Every finding on record at Hillcrest Manor Nursing Center

Based on record review and interview, the facility failed to ensure a CMA provided supervision to prevent a resident from falling for 1 (#2) of 3 sampled residents reviewed for falls. The ADON stated 55 residents resided in the facility. Findings: A facility policy titled Falls and Fall Risk, Managing, dated March 2018, read in part, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. A minimum date set 5-day scheduled assessment, dated 05/01/25, showed in Section C Res #2 had a brief interview for mental status score of 15 (score indicated the resident's cognition was intact). The assessment further showed in Section GG, Res #2 required the assistance of a staff member who would physically support the resident and perform more than half of the physical effort to transfer to and from toileting. A nursing progress note, dated 05/13/25 at 3:30 p.m., showed Res #2 had been found by registered nurse #2 sitting on their bedroom floor. The note showed CMA #2 was in the room as was three family members. The note showed CMA #2 was assisting the resident back from the bathroom when CMA #2 turned around to close the bathroom door Res #2 fell to the floor. The note further showed Res #2 complained of hip pain and was transferred to a local hospital for evaluation. A nursing progress note, dated 05/14/25 at 9:37 p.m., showed Res #2 had received no injuries from the fall on 05/13/25, had been elevated from a one person transfer to a two-person transfer, and had been prescribed the pain medication Tramadol (an opioid) for general pain described by the resident at a level of 7 on a 0 - 10 scale. The note showed the resident had reported their pain level as a 3 at the time of the note. On 05/19/25 at 10:53 a.m., CMA #2 was asked to describe the incident regarding Res #2 on 05/13/25. CMA #2 stated they were assisting Res #2 back from the bathroom in their room when they turned to close the bathroom door. They stated as the bathroom door latched closed, they heard a family member of Res #2 make a statement to catch the resident. CMA #2 stated when they turned to face the resident they were on the bedroom floor. They stated they contacted the nurse who assessed the resident and the resident was sent to a local hospital for evaluation. CMA #2 stated they believed Res #2 had been a one-person transfer at the time. They stated they should have completed the transfer before closing the bathroom door. On 05/19/25 at 2:40 p.m., anonymous #1 stated they had witnessed Res #2 fall on 05/13/25. They stated CMA #2 had completely let go of the resident to close the bathroom door and that was when the resident fell . On 05/19/25 at 3:47 p.m., CMA #2 was asked again to describe Res #2's fall on 05/13/25. They stated when they had turned to close the bathroom door they had completely let go of the resident and were not touching the resident when they fell . On 05/19/25 at 4:34 p.m., ADON stated CMA #2 should not have let go of the resident or tried to close the bathroom door while they transferred the resident. They stated by doing so they had not been following facility policy or best practice.

Based on record review and interview, the facility failed to ensure a resident's care plan was updated to include an intervention to prevent an identified pattern of falls for 1 (#39) of 2 sampled residents reviewed for accidents. The DON stated 54 residents at the facility had care plans. Findings: A facility policy titled Care Plans, Comprehensive Person-Centered, dated December 2016, read in part, The Interdisciplinary Team (IDT), in conjunction with the resident and/or their family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. A progress note, dated 08/12/24 at 2:30 a.m., showed Res #39 had fallen while attempting to go to their bathroom. A progress note, dated 09/25/24 at 11:34 p.m., showed Res #39 had fallen while attempting to go to their bathroom. A progress note, dated 11/06/24 at 3:26 a.m., showed Res #39 had fallen while attempting to go to their bathroom. A progress note, dated 12/20/24 at 3:35 a.m., showed Res #39 had fallen while attempting to go to their bathroom. A progress note, dated 12/25/24 at 3:55 a.m., showed Res #39 had fallen while attempting to go to their bathroom. The note further showed the resident suffered a laceration to their head from the fall. A progress note, dated 01/14/25 at 6:14 p.m., showed Res #39 had fallen on 01/14/25 but did not describe the incident. A progress note, dated 01/14/25 at 9:34 p.m., showed the resident had been uninjured during the fall on 01/14/25. A progress note, dated 01/17/25 at 1:10 a.m., showed Res #39 had fallen in the bathroom of their room. The note further showed the resident suffered a skin tear and abrasion on their left arm from the fall. An annual MDS assessment for Res #39, dated 01/31/25, showed in Section C they had a BIMS score of 13 which indicated normal cognition. The assessment also showed in Section GG the resident was able to use the toilet independently without any assistance. A care plan, revised date 02/06/25, showed Res #30 had fallen on 08/12/24, 09/24/24, 11/06/24, 12/20/24, 12/25/24, 01/14/25, 01/17/25, and 02/22/25. The care plan further showed the fall on 12/25/24 resulted in the resident suffering a laceration, the fall on 01/17/25 resulted in the resident suffering a skin tear and abrasion, and the fall on 02/22/25 resulted in the resident suffering a fracture. The care plan further showed the last care plan revision was on 02/22/25 which was for the resident to have therapy following surgery and for the resident's wheelchair to be kept out of the resident's walking path. There were no interventions to check on the resident for the need to toilet between 3:00 a.m. and 5:00 a.m. A progress note, dated 02/22/25 at 3:30 a.m., showed Res #39 had fallen in their room after tripping over their wheelchair. The note further showed when the staff stood Res #39 up, they cried out in pain and could not bear weight on their left side. An acute care hospital physician's note, dated 02/22/25, documented the resident had been seen for a hip fracture following a fall. The note further showed the resident had reported they had fallen while attempting to go to the bathroom. An acute care hospital physician's examination note, dated 02/23/25, showed the resident had undergone a left hip arthroplasty (a hip replacement surgery using artificial hardware) at the hospital. An acute care hospital discharge summary, dated 02/25/25, showed the resident had been treated for a fracture of the left femoral neck (left hip) and had undergone hip replacement surgery. On 04/04/25 at 9:09 a.m., LPN #3 stated they had provided care to Res #39 during the resident's stay at the facility. When asked about falls LPN #3 stated the resident had time between 3:00 a.m., and 5:00 a.m. when they wanted to go to the bathroom and had some falls during that time. On 04/04/25 at 9:59 a.m., the resident's POA stated on three occasions in 2024 and 2025 they had been called by the facility between 3:00 a.m. and 5:00 a.m. about Res #39 having fell while going to the bathroom. They stated during each of those calls they had asked the staff to check on the resident between those times each day to see if the resident needed to go to the bathroom. The POA stated it was not difficult to figure out the resident was falling about the same time while trying to go to the bathroom. They stated they told the staff if they checked on the resident around those times it might prevent the falls. On 04/04/25 at 10:10 a.m., LPN #3 was asked if they had spoken to the resident's POA about the resident's falls sometime last year. They stated they had and the POA had asked them to check on the resident in the morning around the times the resident had been falling. They stated they had that converation sometime in the Fall of 2024, but they were not sure exactly when. LPN #3 stated they had not told the night shift about what the POA had told her but believed they knew. They stated they could not recall who they may have talked to about the conversations with the POA. On 04/04/25 at 10:20 a.m., the DON was asked about the care plan process at the facility. They stated they received information for the care plan from morning meetings. They stated they kept a book which included all the care plans so they could keep up with residents who were falling and add interventions. They stated they looked for patterns of the falls and possible interventions. They were asked about Res #39's falls and the POA's suggestion to LPN #3 about checking on the resident at a particular time. The DON stated in that situation the nurse should have informed management of the conversation with the POA as well as their own understanding the resident needed to be checked on between 3:00 a.m., and 5:00 a.m. They stated the information could have been acted on and placed in the care plan. They stated they used agency staff at the facility and such information needed to be passed on to them through the care plan. They stated the intervention should have been put into place once it was identified.

