12/02/25 at 12:53 P.M., CNA #410 stated she had cared for Resident #64 on day shift of 10/30/25 and had encountered no problems moving the resident from her bed to the chair early in the shift that day (10/30/25) with the use of a mechanical lift. She stated the resident had asked throughout the day for a drink but had no complaints of pain. During an interview on 12/02/25 at 1:15 P.M., Licensed Practical Nurse (LPN) #800 stated she was the evening shift nurse that had come into work that day around 3:00 P.M. and was the nurse for Resident #64. She stated that around 7:30 P.M. she was alerted to the resident who was complaining about left arm pain, and during her assessment was unable to identify any dislocation or swelling to her left elbow region. She stated she had administered Acetaminophen 325 mg two tablets by mouth as ordered by the physician and would return to reassess. She stated around 10:30 P.M., she returned and reassessed the site of which the resident was still complaining of pain (no pain level obtained), so she notified the physician she provided an order for the resident to be sent to the hospital for evaluation. She then notified family, who stated they would meet the resident at the hospital. During an interview on 12/02/25 at 1:20 P.M., CNA #590 stated she was getting Resident #64 ready for bed on 10/30/25 and transporting her from her chair to her bed. She stated the resident began screaming that her arm was broken again, but she had always done that due to a previous fracture to the same shoulder. CNA #590 thought this was normal for Resident #64. She verified she was the only staff member in the room during the transfer until CNA #650 and CNA #340 responded to the room following the transfer due to the resident screaming in pain. She verified they responded after the resident had already been placed in bed and she was attempting to put on her nightgown. During an interview on 12/10/25 at 1:30 P.M., CNA #340 stated she was walking down the hall with CNA #650 as she had just come onto her shift at 6:30 P.M. CNA #650 and heard loud screaming coming from the resident's room. When they entered, Resident #64 was already in bed being changed by CNA #590. Resident #340 was screaming that her arm hurts and It's broken again. They assisted with care and the resident calmed down and they then left the room. The resident was no longer screaming, and she left the room around 6:45 P.M. During an interview on 12/10/25 at 1:45 P.M., CNA #650 stated she was walking down the hall and heard loud screaming from the resident's room. She stated she walked in with another aide and asked why Resident #64 was screaming like that. She stated she had never heard the resident scream in pain like that, and she was yelling my arm is broken. The resident would not say exactly what was hurting but pointed at her right shoulder, which had been previously broken. She told LPN #800 when she left the room that the resident was in pain and was told she would be administering Resident #64 Tylenol. She stated she did not see the nurse enter the room at all or after reporting it to her. CNA #650 left the room around 6:45 P.M. During a subsequent interview on 12/10/25 at 2:30 P.M., CNA #590 stated it was around 6:30 P.M. when she was transferring the resident and got her into bed. She stated the resident was screaming about her arm hurting when the other two aides entered the room. She stated she let the nurse know the resident was screaming and in pain, and the nurse stated she would check on her in a minute. During an interview on 12/10/25 at 3:00 P.M., the Director of Nursing she would expect the nurse to respond to complaints of pain within usually 30-45 minutes and maybe one hour depending on what they were involved in at the time. She stated she did not know how long it should take after a resident had been provided pain medication for reassessment to take place. She also verified that she was unaware of any follow-up.Review of the facility policy titled Pain Management, revised 02/24/25, revealed the CNAs will report any resident pain to the licensed nurse. The licensed nurse will medicate the resident per physician orders and will also follow-up after administration of the medication for effectiveness and adverse reactions. Documentation in the medical record to include time the as needed medication is administered, pre and post pain levels, the cite of pain, the non-pharmacological interventions attempted (at least three) and the effect on the resident.Review of Medscape guidance titled Acute Pain: Assessment and Treatment dated 01/03/11 found at https://www.medscape.com/viewarticle/735034 revealed Pain is defined by the International Association of the Study of Pain as an unpleasant sensory and emotional experience arising from actual or potential tissue damage. Acute pain is the normal, predicted physiologic response to an adverse chemical, thermal, or mechanical stimulus.associated with which included trauma. Acute pain plays the vital role of providing warning signal that something is wrong and in need of further examination. This deficiency represents non-compliance investigated under Complaint Number 2666893.

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure the environment was maintained in good repair. This had the potential to effect all residents residing in the facility. The facility census was 64.Findings include:Observations on 08/08/25 from 10:22 A.M. through 11:30 A.M., during a tour of the facility, revealed a large portion of the ceiling in the second-floor dining room was missing. The area below the missing ceiling had yellow caution tape set up to keep people from walking underneath it. Continued observation of the second-floor hallway, outside of Resident #2's room, revealed discolored ceiling tiles and water was leaking down into a large and a small trash can placed underneath. The ceiling tiles had a black substance on them, which appeared mold or mildew like. Further observation of the third-floor hallway, located outside of Resident #63's room, revealed discolored ceiling tiles from what appeared to be water damage, and the carpet underneath the area was wet. The ceiling vents, located directly inside the doorways of 14 residents' (#6, #20, #22, #24, #26, #30, #39, #40, #49, #50, #52, #60, #61, and #63) rooms had water dripping down from them, which was being collected in trash cans placed by the facility staff. Many of the vents had areas of rust on them. Concurrent interview with Maintenance Director (MD) #900 revealed the ceiling in the second-floor dining room had fallen on 07/02/25 due to water damage. MD #900 confirmed the water leak had been repaired but the drywall still needed replaced. Further interview with MD #900 verified the hallway ceilings on the second and third floors and the vents in the resident rooms were leaking water and in need of repair. Review of the facility policy titled, Homelike Environment, dated 12/23/19, revealed it was the policy of the facility to provide residents with a safe, clean, comfortable and homelike environment. Staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, home-like setting. These characteristics included cleanliness and order.This deficiency represents non-compliance identified during the investigation of Complaint Number OH00167516 (1385853).