Based on record review and interviews, the facility failed to ensure staff provided supervision to prevent falls which resulted in a fracture for 1 (#39) of 2 sampled residents who were reviewed for accidents. The DON stated 54 residents resided at the facility. Findings: A facility policy titled, Fall and Fall Risk, Managing, dated March 2018, read in part, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try and minimize complications from falling. A progress note, dated 08/12/24 at 2:30 a.m., showed Res #39 had fallen while attempting to go to their bathroom. A progress note, dated 11/06/24 at 3:26 a.m., showed Res #39 had fallen while attempting to go to their bathroom. A progress note, dated 12/20/24 at 3:35 a.m., showed Res #39 had fallen while attempting to go to their bathroom. A progress note, dated 12/25/24 at 3:55 a.m., showed Res #39 had fallen while attempting to go to their bathroom. The note further showed the resident suffered a laceration to their head from the fall. A progress note, dated 02/22/25 at 3:30 a.m., showed Res #39 had fallen in their room after tripping over their wheelchair. The note further showed when the staff stood Res #39 up, they cried out in pain and could not bear weight on their left side. An acute care hospital physician's note, dated 02/22/25, showed the resident had been seen for a hip fracture following a fall. The note further showed the resident had reported they had fallen while attempting to go to the bathroom. An acute care hospital physician's examination note, dated 02/23/25, showed the resident had undergone a left hip arthroplasty (a hip replacement surgery using artificial hardware) at the hospital. An acute care hospital discharge summary, dated 02/25/25, showed the resident had been treated for a fracture of the left femoral neck (left hip) and had undergone hip replacement surgery. On 04/04/25 at 9:09 a.m., LPN #3 stated they had provided care to Res #39 during the resident's stay at the facility. LPN#3 was asked about falls. LPN #3 stated the resident had a period of time between 3:00 a.m. and 5:00 a.m. when they wanted to go to the bathroom and had some falls during that time. On 04/04/25 at 9:59 a.m., the resident's POA (power of attorney) stated on three occasions in 2024 and 2025 they had been called by the facility between 3:00 a.m. and 5:00 a.m. about Res #39 having fell while going to the bathroom. They stated during each of those calls they had asked the staff to check on the resident between those times each day to see if the resident needed to go to the bathroom. The POA stated it was not difficult to figure out the resident was falling about the same time while trying to go to the bathroom. They stated they told the staff if they checked on the resident around those times it might prevent the falls. On 04/04/25 at 10:10 a.m., LPN #3 was asked if they had spoken to the resident's POA about the resident's falls. They stated they had and the POA had asked them to check on the resident in the morning around the times the resident had been falling. LPN #3 stated they thought that conversation took place in the Fall of 2024 but could not be certain. LPN #3 stated they had not told the night shift about what they had spoke about with the POA but believed they knew. They stated they could not recall who they may have talked to about the conversations with the POA. On 04/04/25 at 10:20 a.m., the DON was asked about Res #39's falls and the POA's suggestion to LPN #3 about checking on the resident at a particular time. The DON stated in that situation, the nurse should have informed management of the conversation with the POA as well as their own understanding the resident needed to be checked on between 3:00 a.m. and 5:00 a.m. The DON stated the information could have been acted on and placed in the care plan. They stated they used agency staff at the facility and such information needs to be passed on to them through the care plan. The DON stated the intervention should have been put into place once it was identified.