Based on record review and staff interview, the facility failed to update the Preadmission Screening and Resident Review (PASARR) with new mental illness diagnoses for residents. This affected two (Residents #28 and #33) of 18 residents reviewed for PASARR completion. The facility census was 53 residents. Findings include: 1.Review of the medical record for Resident #28 revealed an admitted [DATE] with diagnoses including congestive heart failure, hypertension, encephalopathy and major depressive disorder. On 09/07/21 Resident #28 was diagnosed with unspecified psychosis. Review of the admission PASARR document for Resident #28 dated 09/04/19 revealed the had no indications of serious mental illness or developmental disability. Review of the plan of care for Resident #28 dated 02/26/24 revealed the resident had unspecified psychosis with paranoia, hallucinations and increased anxiety. Interventions included the following: monitor and record occurrences of target behavior symptoms such as pacing, wandering, disrobing, inappropriate response to verbal communication, violence and aggression towards the staff and others, document per the facility protocol. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #28 dated 05/09/24 revealed the resident had mild cognitive impairment with delusions. Resident #28 required maximum assistance with activities of daily living (ADLs). Interview on 07/02/24 at 2:50 P.M. with Admissions Director (AD) #36 confirmed the PASARR document for Resident #28 dated 09/04/19 indicated the resident did not have a serious mental illness. AD #36 confirmed a new diagnosis of unspecified psychosis was added on 09/07/21 for Resident #28. AD #36 confirmed this was a serious mental illness and a new PASARR should have been completed for Resident #28. 2. Review of the medical record for Resident #33 revealed an admitted [DATE] with diagnoses including multisystem inflammatory syndrome, hypothyroidism, paranoid personality disorder, non-traumatic subarachnoid hemorrhage, dementia and diabetes mellitus type two. On 11/30/21 Resident #33 was diagnosed with psychosis. Review of the admission PASARR dated 06/27/19 indicated Resident #33 had no indications of serious mental illness or developmental disability Review of the quarterly MDS assessment for Resident #33 dated 04/09/24 revealed the resident had severe impaired cognition with delusions. Resident #33 required maximum assistance of staff with ADLs. Resident #33 received antipsychotic medication and diagnoses on the MDS included psychotic disorder other than schizophrenia. Review of the admission PASARR dated 06/27/19 indicated Resident #33 had no indications of serious mental illness or developmental disability. Interview on 07/02/24 at 2:50 P.M. with AD #36 confirmed the PASARR document for Resident #33 dated 06/27/19 indicated Resident #33 did not have a serious mental illness. AD #36 confirmed a new diagnosis of psychosis was added on 11/30/21 for Resident #33. AD #36 confirmed this was a serious mental illness and a new PASARR should have been completed for Resident #33.

Based on medical record review, observation, and staff interview the facility failed to provide adequate nail care to dependent residents. This affected one (Resident #13) of five dependent residents reviewed for bathing and nail care. The facility census was 53 residents. Findings include: Review of the medical of the medical record for Resident #13 revealed an admitted [DATE] with diagnoses including congestive heart failure, dementia, and diabetes mellitus type two. Review of the care plan for Resident #13 dated 08/31/22 revealed staff would clean and trim the resident's nails weekly, as needed, and when soiled. Review of the Minimum Data Set (MDS) assessment for Resident #13 dated 04/12/24 revealed the resident was unable to make her needs known as she rarely/never was understood. Resident #13 was dependent on the assistance of staff with bathing and nail care. Review of shower sheet for Resident #13 dated 06/30/24 revealed the resident had received bathing per the schedule with nail care documented as completed 06/30/24. Observation on 06/30/24 at 1:38 P.M. of Resident #13 revealed the resident had a dry black substance under the fingernails. Observation on 07/01/24 at 03:48 P.M. with Resident #13 revealed the resident's fingernails extended approximately one fourth to one-half inch from the end of the fingertips. There was a black substance underneath all fingernails on both hands. Observation on 07/02/24 at 08:50 A.M of Resident #13 on 07/02/24 at 08:50 A.M. revealed the resident's fingernails remained long and uncut with a black substance under all of the fingernails. Observation on 07/02/24 at 3:48 P.M. of Resident #13 revealed the resident's fingernails remained long and uncut with a black substance under all of the fingernails. Interview on 07/02/24 at 3:49 P.M. with Registered Nurse (RN) #87 confirmed Resident #13 was dependent on staff for nail care. RN #87 further confirmed Resident #13's fingernails were long and dirty and needed to be trimmed and cleaned.

Based on observation, interviews, record reviews, and review of facility policies, the facility failed to ensure adequate monitoring of a [CONDITION(S)] residents AV shunt. This affected the one resident (#31) who was receiving [CONDITION(S)] while residing in the facility. The facility census was 49. Findings include: Record review for Resident #31 revealed this resident was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment, dated 04/23/22, revealed this resident had moderately impaired cognation evidenced by a BIMS assessment score of 07. This resident was assessed to require extensive assistance from two staff members for bed mobility and extensive assistance from one staff member for transfers and toileting. Review of the care plan, dated 5/23/22, revealed this resident received [CONDITION(S)]. The only intervention listed was to send a sacked snack with the resident to [CONDITION(S)] Review of the physicians order, dated 05/19/22, revealed this resident was scheduled to receive [CONDITION(S)] every Monday, Wednesday, and Friday. Review of the physicians orders revealed there was not an order to assess the AV shunt for thrill and bruit until 06/22/22. Review of the Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 06/21/22 at 2:45 P.M. revealed Resident #31 was sitting in a recliner and had an AV shunt present in her left upper arm. Interview with Licensed Practical Nurse (LPN) #600 on 06/22/22 at 10:45 A.M. verified Resident #31 had an AV shunt present and there were not orders to monitor the AV shunt for thrill and bruit. Review of the facility policy titled Hemo-[CONDITION(S)], dated 04/20/2008, revealed the facility would monitor the [CONDITION(S)] access site per physician's orders and report any concerns.