Based on observation, records review, and interview, the facility failed to ensure a resident who self-administered their medication had been assessed for the ability to safely administer to do so for 1 (#13) of 9 sampled residents observed during medication administration observations. The DON stated one resident had self-administered medication at the facility. Findings: On 04/03/25 at 12:49 p.m., RN #1 was observed pre-setting an injector of insulin for Res #13. RN #1 was observed entering the resident's room and handing the insulin injector to the resident who raised their blouse, pushed the injector against their abdomen and pushed the button to release the insulin. The resident did not look to check the dose set on the injector prior to administering. The resident then handed the injector back to RN #1 and the RN departed the room. A policy titled Self-Administration of Medications, dated December 2016, read in part, As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate and safe for the resident. Res #13's medication administration records (MAR) from March 2024 through March 2025 were reviewed. Each month showed the resident had a physician's order for Novolog insulin ( a medication used in the mangement of diabetes mellitus and hyperglycemia) to be administered simultaneously with each meal. The records showed the resident had received 1,113 doses of the Novolog insulin during the reviewed months. An annual assessment, dated 02/02/25, showed Res #13 had a BIMS score of 15 which is considered normal cognitive functioning. Res #13's medical record was reviewed for an assessment to determine if Res #13 could safely self-administer medications. None were observed. On 04/03/25 at 1:03 p.m., Res #13 stated they had begun self-administering their insulin about one year ago. They stated they started doing it because they did not believe the staff kept the injector in long enough and not all the insulin was being injected. They stated their blood sugars were controlled better now that they injected the medication themselves. On 04/03/25 at 1:08 p.m., RN #1 stated they allowed Res #13 to administer their insulin the first time they attempted to administer it to them. They stated on that occasion the resident had told them they injected themselves so they allowed the resident to give the injection. On 04/03/25 at 1:11 p.m., LPN #1 was asked about Res #13 self-administering their insulin. LPN #1 stated the resident had been self-administering their insulin for about two years. LPN #1 stated they would set up the injector and hand it to the resident for administration. They stated they had been told the resident's doctor had written an order for the self-administration but could not recall by whom. They stated they were not sure if there was an order for the resident to self-administer their insulin. On 04/03/25 at 1:15 p.m., the DON was asked if they were aware of any residents that self-administered medications. The DON stated they were not aware of any. They were informed of the observation of Res #13 self-administering their insulin. The DON stated they were aware of that situation. They stated they did not know if the resident had been assessed for safety prior to them self-administering the insulin. On 04/03/25 at 1:19 p.m., the ADON stated they did not know if there was an order or assessment for Res #13 to self-administer but would look for them. The ADON stated they did have a policy on self-administering medications by residents. On 04/03/25 at 2:54 p.m., the ADON stated they had not found an order or assessment for the resident to self-administer insulin. They stated they were starting the process for getting Res #13 assessed to self-administer. The ADON stated they have alerted the nurses to wait for the process to be completed prior to allowing the resident to self-administer again. On 04/03/25 at 2:57 p.m., the DON stated the nurses would not allow the resident to administer until the process is complete. On 04/03/25 at 2:59 p.m., Corp VP #1 stated the facility had not been following their policy regarding resident self-administration but had now started the process for Res #13.

Based on record review and interview, the facility failed to ensure: a. a psychotropic medication had an appropriate diagnosis for 1 (#50), and b. the physician addressed a GDR for 1 (#39) of 5 residents sampled for unnecessary medications. The DON reported nine residents received antipsychotic medications. Findings: A facility policy titled Antipsychotic Medication Use, dated December 2016, read in part, Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. 1. A medication administration record for Res #50, dated 04/01/25 through 04/30/25, showed they had diagnoses which included dementia and delusional disorder. A Medicare five-day assessment, dated 02/14/25, showed Res #50 had a BIMS score of 12, which was indicative of a moderate impairment for daily decision making. The assessment also showed Resident #50 was receiving antipsychotic medication on a routine basis. A physician's order, dated 02/07/25, showed Res #50 was to receive risperidone (an antipsychotic medication) 0.5 mg by mouth daily for unspecified dementia. 2. A care plan for Res #39, dated 01/25/24, showed they had diagnoses which included depression and anxiety. A pharmaceutical consultation report, dated 02/10/25, showed a pharmacist suggested gradual dose reduction (GDR) of three psychotropic medications for Res. #39. Buspirone (antianxiety medications) 5mg administered twice daily, Celexa (antidepressant medication) 10 mg administered once daily, and Remeron (antidepressant medication) 15 mg administered at each bedtime, were listed on the consultation report as those suggested for reduction. The document showed the physician addressed a reduction of Celexa, but did not have any documentation addressing the two other psychotropic medications. On 04/03/25 at 10:39 a.m., the ADON stated they had reviewed the GDR for Res #39, dated 02/10/25. They stated the section for the physician to respond to the consultation only addressed the antidepressant medication, Celexa. They stated the physician did not address the two other medications. They stated there were also check boxes the physician could use to indicate whether they wanted to change or keep a medication as they were, but those boxes had not been used by the physician either. They stated because the medications were not addressed the staff could not know the physician's intentions for those medications. On 04/03/25 at 8:40 a.m., the DON stated the physician had not followed facility policy by not addressing each medication on the pharmacist's consultation for Res #39. On 04/04/25 at 10:33 a.m., the DON stated that dementia was not an appropriate diagnosis for an antipsychotic medication.

Based on record review and interview, the facility failed to ensure a resident was provided a written notice of transfer prior to being transferred to a hospital for 1 (#33) of 2 sampled residents reviewed for hospitalizations. The DON stated 54 residents resided in the facility. Findings: A progress note, dated 02/15/25 at 9:51 a.m., showed the facility initiated a transfer to a hospital for Res #13. A progress note, dated 03/16/25 at 12:36 p.m., showed the facility initiated a transfer to a hospital for Res #13. On 04/04/25 at 11:58 a.m., LPN #3 stated they had been on duty on 02/15/25 and was the nurse who transferred Res #33 to a hospital that day. When asked about what documentation was sent with the resident they stated that such items as code status, orders and face sheet. LPN #3 stated they had not heard of a written notice of transfer or that it was required to be given to a resident when they go to a hospital. They stated they had never sent such a notice with a resident. On 04/04/25 at 12:01 p.m., the DON stated when they had sent residents to a hospital they would send the resident's face sheet, MAR, and code status. The DON stated they had not heard of a written notice of transfer. They stated they had not been doing that. The DON stated they did not have a policy or procedure that included a written notice of transfer.