Based on observation, interview, record review and review of the facility policy the facility failed to revise a resident's plan of care to reflect the pressure ulcer prevention device of Prevalon Boots. This affected one of six residents (#12) reviewed for pressure ulcers. The facility census was 49. Findings include: Review of the medical record for Resident #12 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (3.0) dated 04/08/22 revealed Resident #12 had severe cognitive impairment. Resident #12 was totally dependent on one person for bed mobility, transfers, dressing, toileting, and personal hygiene. Resident #12 had impaired range of motion to bilateral upper extremities. Resident #12 had no skin impairments documented. Review of the physician telephone orders for Resident #12 revealed an order dated 05/03/22 for the resident to wear Prevalon boots while in bed. Staff may remove for dressing and hygiene per resident's tolerance. Review of the Treatment Administration Record (TAR) for May 2022 and June 2022 revealed documentation Resident #12 was wearing Prevalon boots when in bed and may remove for hygiene and dressing. Review of the Braden scale for predicting pressure ulcers score risk dated 5/10/22 revealed Resident #12 was at high risk. The assessment indicated Resident #12's bilateral heels would become reddened in 120 minutes while lying in bed making Resident #12 at risk for pressure ulcer development to bilateral heels. Review of Resident #12's plan of care dated 04/20/22 revealed a plan in place for impaired skin integrity as evidenced by a stage two pressure ulcer to left buttocks related to immobility. The interventions included pressure relieving cushion to wheelchair, protective cream to peri/anal areas every shift and as needed, gel overlay to bed, follow up with local hospital wound care center if skin issues occur, treatment per physician orders and turn and reposition every two hours and as needed for comfort. The plan of care was not revised to include the Prevalon boots to Resident #12's bilateral heels when in bed. Observations of Resident #12 on 06/22/22 at 2:42 P.M., 06/23/22 at 10:02 A.M. and at 2:30 P.M. revealed the resident's heels were lying flat on the bed. Resident #12 did not have on her Prevalon boots as ordered. An interview on 06/23/22 at 2:30 P.M. with State tested Nursing Assistant (STNA) #440 confirmed Resident #12 did not have on her Prevalon boots, and the STNA could not locate the Prevalon boots in Resident #12's room. An interview on 06/24/22 at 11:19 A.M. with Registered Nurse (RN) #60 confirmed the plan of care was not revised to include the Prevalon boots to bilateral heels when in bed. Review of the facility polity titled Preventative Skin Care dated 11/27/17 indicated the RN manager would complete a skin risk assessment for each resident on admission, quarterly, with significant change and acute episode. The Braden's risk scale would be completed on admission weekly times four then monthly, with significant change per Resident Assessment Instrument (RAI) and acute episode. A pressure point skin tolerance test will be completed with the risk scale. All identified risk factors will be documented and interventions will be initiated and documented in the care plan with changes added or deleted as needed.

Based on record review and interviews the facility failed to provide an appropriate diagnosis for the use of an antipsychotic and failed to discontinue an antianxiety medication due to non-use. This affected two residents(Resident #44 and Resident #201) of five residents reviewed for unnecessary medications. The facility census was 49. Findings include: 1. Record review of Resident #201 on 06/22/22 at 3:28 P.M. revealed this resident was admitted to the facility on [DATE] with the following medical diagnoses: left femur fracture, dysphagia, muscle weakness, [CONDITION(S)], depression, anxiety, hypertension, carotid artery stenosis, gastroenteritis, [CONDITION(S)], diarrhea, and transient ischemic attacks. This resident is currently alert and oriented to person, place, and time per admission assessment and nursing notes as this resident does not have an active BIMS score as this resident has been residing in the facility for approximately 2 days. Review of Physician Orders revealed this resident is receiving the following medications: [MEDICATION(S)] 2.5mg PO daily at bedtime for mood. Review of current medical diagnoses revealed this resident does not have an active diagnosis of mood disorder or any other psychiatric disorder. Interview with Registered Nurse #40 on 06/23/22 at 09:17 A.M. verified this resident does not have a current diagnosis of mood disorder or any other psychiatric disorder. 2. Record review for Resident #44 revealed this resident was admitted to the facility on [DATE] and had diagnoses including essential tremors, [CONDITION(S)], dementia without behavioral disturbances, and anxiety. Review of the admission MDS assessment, dated 05/30/22, revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15. This resident was assessed to require extensive assistance from one staff member for bed mobility, transfers, and toileting. Review of the active physicians order, dated 05/26/22, revealed an order to administer [MEDICATION(S)] (an antianxiety medication) 0.5 milligrams (mg) every hour of sleep as needed. Interview with Registered Nurse (RN) #30 on 06/23/22 at 2:12 P.M. verified Resident #44 has an active order for [MEDICATION(S)] to be administered as needed which did not contain a stop date.

Based on observations, interviews, and record reviews, the facility failed to ensure fall interventions were in place as per the plan of care and failed to ensure evidence of monitoring a resident who was at risk for elopement. This affected two residents (#29 and #44) of the five residents reviewed for falls and elopement during the annual survey. The facility census was 49. Findings include: 1. Record review for Resident #29 revealed this resident was admitted to the facility on [DATE] and had diagnoses including [CONDITION(S)], stage three [CONDITION(S)], hypertension, and systolic heart failure. Review of the admission Minimum Data Set (MDS) assessment, dated 05/03/22, revealed this resident had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 03. This resident was assessed to require extensive assistance from one staff member for bed mobility, transfers, and toileting. Review of the active care plans for this resident revealed no care plan was implemented for wandering, being at risk for elopement, or the use of a wander guard until 06/21/22. Review of the physicians orders for Resident #29 revealed there was not an order in place for a wander guard or monitoring of the wander guards placement or function until 06/21/22. Observation on 06/21/22 at 3:00 P.M. revealed Resident #29 was being assisted onto the elevator by family members when an alarm sounded due to the placement of a wander guard bracelet on the resident. The residents daughter alerted staff the bracelet should probably be cut off for a while since it had been in place for a couple of weeks. Interview with Licensed Practical Nurse (LPN) #90 on 06/21/22 at 3:28 P.M. verified there was no documentation of monitoring of the placement or function of Resident #29's wander guard present on the Medication Administration Record (MAR) or Treatment Administration Record (TAR) for the for the month of 06/2022. Interview with Registered Nurse (RN) #20 on 06/21/22 at 3:36 P.M. verified there was not an order for a wander guard or to check the placement or function of the wander guard for Resident #29. Interview with RN #60 on 06/24/22 at 11:00 A.M. verified there had not been a care plan in place for wandering, being at risk for elopement, or use of a wander guard for Resident #29 prior to 06/21/22. 2. Record review for Resident #44 revealed this resident was admitted to the facility on [DATE] and had diagnoses including repeated falls, essential tremors, reduced anxiety, and dementia without behavioral disturbances. Review of the admission MDS assessment, dated 05/30/22, revealed this resident had intact cognition evidenced by a BIMS assessment score of 15. This resident was assessed to require extensive assistance from one staff member for bed mobility, transfers, and toileting. This resident was assessed to have had one fall with injury since admission or the prior assessment. Review of the care plan, dated 05/23/22, revealed this resident was at risk for falls. Interventions included to change the call light button to a touch pad call light and to position the resident's walker within reach. Review of the nurses progress note, dated 06/15/22, revealed the resident was found on the floor next to the commode. The resident reported to the nurse using the call light to summons assistance to the bathroom, however, the call light was not on. The new intervention put into place was to change the call light to a touch pad call light. Observation and interview on 06/23/22 at 2:39 P.M. revealed Resident #44 was sleeping in a recliner located on one side of the room while the resident's walker was located by the wall across the room from the resident. Two button call lights were observed in the resident's room, one connected to the resident's recliner and one connected to the bed. There was no touch pad call light observed in the room. RN #30 verified the resident's walker was not within reach of the resident and there were only push button call lights in the resident's room at the time of the observation.

Based on observations, interviews, record reviews, and review of facility policies, the facility failed to ensure medications were stored appropriately and provided for the use intended. This affected one resident (#48) out of the 49 residents observed during the annual survey. The facility census was 49. Findings include: Record review for Resident #48 revealed this resident was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/05/22, revealed this resident had mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 11. This resident was assessed to require extensive assistance from one staff member for bed mobility, transfers, and toileting. Review of the care plan, dated 06/13/22, revealed this resident had asthma and shortness of breath. Interventions included to give aerosols or bronchodilators as ordered. Review of the facility Self Administration of Medication assessment, dated 06/06/22, revealed this resident was unaware of medications, doses, etc. and nursing staff was to administer all medications. Review of the active physicians orders revealed there were no orders to leave medications or inhalers at bedside. Observation and interview on 06/21/22 at 10:53 A.M. revealed Resident #48 was sitting in a recliner and had an inhaler located within easy reach on the tray table located directly beside the recliner. Resident #48 picked up the inhaler and stated it did not seem to be working correctly and was not able to read the label. The label was observed to be severely faded and contained the the wording [MEDICATION(S)] Aer HFA inhale two puffs by mouth every four hours as needed for dyspnea. Interview with Licensed Practical Nurse (LPN) #90 on 06/21/22 at 11:08 A.M. revealed staff provided the inhaler to Resident #48 as a placebo due to the resident's anxiety if the inhaler was not there. Observation on 06/22/22 at 10:05 A.M. revealed Resident #48 was sitting in a recliner and had the inhaler located within easy reach on the tray table located directly beside the recliner. Observation and interview on 06/23/22 at 12:55 P.M. with Registered Nurse (RN) #30 verified there was an inhaler lying on the table within easy reach of Resident #48. RN #30 picked up the inhaler and took it out of the room as she informed Resident #48 she would have to check and see what the inhaler was and if it could be left in the room. RN #30 then verified the inhaler was labeled [MEDICATION(S)] Aer HFA and demonstrated the inhaler being depressed with aerosolized medication coming out of the inhaler. RN #30 then checked the physician's orders for Resident #48 and verified there was no order for the resident to have the inhaler at bedside. RN #30 stated she was unsure as to why the resident had the inhaler in room. Review of the facility policy titled Self Administration of Medications, dated 06/08/10, revealed residents would not be allowed to administer or retain medications in their rooms unless ordered so by the physician and approved by the care planning team.