Based on observation, recored review, and interview, the facility failed to ensure enhanced barrier precautions were implemented for 1 (#7) of 3 sampled residents reviewed for enhanced barrier precautions. The DON reported 14 residents were on enhanced barrier precautions. Findings: On 04/02/25 at 2:19 p.m., RN #1 and CNA #2 were observed providing wound care to Resident #7. RN #1 was observed wearing a gown and CNA #2 was not observed wearing a gown. On 04/02/25 at 2:30 p.m., CNA #2 was observed providing incontinent care to resident #7. They were not wearing a gown. A medication administration record, dated 04/25, showed Resident #7 had diagnoses which included neuromuscular dysfunction of the bladder and stage IV pressure ulcer to the left heel. A quarterly assessment, dated 1/17/25, showed a staff assessment of Resident #7 was conducted. The staff assessment showed Resident #7 was severely impaired for daily decision making and was totally dependent on staff for care. On 04/02/25 at 2:39 p.m., CNA #2 stated they should have been wearing a gown. On 04/02/25 at 2:44 p.m., RN # 1 stated the facility used enhanced barrier precautions and CNA #2 should have been wearing a gown while providing direct care. On 04/04/25 at 8:30 a.m., the ADON stated gowns should be worn when providing care to residents on enhanced barrier precautions.

Based on record review and interview, the facility failed to ensure resident assessments were completed and submitted to Centers for Medicare and Medicaid Services for 1 (#21) of 19 sampled residents who were reviewed for resident assessments. The DON identified 54 residents resided in the facility. Findings: A discharge summary, dated 10/25/24 at 2:18 p.m., showed Resident #21 was discharged from the facility on 10/25/24. The electronic health record showed the last assessment completed was a quarterly assessment, dated 10/25/24. The electronic health record did not show a discharge assessment had been completed on 10/25/24. 04/02/25 at 1:31 p.m., Corporate Vice-President of Operations #1 stated a quarterly assessment had been completed instead of a discharge assessment by mistake.

Based on record review and interview, the facility failed to ensure residents were bathed as scheduled for 1 (#1) of 3 residents reviewed for assistance with ADL's. The DON identified 54 residents who resided in the facility. Findings: An undated policy titled Activities of Daily Living (ADLs), Supporting, read in part, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. A quarterly assessment, dated 01/29/25, showed resident #1 had a BIMS score of 15 which is indicative of independence for daily decision making and they required moderate assistance with bathing. Shower sheets from 02/01/25 through 04/03/25 showed out of 18 opportunities, Resident #1 did not have a shower documented on 02/08/25, 02/18/25, 02/22/24, 02/25/25, 03/04/25, 03/08/25, or 04/01/25. On 04/03/25 at 10:18 a.m., Resident #1 stated they were supposed to receive a bath twice a week on Tuesday and Saturday, but sometimes they do not get a bath. Resident #1 also stated when they asked staff about getting a shower, they say they will do it later, but they do not always follow-up. On 04/04/25 at 8:10 a.m., CNA #1 stated the CNA working on hall was responsible for giving the showers to the residents on that hall. They stated shower sheets were filled out for every shower they completed, and the shower sheets were kept in a book at the nurse's desk. They also stated if a resident refused a shower it should be documented on a shower sheet. CNA #1 stated if they did not have a shower sheet, they could not say for sure if the resident had a shower or not.

Based on record review and interview, the facility failed to ensure a comprehensive assessment contained accurate health care information for 1 (#4) of 24 sampled residents reviewed for comprehensive assessments. The DON stated 54 residents resided at the facility. Findings: A facility policy titled Certifying Accuracy of the Resident Assessment, dated November 2019, showed that each assessment must be accurate. An MDS annual assessment for Res #4, dated 01/08/25, showed in Section N0415 the resident was taking antipsychotic medications. Section N0450 of the same assessment showed the resident had not received antipsychotic medications. Res #4's medication administration record (MAR) for the month of January 2025, showed the resident had been administered the antipsychotic medication Latuda each of the seven days prior to the date of the MDS annual assessment, dated 01/08/25. On 04/03/25 at 8:07 a.m., Corp. VP #1 stated they had reviewed Res. #4's annual MDS assessment dated [DATE] and the resident's January 2025 MAR. They stated section N of the assessment showed the resident was both on and not on antipsychotic medication. They stated the resident's chart showed they were taking the antipsychotic medication Latuda now and at the time of the assessment. They stated they and the DON did spot checks of the MDS coordinator work, but do not review each assessment. On 04/03/25 at 8:46 a.m., the DON reviewed Res #4's annual MDS dated [DATE] and stated section N stated the resident was both taking and not taking antipsychotic medications. They stated the resident was taking an antipsychotic at that time. They stated the Corp. VP #1 checked the work of the MDS coordinator, but they did not. They stated the MDS was inaccurate.

Based on record review and interview, the facility failed to ensure labs were completed as ordered by the physician for 1 (#24) of 6 sampled residents whose labs were reviewed. The DON reported 54 residents resided in the facility. Findings: A care plan, initiated 06/06/24 showed Resident #24 had diagnoses which included heart failure and hypertension. A quarterly assessment, dated 03/20/25, showed Resident #24 had a BIMS score of 13, which was indicative of no impairment for daily decision making. A health status note, dated 03/19/25 at 5:42 p.m., showed the physician was notified Resident #24 was complaining of a cough and congestion. The note also showed the physician ordered guaifenesin (an expectorant) 15 mg every four hours as needed and a test for RSV. A review of Resident #24's health record did not show a physician order for an RSV test on 03/19/25 or results of an RSV test collected on 03/19/25. On 04/03/25 at 4:02 p.m., LPN #1 stated when a nurse received an order for lab work they should collect the sample and put an order in the computer. They also stated if the lab was routine the lab company would come pick it up on Monday or Thursday. LPN #1 stated when the results were ready they would automatically go into the resident's electronic health record. On 04/04/25 at 8:28 a.m., the ADON stated the order for the RSV test was not put into the computer. They also stated they were out of swabs and the lab company was bringing more and the facility did not follow up to ensure the sample was collected.

Based on record review and interview, the facility failed to provide supervision to prevent elopement for one (#1) of three sampled residents who were reviewed for elopement. The administrator identified 12 residents who were high risk for elopement. Findings: The undated Wandering and Elopements policy, read in parts, .If a resident is missing initiate the 'Elopement/Missing Resident Emergency Procedure' .Determine if the resident is out on an authorized leave or pass .If the resident was not authorized to leave, initiate a search of the building(s) and premises; and .If the resident is not located notify the administrator and the DON, the resident's legal representative, the attending physician and law enforcement . Resident #1 had diagnoses which included dementia. The Wandering Risk Scale, dated 07/04/24, documented the resident was at risk to wander. The Care Plan, dated 07/22/24, documented the resident was an elopement risk/wanderer related to a history of attempts to leave the facility unattended and wandered aimlessly. A Form 283 Incident Report, dated 08/12/24, documented an employee found resident #1 walking beside the street in front of the facility. The incident report documented the employee brought the resident back into the facility and the southwest door was checked and the alarm did not sound. The incident report documented that upon investigation the administrator found that no Wander Guard alarms were on the Southwest or the Northwest doors. On 08/28/24 at 12:38 p.m., LPN #1 stated residents that wandered wore a Wander Guard bracelet on their ankle or wrist. The nurse stated they walked the residents to the door to make sure the alarm was working and documented on the resident's TAR. On 08/28/24 at 3:08 p.m., LPN #2 stated the residents that wandered had a Wander Guard on their ankle. LPN #2 stated if the resident got within 10-15 feet of the door the alarm sounded and the alarms were tested every Saturday. On 08/29/24 at 2:02 p.m., the administrator stated the maintenance supervisor was responsible for testing the Wander Guard every week and documented it in a log book. On 08/29/24 at 2:26 p.m., the ADON stated residents that were at risk for wandering were checked every 15 minutes during the day and hourly at night. Review of the maintenance log book, provided by the facility, revealed monitoring of the Wander Guard system had not been initiated until 08/12/24.

Based on observation, record review, and interview, the facility failed to ensure the correct dose of an ordered medication was administered for one (#9) of seven residents observed for medication administration. The DON stated 53 residents received medications. Facility census: 54 Findings: Resident #9 had diagnoses which included congestive heart failure, chronic kidney disease, atrial fibrillation, cellulitis, and venous stasis ulcers of the bilateral lower extremities. A physician's order, dated 11/10/23, increased the resident's furosemide, a diuretic, from 20mg twice daily to 40mg twice daily. A hospital discharge summary, dated 11/20/23, documented the resident was hospitalized from 11/17/23 to 11/20/23 for pneumonia, cellulitis, and congestive heart failure. A prescription history report, dated 12/14/23, documented the pharmacy delivered 28 tablets of 40mg furosemide on 11/10/23 and again on 12/11/23. There were 31 days between fill dates and 28 tablets was enough medication to administer the twice daily dose for 14 days. On 12/13/23 at 4:20 p.m., CMA #1 was observed to administer one furosemide 20mg tablet to Resident #9. On 12/14/23 at 9:15 a.m., CMA #1 stated they had not noticed the dosage change and there should have been a change of direction sticker on the medication card for the resident's furosemide. The CMA stated they were to follow the five rights of medication administration to ensure the residents received the correct medication and dosage. On 12/14/23 at 12:20 p.m., the DON stated the CMA's were to read the medication administration record and check the prescription label to ensure the information matched before administering a medication.

Based on record review and interview, the facility failed to maintain a bond greater than the balance of the facility managed residents' trust. The DON documented 13 residents with funds in the trust. Facility census: 54 Findings: The facility bond, dated 09/21/08, documented an $8000.00 bond securing the residents' funds in the trust. The facility bond, dated 04/14/16, documented the bond was adjusted from $8,000.00 to $20,000. The facility trust bank statement balance, dated 09/06/23, documented a balance of $51,229.43. The facility trust bank statement balance, dated 10/05/23, documented a balance of $46,080.48. The facility trust bank statement balance, dated 11/08/23, documented a balance of $48,194.53. On 12/14/23 at 2:00 p.m., the accounts receivable manager stated the bond was not high enough to cover the resident trust and would be adjusted.

Based on record review and interview, the facility failed to maintain an accurate accounting of resident monies for one (#28) of five residents whose funds were managed in the facility trust and failed to ensure the accuracy of vendor payments for two (#34 and #43) of five residents whose funds were managed in the facility trust. The DON documented 13 residents with funds in the trust. Facility census: 54 Findings: 1. The ledger sheet for Resident #28 documented in July 2023, the resident was charged for two vendor payments, leaving a net gain of $252.00 to their account. The ledger sheet documented in August 2023, the resident was charged one vendor payment, leaving a net gain of $411.00 to their account. The ledger sheet documented in September 2023, the resident was charged one vendor payment, leaving a net gain of $411.00 to their account. The ledger sheet documented in October 2023, the resident was charged one vendor payment, leaving a net gain of $365.00. On 12/14/23 at 1:40 p.m., the administrator was shown the ledger sheet for Resident #28. The administrator stated the resident should have $75.00 left for personal use after DHS approved monthly vendor payments were applied to their accounts. On 12/14/23 at 2:00 p.m., the accounts receivable manager stated the business office manager had thought the resident was not to be charged the additional vendor payments and they would contact those vendors to clarify the resident's account balance. 2. The ledger sheet for Resident #34 documented the monthly deposit for February 2023 through May 2023 was equal to the one monthly approved vendor payment for the four months, which left no additional funds for the resident's personal use. The ledger sheet for Resident #34 documented the monthly deposit for June 2023 and July 2023 was equal to the two monthly approved vendor payments for the two months, which left no additional funds for the resident's personal use. The ledger sheet for Resident #34 documented the monthly deposit for August 2023 through November 2023 was equal to the three monthly approved vendor payments for the four months, which left no additional funds for the resident's personal use. 3. The ledger sheet for Resident #43 documented the monthly deposit for October 2023 and November 2023 was equal to the three approved vendor payments for the two months, which left no additional funds for the resident's personal use. On 12/14/23 at 1:40 p.m., the administrator was shown the ledger sheet for Resident #28. The administrator stated the resident should have $75.00 left for personal use after DHS approved monthly vendor payments were applied to their accounts. On 12/14/23 at 2:00 p.m., the accounts receivable manager stated they would contact DHS to confirm the amount of their vendor payments for Resident #34 and Resident #43 and make adjustments accordingly.