Based on observations, interviews, record reviews, and online guidance, the facility failed to adequately implement care plans and interventions. This affected three residents (#3, #29, and #31) of 20 residents whose care plans were reviewed during the annual survey. The facility census was 49. Findings include: 1. Record review for Resident #29 revealed this resident was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment, dated 05/03/22, revealed this resident had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 03. This resident was assessed to require extensive assistance from one staff member for bed mobility, transfers, and toileting. Review of the active care plans for this resident revealed no care plan was implemented for wandering, being at risk for elopement, or the use of a wander guard until 06/21/22. Observation on 06/21/22 at 3:00 P.M. revealed Resident #29 was being assisted onto the elevator by family members when an alarm sounded due to the placement of a wander guard bracelet on the resident. The resident's daughter alerted staff the bracelet should probably be cut off for a while since it had been in place for a couple of weeks. Interview with Registered Nurse (RN) #60 on 06/24/22 at 11:00 A.M. verified there had not been a care plan in place for wandering, being at risk for elopement, or use of a wander guard for Resident #29 prior to 06/21/22. 2. Record review for Resident #31 revealed this resident was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment, dated 04/23/22, revealed this resident had moderately impaired cognition evidenced by a BIMS assessment score of 07. This resident was assessed to require extensive assistance from two staff members for bed mobility and extensive assistance from one staff member for transfers and toileting. Review of the care plan, dated 5/23/22, revealed this resident received [CONDITION(S)]. The only intervention listed was to send a sacked snack with the resident to [CONDITION(S)]. Interview with RN #60 on 06/24/22 at 11:00 A.M. verified the only intervention listed on the resident's care plan was to send a sacked snack with the resident to [CONDITION(S)] and did not contain any additional interventions detailing the plan of care the facility was to provide to the resident regarding [CONDITION(S)] care and treatment. Review of the online guidance from NurseJournal titled Nursing Care Plans Explained (https://nursejournal.org/articles/nursing-care-plans-explained/), modified on 04/28/2022, revealed nursing care plans were a vital part of the nursing process and provided a centralized document of the residents conditions, diagnoses, the nursing teams goals for the resident, and a measure of the residents progress. Nursing care plans were structured to capture all the important information for the nursing team in one place and ensured everything important was documented and available to all team members. Without nursing care plans, communication could become disjointed, and resident information may have been scattered across different records, or nursing staff may have had to rely on verbal handoff's which the new nurse may mishear or even forget. 3. Review of the medical record for Resident #3 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 for Resident #3 dated 06/12/22 revealed the resident had moderate cognitive impairment with no behaviors. Resident #3 required extensive assistance of one person for bed mobility, transfers, dressing, toileting, and personal hygiene. Resident #3 was always incontinent of bowel and bladder. Resident #3 had an unstageable pressure ulcer with a treatment. Review of the Braden scale (used to determine risk of developing a pressure ulcer) dated 06/13/22 indicated Resident #3 was a low risk for developing pressure ulcers. Review of the pressure ulcer assessment dated [DATE] revealed the assessment to be incomplete and no indication Resident #3 had an unstageable pressure ulcer to his right heel. Review of the physician orders for June 2022 for Resident #3 revealed an order to paint right heel with [MEDICATION(S)], wrap with kerlix daily and leave for protection. The June 2022 orders also included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the treatment administration record for May 2022 and June 2022 revealed Resident #3 received the treatment to his right heel daily. Review of the pressure ulcer weekly skin assessment report/tracking log for Resident #3 revealed on 03/28/22 an unstageable pressure ulcer to right heel measured 2 centimeters (cm) by 1.5 cm with purple wound base. On 06/21/22 the unstageable pressure ulcer to right heel measured 0.5 cm by 0.2 cm with a light scab. Review of the plan of care initiated on 03/07/22 with no revisions revealed Resident #3 had the potential for pressure ulcer development related to immobility. The interventions included: cushion to wheelchair/chair dated 03/07/22, protective barrier cream to peri-anal area every shift and as needed dated 03/07/22, gel overlay to bed dated 03/07/22, inform the resident, family/caregivers of any new area of skin breakdown dated 03/07/22, may follow wound care clinic if skin issues occur dated 03/07/22 and turn and reposition every two hours and as needed for comfort as resident will allow dated 05/17/22. The plan of care did not address the actual active unstageable pressure ulcer to Resident #3's right heel. Observations of Resident #3 on 06/22/22 at 12:04 P.M., and on 06/23/22 at 9:53 A.M. revealed the resident was not wearing the Prevalon boots as ordered to bilateral lower extremities while in bed and up in his chair. An interview on 06/23/22 at 10:22 A.M. with State tested Nursing Assistant (STNA) #280 revealed the resident had skin issues to his buttocks and right heel. The STNA said Resident #3 did not have any heel protectors such as Prevalon boots to wear while in bed or up in wheelchair. An interview on 06/24/22 at 10:34 A.M. with Licensed Practical Nurse (LPN) #100 revealed Resident #3 had a small scabbed area to right heel that was a blister. The current treatment was swab with iodine, and cover it with a foam dressing. An observation on 06/24/22 at 11:24 A.M. of Resident #3 sitting in his recliner. The resident was not wearing his Prevalon boots, and he proceeded to peel the foam dressing away from his heel. There was a dark dry scabbed area approximately 2 cm in diameter with no redness, drainage or odor noted. Resident #3 then put the dressing back over the area. The dressing was dated 06/23/22 and Resident #3 said someone would be changing it soon. An interview on 06/24/22 at 12:50 P.M. with Registered Nurse (RN) #60 confirmed Resident #3 did not have a care plan in place for the unstageable pressure ulcer to his right heel. Review of the facility policy titled Preventative Skin Care dated 11/27/17 indicated the licensed nurse will document the resident's response to all treatments by completing a weekly progress note to include length, width, depth,odor,drainage, color, pain, and effects of treatment. The RN manager will assess the weekly progress and determine if a new treatment order is needed. Documentation will be done in the medical record and interventions will be incorporated in the resident's care plan.