Based on record review and interview, the facility failed to post the accrued interest on three (#12, 23, and #28) of five residents whose funds were deposited in the facility trust. The DON documented 13 residents with funds in the trust. Facility census: 54 Findings: The facility's Deposit of Resident Funds policy, revised 12/2006, documented the deposited funds in excess of fifty dollars would be placed in an interest-bearing account maintained at a bank. 1. The ledger sheet for Resident #12 documented funds in excess of $100 dollars from 07/12/23 through 12/03/23. There was no documentation accrued interest was applied to the account. 2. The ledger sheet for Resident #23 documented funds in excess of $100 dollars from 05/08/23 through 12/14/23. There was no documentation accrued interest was applied to the account. 3. The ledger sheet for Resident #28 documented funds in excess of $100 dollars from 06/27/23 through 12/14/23. There was no documentation accrued interest was applied to the account. On 12/14/23 at 2:13 p.m., the accounts receivable manager stated the ledger sheets for Resident #12, Resident #23, and Resident #28 did not document the accrued interest and the facility would correct it.

Based on observation, record review, and interview, the facility failed to ensure: a. CMA #1 dispensed an oral medication without touching the medication with their bare hands; b. the registered nurse rinsed a nebulizing mask clean after use; c. LPN #1 cleansed a wound in a manner to prevent contamination of the wound bed; and d. Paid Feeding Assistant #1 fed each spoonful of food to a resident in a manner which minimized the risk of infection. The DON stated 53 residents received medications. The DON documented four residents received nebulizing breathing treatments. The DON documented seven residents received wound care. The administrator stated there was one feeding assistant. Facility census: 54 Findings: 1. On 12/13/23 at 4:20 p.m., CMA #1 was observed to drop a Celebrex tablet onto the medication cart. With their bare hands, CMA #1 picked up the tablet and placed it in the souffle cup with the other medications to administer. CMA #1 was observed to administer the Celebrex to resident #9. On 12/14/23 at 9:15 a.m., CMA #1 stated handling the medication with their bare hands was an infection control issue. On 12/14/23 at 12:10 p.m., the DON stated medications were not to be touched with bare hands by anyone but the resident who received the medication. 2. On 12/14/23 at 8:30 a.m., RN #1 was observed to administer a nebulizing breathing treatment to resident #8. Afterward, the RN placed the nebulizing mask back into a storage bag. The nebulizing chamber was observed to have a small amount of clear liquid remaining in the chamber. On 12/14/23 at 9:08 a.m., RN #1 stated the masks were changed out weekly but were not rinsed clean unless visibly dirty. On 12/14/23 at 12:10 p.m., the infection preventionist stated they did not know nebulizing masks were to be rinsed after use. On 12/14/23 at 12:10 p.m., the DON stated the nurses were to rinse the nebulizing mask after each use. 3. On 12/14/23 at 10:10 a.m., LPN #1 and CNA #1 were observed to perform wound care for resident #7. The resident's left foot was resting on a towel. CNA #1 held the resident's left leg up and LPN #1 cleansed the wound bed with 4x4 gauze soaked in saline. The LPN used long brushing strokes across the wound bed, from edge to opposite edge, which had the potential to draw contaminates from the surface of the surrounding skin into the wound bed. After cleansing the wound, CNA #1 placed the resident's foot back down on the towel, potentially recontaminating the wound. LPN #1 stated they were ready and the CNA picked the resident's leg up again. LPN #1 used their gloved hands to remove small tabs of collagen to the wound bed, hold a foam pad over the wound site, and secure the dressing with a gauze wrap and tape. On 12/14/23 at 10:25 a.m., LPN #1 was asked what happened when the CNA placed the freshly cleaned foot back down on the same towel the foot was on prior to them cleaning the wound. The LPN stated the wound bed got dirty again. The LPN stated they were not taught any technique to clean a wound which might minimize the risk of contaminating the wound bed. 4. On 12/14/23 at 12:00 p.m., paid feeding assistant #1 was observed blowing on a resident's food before feeding it to the resident. On 12/14/23 at 12:15 p.m., paid feeding assistant #1 was asked if it was sanitary to blow on a resident's food. The feeding assistant stated no.

Based on record review and interview, the facility failed to ensure that the proper SNF ABN or NOMNC for two (#100, and #101) of three sampled residents who where reviewed for SNF beneficiary notices. A Beneficiary Notices form, undated, documented 15 residents had been discharged from skilled services with days remaining in the past six months. Findings: A Transfer or Discharge policy, dated December 2016, read in part, The business office is responsible for, informing the resident, of his or her representative of NOMNC and ABN per Medicare guidelines. 1. Resident #101 admitted to skilled services on 07/01/22 with a diagnosis of stage four pressure ulcer of the sacral region and was discharged from skilled services on 08/13/22 due to therapy goals being met. 2. Resident #100 admitted to skilled services on 08/01/22 with a diagnosis of surgical amputation due to gangrene. They were discharged from skilled services on 10/08/22 due to therapy goals being met. Residents #101 and #102 should have been provided a NOMNC. On 11/30/22 at 2:10 p.m., the Administrator was asked if Residents #100 and #101 had been provided with the NOMNC or ABN. He stated, It was just an oversight on our part.

Based on record review, observation, and interview, the facility failed to ensure: a. a treatment was provided as ordered, b. staff washed their hands during wound care treatments, and c. pressure relieving boots were applied as ordered for one (#1) of one sampled resident reviewed for pressure ulcers. Findings: Resident #1 had diagnoses which included pressure ulcers. An Admission Summary report, dated 09/21/22 at 3:45 p.m., read in part, .Arrived via ambulance .[11:50 a.m.] .Air mattress on bed .multiple wounds .Wound to coccyx, right heel, two wounds on left heel . Braden Scale assessments, dated 09/21/22, 09/28/22, and 10/12/22, documented Resident #1 was at high risk for pressure ulcers. An Admission Resident Assessment, dated 09/28/22, documented Resident #1's cognition was intact, they required limited assistance with bed mobility, had unhealed pressure ulcers, three stage four pressure ulcers that were present on admit, and one unstageable pressure ulcer that was present on admit. A Care Plan, dated 10/16/22, documented Resident #1 required total dependence of two for repositioning and bed mobility, and required a mechanical lift with two staff for transfers. It documented Resident #1 had actual skin impairment and to provide wound care per physician's orders. A Health Status note, dated 10/26/22 at 11:06 a.m., read in part, .Resident [#1] returned to facility .Open area to coccyx, back of left calf, left heel and right heel. Bandages are CDI. Feet floated at this time to prevent further breakdown to heels . A Physician's Order, dated 1026/22, read in part, Prevalon boots to be worn at all times per wound care doctor every shift for heel breakdown/wounds . A Skin/Wound note, dated 11/14/22 at 2:22 p.m., read in part, .Dr .in facility this shift seeing residents wounds. Dressings to bilateral heels and left calf to remain the same. Verbal order received to change dressing cover to ABD pad on coccyx wound . A Physician's Order, dated 11/14/22, read in part, .Cleanse left heel, right heel and area to left lower calf with NS, pat dry, apply gentamycin to wound bed, then calcium alginate over, wrap with kerlix. DO NOT PLACE TELFA OVER ALGINATE every day shift for wound . A Physician's Order, dated 11/15/22, read in part, .Cleanse wound to coccyx with NS, pat dry, apply gentamycin ointment and calcium alginate, place ABD pad over wound. ONLY SECURE ABD WITH TAPE WHEN RESIDENT IS OUT OF BED. every day shift for wound . On 11/27/22 01:56 p.m., Resident #1 was observed sitting up in a chair. They were observed to have dressings to bilateral lower legs and feet. The dressings did not have a date on them. Resident #1 was asked if they had any pressure ulcers. They stated they had one on their left heel and left leg, one on their right heel, and stated staff was doing a treatment to their bottom. They were asked how frequently staff dressed the wounds to their heels. They stated staff usually did it daily, but had not done it today. A November TAR, dated 11/27/22, documented staff had provided the treatment to Resident #1's coccyx area and the prevalon boots were in place. On 11/28/22 at 2:10 p.m., Resident #1 was observed in bed. A pressure relieving boot was observed on the floor next to Resident #1's dresser. A November TAR, dated 11/28/22, documented the prevalon boots were in place. On 11/28/22 at 2:10 p.m., CNA #2 was asked if the resident utilized any type of boots for pressure ulcer relief. They stated no, just pillows and wraps. On 11/28/22 at 2:14 p.m., RN #1 was asked if Resident #1 utilized any type of pressure relieving boot. They stated, No, well yeah. They were observed looking at the EMR and stated, [Resident #1] has an order for prevalon [boot] to be worn at all times per the wound care doctor. RN #1 was asked if the Resident had the boots on at any time in the past few days. They stated, No. On 11/28/22 at 10:42 a.m., RN #1 was observed to provide wound care to Resident #1's coccyx and bilateral buttocks. RN #1 donned gloves, cleaned the areas with gauze and normal saline, and then applied gentamycin ointment and collagen powder to a large allevyn dressing. RN #1 applied the dressing to Resident #1's buttocks and secured it with tape. RN #1 then removed his gloves. RN #1 did not wash his hands prior to donning gloves, did not remove his gloves and sanitize his hands after cleaning the wounds, and did not sanitize or wash his hands after he finished the treatment. On 11/28/22 at 11:00 a.m., RN #1 entered Resident #1's room to provide wound care to Resident #1's bilateral heels and the back of the left calf. RN #1 donned gloves and was observed to remove a dressing from the left calf and heel. They were observed to clean the areas with NS and gauze, applied gentamycin to the areas, covered with an ABD pad and wrapped the lower leg and heel with kerlix. RN #1 did not wash his hands prior to donning gloves, he did not remove his gloves and sanitize his hands after removing the soiled bandage, he did not remove his gloves and sanitize his hands after cleaning the wound, and did not sanitize or wash his hands after he finished the treatment. RN #1 then removed a dressing from Resident #1's right heel. He then removed his gloves and donned another pair of gloves. He was observed to clean the area to the right heel, removed his gloves, donned gloves and applied gentamycin and an ABD pad, and wrapped the lower leg and heel with kerlix. RN #1 then removed their gloves. RN #1 was not observed to wash their hands before providing wound care, between glove changes, and did not change gloves and wash his hands between removing a soiled dressing and applying new dressings. RN #1 was not observed to wash their hand after the treatment had been provided. On 11/30/22 at 2:14 p.m., the DON was asked how the facility ensured residents were administered the correct treatments. The DON stated the treatments come off the TAR. The DON was inform of the above observation of RN #1 providing an incorrect wound treatment to Resident #1's coccyx area, and not having the prevalon boot in place as documented and ordered. The DON was asked what the policy was for handwashing during wound care. She stated to wash hands or use sanitizer every time gloves are changed. She was made aware of the wound care observation and RN #1 not washing their hands.