Based on observation, interview, record review and review of facility policy the facility failed to ensure pressure prevention devices were in place as ordered by the physician. The affected two of five residents (#12 and #3) reviewed for pressure ulcers. The facility census was 49. Findings include: 1. Review of the medical record for Resident #3 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 for Resident #3 dated 06/12/22 revealed the resident had moderate cognitive impairment with no behaviors. Resident #3 required extensive assistance of one person for bed mobility, transfers, dressing, toileting, and personal hygiene. Resident #3 was always incontinent of bowel and bladder. Resident #3 had an unstageable pressure ulcer (defined as full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) with a treatment. Review of the Braden scale (used to determine risk of developing a pressure ulcer) dated 06/13/22 indicated Resident #3 was a low risk for developing pressure ulcers. Review of the pressure ulcer assessment dated [DATE] revealed the assessment to be incomplete and no indication Resident #3 had an unstageable pressure ulcer to his right heel. Review of the physician orders for June 2022 for Resident #3 revealed an order to paint right heel with [MEDICATION(S)], wrap with kerlix daily and leave for protection. The June 2022 orders also included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the treatment administration record for May 2022 and June 2022 revealed Resident #3 received the treatment to his right heel daily. Review of the pressure ulcer weekly skin assessment report/tracking log for Resident #3 revealed on 03/28/22 an unstageable pressure ulcer to right heel measured 2 centimeters (cm) by 1.5 cm with purple wound base. On 06/21/22 the unstageable pressure ulcer to right heel measured 0.5 cm by 0.2 cm with a light scab. Review of the plan of care initiated on 03/07/22 revealed Resident #3 had the potential for pressure ulcer development related to immobility. The interventions included: cushion to wheelchair/chair, protective barrier cream to peri-anal area every shift and as needed, gel overlay to bed, inform the resident, family/caregivers of any new area of skin breakdown, may follow wound care clinic if skin issues occur, and turn and reposition every two hours and as needed for comfort as resident will allow. Observations of Resident #3 on 06/22/22 at 12:04 P.M., and on 06/23/22 at 9:53 A.M. revealed the resident was not wearing the Prevalon boots as ordered to bilateral lower extremities while in bed and up in his chair. An interview on 06/23/22 at 10:22 A.M. with State tested Nursing Assistant (STNA) #250 revealed the resident had skin issues to his buttocks and right heel. The STNA said Resident #3 did not have any heel protectors such as Prevalon boots to wear while in bed or up in wheelchair. STNA #250 confirmed Resident #3 was not wearing his Prevalon boots. An interview on 06/24/22 at 10:34 A.M. with Licensed Practical Nurse (LPN) #100 revealed Resident #3 had a small scabbed area to right heel that was a blister. The current treatment was swab with iodine, and cover it with a foam dressing. An observation on 06/24/22 at 11:24 A.M. of Resident #3 sitting in his recliner revealed the resident was not wearing his Prevalon boots, and he proceeded to peel the foam dressing away from his heel. There was a dark dry scabbed area approximately 2 cm in diameter with no redness, drainage or odor noted. Resident then put the dressing back over the area. The dressing was dated 06/23/22 and Resident #3 said someone would be changing it soon. Review of the facility policy titled Preventative Skin Care dated 11/27/17 indicated the licensed nurse will document the resident's response to all treatments by completing a weekly progress note to include length, width, depth,odor,drainage, color, pain, and effects of treatment. The RN manager will assess the weekly progress and determine if a new treatment order is needed. Documentation will be done in the medical record and interventions will be incorporated into the resident's care plan. 2. Review of the medical record for Resident #12 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (3.0) dated 04/08/22 revealed Resident #12 had severe cognitive impairment. Resident #12 was totally dependent on one person for bed mobility, transfers, dressing, toileting, and personal hygiene. Resident #12 had impaired range of motion to bilateral upper extremities. Resident #12 had no skin impairments documented. Review of the physician telephone orders for Resident #12 revealed an order dated 05/03/22 for the resident to wear Prevalon boots while in bed. Staff may remove for dressing and hygiene per residents tolerance. Review of the Treatment Administration Record (TAR) for May 2022 and June 2022 revealed documentation Resident #12 was wearing Prevalon boots when in bed and may remove for hygiene and dressing. Review of the Braden sale for predicting pressure ulcers score risk dated 5/10/22 revealed Resident #12 was at high risk. The assessment indicated Resident #12 bilateral heels would become reddened in 120 minutes while lying in bed making Resident #12 at risk for pressure ulcer development to bilateral heels. Review of Resident #12 plan of care dated 04/20/22 revealed a plan in place for impaired skin integrity as evidenced by a stage two pressure ulcer (defined as partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister) to left buttocks related to immobility. The interventions included pressure relieving cushion to wheelchair, protective cream to peri/anal areas every shift and as needed, gel overlay to bed, follow up with local hospital wound care center if skin issues occur, treatment per physician orders and turn and reposition every two hours and as needed for comfort. The plan of care was not revised to include the Prevalon boots to Resident #12's bilateral heels when in bed. Observations of Resident #12 on 06/22/22 at 2:42 P.M., 06/23/22 at 10:02 A.M. and at 2:30 P.M. revealed the resident's heels were lying flat on the bed. Resident #12 did not have on her Prevalon boots as ordered. An interview on 06/23/22 at 2:30 P.M. with STNA #440 confirmed Resident #12 did not have on her Prevalon boots, and the STNA could not locate the Prevalon boots in Resident #12's room. Review of the facility policy titled Preventative Skin Care dated 11/27/17 indicated the licensed nurse will document the resident's response to all treatments by completing a weekly progress note to include length, width, depth,odor,drainage, color, pain, and effects of treatment. The RN manager will assess the weekly progress and determine if a new treatment order is needed. Documentation will be done in the medical record and interventions will be incorporated in to the resident's care plan.

Based on observation and staff interview the facility failed to ensure a sanitary and comfortable resident environment. This affected seven of 68 residents currently residing in the facility Findings include: 1. Observation of Resident #11 on 12/10/19 at 9:41 [NAME]M. revealed the resident was in her room seated in a wheelchair with a pommel cushion in place. The covering was missing from the center of the cushion exposing discolored foam. Resident #11 stated she was embarrassed by it and attempted to cover it with her pants. Observation with the Director of Nursing (DON) on 12/12/19 between 4:00 P.M. and 4:09 P.M. confirmed Resident #11's pommel cushion still had missing covering. 2. Observation of Resident #38 on 12/10/19 at 9:53 [NAME]M. revealed the wheelchair covering on the right wheel was soiled, there was dried food on the brake, dried food was on the leg rest, and the covering on the left leg rest was torn with exposed foam. Observation with the DON on 12/12/19 between 4:00 P.M. and 4:09 P.M. confirmed Resident #38's wheel chair brakes, wheel covering, and leg rests were dirty, and the left leg rest cover was torn with exposed foam. 3. Observation of Resident #31 on 12/10/19 on 10:11 [NAME]M. revealed the seat of the resident's wheelchair seat was soiled and the left seat corner was torn exposing a metal edge. Observation with the DON on 12/12/19 between 4:00 P.M. and 4:09 P.M. confirmed Resident #31's wheelchair seat was soiled, and the left seat corner was torn exposing a metal edge. 4. Observation of the activity room on 12/11/19 at 9:40 [NAME]M. revealed seven chairs in the room had worn covering with exposed foam padding. Observation with the DON on 12/12/19 between 4:00 P.M. and 4:09 P.M. confirmed the seven chairs were in disrepair. The facility identified Residents #28, #8, #17 and #10 used these chairs on a regular basis.

Based on Record Review and Interview the facility failed to obtain a physician order for [REDACTED].#31, #50, #18, and #163) out of four reviewed for Advance Directives. The facility census was 68. Findings include: 1. Record Review of Resident #31 revealed the resident was admitted to the facility on [DATE] with the following medical Diagnoses: [REDACTED]. The most recent Minimum Data Set (MDS) assessment completed on 10/23/19, indicated the resident had minimal cognitive impairment. Review of current physician orders revealed the resident did not have a valid Do Not Resuscitate-Comfort Care (DNR-CCA) order in place either in paper chart or electronic record, but did have an DNR-CCA form dated 11/21/19 in the chart. The resident did not have a care plan to address code status. On 12/12/19 at 09:29 [NAME]M. interview with Registered Nurse (RN) #162 verified the resident did not have a written physician order in place in regards to her DNR-CCA status. She also verified the resident had no care plan to address her code status. 2. Record Review of Resident #50 revealed the resident was admitted to the facility on [DATE] with the following medical Diagnoses: [REDACTED]. The most recent MDS assessment completed on 11/09/19, indicated the resident was rarely/never understood. Review of current physician orders revealed the resident did not have a valid DNR order in place either in paper chart or electronic record, but did have a DNR-CCA form dated 11/09/19 in the chart. The resident was accepted into hospice services on 11/07/19. The resident did not have a care plan to address code status. On 12/12/19 at 09:29 [NAME]M. interview with RN #162 verified the resident did not have a written physician order in place in regards to her DNR-CCA status. She also verified the resident did not have a care plan to address her code status. 3. Review of Resident #18's medical record revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #18's quarterly MDS dated [DATE] revealed the following. Resident #18's speech was clear, she usually understood, understands, and her cognition was severely impaired. Review of Resident #18's plan of care dated 03/06/17 revealed no advanced directives were identified on the plan of care. Review of Resident #18's (MONTH) 2019 physician's orders revealed the resident had advanced directives, but no specific advance directive was identified. Review of Resident #18's medical record revealed on 11/23/03 she formulated a living will and on 06/06/11 the resident's durable power of attorney elected Do Not Resuscitate Comfort Care-Arrest (DRNCC-A) as their advanced directive. Interview of Assistant Director of Nursing (ADON) #159 on 12/11/19 at 11:29 [NAME]M. confirmed there was no order for DRNCC-A for Resident #18. Interview of the DON on 12/11/19 at 1:49 P.M. confirmed there was no physician order for [REDACTED].>Interview of ADON #16 on 12/11/19 at 2:29 P.M. confirmed there was no care plan for advanced directives for Resident #18. 4. Review of Resident #163's medical record revealed an admission date of [DATE] with the admitting [DIAGNOSES REDACTED]. Review of the resident's comprehensive MDS 3.0 assessment dated [DATE] revealed the resident had clear speech, understands others, makes herself understood and had no cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of 13. Review of the resident's Do Not Resuscitate (DNR) Identification Form, not dated revealed the resident was determined to be a DNR comfort care (DNRCC) status. Review of the resident's physician's orders failed to identify an order to reflect the resident's wishes for the DNRCC status. Review of the resident's plan of care failed to identify a care plan addressing the resident's DNRCC status. Review of the resident's Care Conference Note dated 12/04/19 revealed the resident had a DNRCC advance directive. On 12/11/19 at 9:15 [NAME]M. interview with the DON verified the resident had no physician's order for the DNRCC status in place. On 12/11/19 at 9:55 [NAME]M. interview with Registered Nurse (RN) #200 verified the resident did not have an advance plan of care addressing her desired code status. Review of the facility's advanced medical directives (dated 09/08/04) revealed the facility would ensure a resident's choice concerning the implementation of advance directives would be followed.

Based on medical record review. observation, and staff interview the facility failed to ensure a resident maintained good nutrition with respect to maintaining food and liquid consistency. This affected one of three residents reviewed for decline in activities of daily living (Resident #11). Findings include: Review of Resident #11's medical record revealed she was admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #11's admission physician orders [REDACTED]. Review of Resident #11's admission Minimum Data Set ((MDS) dated [DATE] revealed her cognition was severely impaired. Resident #11 had no behaviors and did not reject care. Resident #11 required extensive assistance of two staff for bed mobility, to transfer, and required supervision with set up help to eat. Resident #11 had no swallowing problems, no significant weight changes, a mechanically altered diet, and no dental problems. Resident #11 had no special treatments, and she received therapy after admission. Review of Resident #11's nursing progress notes dated 09/11/19 revealed the resident was pocketing food and her diet was changed to pureed foods with regular consistency liquids. On 09/25/19 Resident #11's diet was changed again to pureed foods with nectar consistency liquids, built up utensils and a no spill cup. Review of Resident #11's quarterly MDS dated [DATE] revealed the following changes; she had unclear speech, sometimes she understood, sometimes she understands, was dependent on one staff to eat. Resident #11 received therapy that ended on 08/26/19 and she received no restorative nursing programs. Review of Resident #11's weights revealed the following. On 09/13/2019 she weighed 147.7 pounds, on 09/20/2019 her weight was 147.0 pounds, and on 09/27/2019 her weight was 129.4 pounds. There was no evidence the Resident #11 received services to prevent a down grade in her diet, a change in the consistency of her liquids, or the need for adaptive equipment. Resident #11 was not evaluated by therapy for services until 10/11/19 when occupational therapy (OT) evaluated her. Resident #11 was not evaluated by speech therapy (ST). Observation of Resident #11 on 12/11/19 at 11:49 [NAME]M. in the dining room revealed the resident received pureed food, nectar thick liquids, built up utensils, and staff was feeding her. Interview of Assistant Director of Nursing (ADON) #159 on 12/12/19 at 5:16 P.M. confirmed there was no evidence Resident #11 received services to maintain her diet consistency and no evaluation of her diet after her diet was downgraded. No plan was developed and implemented to maintain the resident's ability to eat.

Based on observation, staff interview and policy review the facility failed to ensure residents were treated with dignity with respect related to names boldly printed on the back of a wheelchair as well as devices hanging off the back of a wheelchair. This affected one (Resident #18) of one sampled resident reviewed for dignity. Findings include: Review of Resident #18's medical record revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #18's quarterly Minimum Data Set ((MDS) dated [DATE] revealed the following. Resident #18's speech was clear, she usually understood, understands, and her cognition was severely impaired. Resident #18 was dependent on two staff for bed mobility, required extensive assistance of two staff for transfers, did not walk, used a wheelchair, and did not use a restraint. Observation of Resident #18 on 12/10/19 at 9:57 [NAME]M. revealed she was seated in a wheelchair in a common area. The back of Resident #18's wheelchair had another person's name on it and the seat belt was fastened and dangling from the back of the wheelchair. Observation of Resident #18 on 12/11/19 at 8:28 [NAME]M. revealed she was in the same wheelchair, in a common area, at 9:54 [NAME]M. she was in the same wheelchair in the activity room, and at 11:29 [NAME]M. she was again in the dining room in the same wheelchair. Interview of Assistant Director of Nursing (ADON) #159 on 12/11/19 at 11:29 [NAME]M. confirmed another person's name was on the back of the wheel chair Resident #18 was using. ADON #159 stated families donated wheelchairs and they were used for other residents. ADON #159 confirmed a seatbelt was dangling off the back of the wheel chair and Resident #18 did not use a seat belt. Interview of the Director of Nursing (DON) on 12/11/19 at 1:49 P.M. confirmed it was not dignified to have a name printed on the on the back of a wheelchair, nor was it dignified having the seatbelt dangling off the back of the wheelchair. Review of the facility policy regarding dignity (dated 11/28/16) revealed each resident is accepted as a valued individual, who deserves to be treated with dignity and respect.

Based on clinical record review, policy review and staff interview, the facility failed to provide services to a resident to promote restoration or prevent further decline of bladder function. This affected one of one discharged residents reviewed for decline in urinary continence since admission (Resident #73). The facility census was 62. Harm occurred to Resident #73 when the facility failed to thoroughly assess the cause of the resident's decline in urinary continence and failed to implement interventions to prevent further decline or restore as much bladder function as possible resulting in the resident becoming incontinent of urine and experiencing skin excoriation. Findings included: Review of Resident #73's closed clinical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #73 was discharged from the facility on 06/18/12 to an Alzheimer's assisted living. At the time of discharge, the resident continued with skin excoriation. Review of Resident #73's admission assessment dated [DATE] revealed the resident used the toilet and was continent of bladder. Review of Resident #73's three day bowel and bladder observation dated 03/09/12 revealed documentation the resident was continent and voided on 03/09/12, 03/10/12 and 03/11/12. Review of Resident #73's Alteration in Patterns of Elimination care plan dated 03/09/12 revealed interventions which included to check and change the resident every two hours and as needed (PRN) and the resident wore adult briefs. Review of Resident #73's skilled nursing notes dated 03/09/12 through 04/03/12 revealed the resident was assessed as being continent of bladder every shift. Resident #73's skilled nursing notes dated 04/04/12 through 06/05/12 revealed the resident had varying periods of bladder continence and incontinence. Resident #73's skilled nursing notes dated 06/06/12 through 06/18/12 revealed documentation the resident was incontinent of bladder every shift. Review of Resident #73's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognitive status using the Brief Interview for Mental Status (BIMS) revealed the resident was severely impaired. Resident #73 was assessed as requiring extensive of one person for toilet use. The resident was assessed as being always continent and not being on a urinary toileting program. Review of Resident #73's bowel and bladder assessment dated [DATE] revealed the resident was assessed as being continent with the plan to toilet the resident every two hours and promptly upon request. The documentation revealed there was no bladder retraining program in place. Review of Resident #73's Resident Voiding Pattern and Habit Scheduled Toileting Plan dated 04/07/12 through 04/13/12 revealed documentation the resident was continent and incontinent. Review of Resident #73's bowel and bladder assessment dated [DATE] revealed the resident was assessed as being continent with a plan which included to toilet every two hours and promptly upon request. The documentation revealed there was no bladder retraining program in place. Review of Resident #73's physicians order dated 05/25/12 revealed an order for [REDACTED]. Review of Resident #73's 90-day MDS dated [DATE] revealed the resident was severely impaired. The resident was assessed as requiring extensive assistance of one person for toileting. For bladder the resident was assessed as being frequently incontinent (included seven or more episodes of urinary incontinence but at least one episode of continent voiding). Interview on 09/07/12 at 7:36 A.M. with the Director of Nursing (DON) revealed the resident did have a change in continence and the resident was not placed on a bladder restorative program. Interview on 09/07/12 at 10:52 A.M. with Registered Nurse (RN) #88 revealed the resident was on a toilet every two hours and promptly on request toileting plan in an attempt to keep the resident continent. The DON revealed the facility did a three day bladder assessment and the resident was continent so they did not place her on a bladder retraining program. On 05/09/12, a seven day bladder assessment was completed which showed no pattern to the resident's continence and incontinence. The DON identified that because of this, the facility determined the resident was not appropriate for a bladder retraining program. RN #88 verified there was no documentation of the resident not being appropriate for a bladder retraining program. Interview on 09/07/12 at 12:29 P.M. with DON verified there was no documentation of a bladder retraining program or any other bladder restoration service attempted for Resident #73 after her decline in bladder continence.