Based on record review, observation, and interview, the facility failed to ensure bathing was provided to dependent residents for three (#1, 17, and #44) of three sampled residents reviewed for bathing and nail care had been provided to two (#1 and #17) of three sampled residents reviewed for ADLs. The Resident Census and Conditions of Residents report, dated 11/28/22, documented 48 residents resided in the facility, 37 residents required one to two person assistance for bathing, and 11 residents were dependent on staff for bathing. Findings: A Fingernails/Toenails policy, revised February 2018, read in parts, .Nail care includes daily cleaning and regular trimming .Documentation .The date and time that nail care was given . 1. Resident #1 admitted on [DATE] with diagnoses which included DM. An Admission Assessment, dated 09/28/22, documented the resident required extensive assistance for bathing and personal hygiene. On 11/27/22 at 1:41 p.m., Resident #1 was asked if they had been receiving baths as often as they would like. They stated no. They stated they wanted bathed and their hair washed weekly. Resident #1 stated they had not been bathed or had their hair washed in over a week. Resident #1's hair was observed to be greasy and unbrushed. Their toenails were observed to be very long. Their fingernails were observed to have light brown residue under them. Resident #1 was asked if staff provided them with nail care. They stated they trimmed their own fingernails and that their toenails had not been trimmed since they admitted to the facility. Flow sheets, dated November 2022, did not document Resident #1 had been bathed from 11/01/22 through 11/11//22 and from 11/22/22 through 11/27/22. A Shower Check Off sheet, dated 11/13/22, documented nail care had been provided. There was no other documentation the resident had been provided nail care. On 11/28/22 at 11:00 a.m., RN #1 was observed providing wound care to Resident #1. They were asked who was responsible to provide nail care. RN #1 stated CNAs were, unless the resident was diabetic, then the nurse would be responsible. RN #1 was asked if Resident #1 was diabetic. They stated, Yes. On 11/28/22 at 11:05 a.m., Resident #1 was asked if anyone had trimmed their toenails or fingernails since they admitted . They stated no. Resident #1 was observed using their fingernails from each hand to clean light brown substance from underneath their fingernails. On 11/28/22 at 11:24 a.m., after RN #1 was asked if they had looked at Resident #1's fingernails and toenails. They stated, Yes, I will cut them this afternoon. 2. Resident #17 had diagnoses which included cerebral ataxia and dementia. A Resident Assessment, dated 09/22/22, documented the resident had long and short term memory problems, and required total assistance for bathing and personal hygiene. Bathing Flow Sheet records, dated 11/02/22 and 11/05/22, documented Resident #17 had been bathed, and on 11/12/22, the Resident refused a bath. An ADL Bathing task, dated 11/26/22, documented the Resident refused a bath. There was no documentation that showed Resident #17 had been bathed from 11/12/22 through 11/26/22. On 11/28/22 at 9:32 a.m., Resident #17 was observed sitting in the living area in a geri chair. Their fingernails were observed to be long with debris under them and their hair was observed to be greasy and unbrushed. On 11/29/22 2:29 p.m., CNA #3 was asked what type of assistance Resident #17 required for bathing and personal hygiene. They stated the Resident #17 required total assistance. CNA #3 was asked how frequently the resident was to be bathed. They stated twice weekly. CNA #3 was asked how they documented when a bath had been provided. They stated staff documented on a flow sheet and in the computer. On 11/30/22 at 8:25 a.m., Resident #17 was observed sitting in a geri chair in the dining room. Their hair was observed to be greasy. On 11/30/22 at 8:49 a.m., LPN #2 was asked what the policy was for providing bathing and shampoos. They stated residents get bathed and their hair washed two to three times a week. LPN #2 was asked to observe Resident #17's hair. They were asked if it looked greasy. They stated the Resident's hair gets oily. LPN #2 was made aware the bathing records did not document Resident #17 had been bathed from 11/12/22 through 11/26/22. On 11/30/22 at 3:28 p.m., the DON was asked the reason baths weren't getting provided as schedule. She stated they used a lot of agency staff and they don't always work together. 3. Resident #44 had diagnoses which included dementia. A Resident Assessment, dated 11/7/22, documented the resident's cognition was intact and required extensive assistance for bathing and personal hygiene. On 11/28/22 at 7:52 a.m., Resident #44 asked if they had been receiving baths as often as they would like. They stated, No, it's been about two weeks. They were asked how often they get their hair washed. Resident #44 stated it had been two weeks since their hair had been washed. Resident #44's hair was observed to be greasy. They were asked how often they would like to receive a bath and hair wash. They stated, When I'm dirty. Resident #44 was asked if they felt dirty. They stated, Oh, yes. There was no documentation to show Resident #44 had been bathed from 11/16/22 through 11/27/22. On 11/30/22 at 2:06 p.m., the DON was made aware of the findings.

On [DATE], an Immediate Jeopardy situation was determined to exist related to the facility's failure to assess, monitor and intervene for a resident with a change in condition. Resident #42 was readmitted to the facility following a hospitalization for pneumonia. No assessments were documented for the resident following an initial assessment when he was readmitted at 3:34 p.m., and a nurse's note at 12:40 a.m., that documented he was found without respirations and a pulse at 12:20 a.m. The note documented that earlier in the evening he was restless, with profuse sweating and oxygen saturations in the 70's. OSDH verified the existence of the Immediate Jeopardy Situation. At 10:00 a.m., the administrator and DON were informed of the IJ related to the failure to assess, monitor and intervene. A plan of removal for the IJ situation was requested. At 12:30 p.m., an acceptable plan of removal was provided by the administrator. The plan of removal documented, [NAME]crest Manor Nursing Center PLAN OF REMOVAL [DATE] ~ [NAME]crest Manor will report the said nurse to the proper licensing board. ~ All employees will be InServiced by 18:30 (6:30 p.m.) related to monitoring and intervening with residents with any change of condition. Employees not in the building on (MONTH) 17, 2019 will be InServiced via the telephone. Any employee unable to be contacted will not be allowed to work until InServiced. The assessing and monitoring policy will be added to new employee paperwork for all clinical staff. ~ Staff will be InServiced that they are to contact the DON/Designee with any resident experiencing a significant change of condition to include discharges to the hospital/funeral home, new admissions or readmissions. ~ All residents have the potential to be affected to prevent potential reoccurrence. ~ Nursing staff to take a full set of vitals of each resident to ensure no one is experiencing a significant change of condition or respiratory distress. If any resident shows signs of either, the nursing staff is to contact the DON and Physician. The above steps will be completed by 18:30 on (MONTH) 17, 2019. On [DATE], interviews were conducted with a total of seven employees who worked different shifts and in different departments. The employees verified they had been in-serviced regarding the components documented in the plan of removal and they understood the information provided. The IJ was removed as of [DATE] at 6:30 p.m., when all components of the plan of removal had been completed. The deficient practice remained at an isolated level of actual harm. Based on record review and interview, it was determined the facility failed to assess, monitor and intervene for one (#42) of one sampled resident who had a change in condition. Resident #42 was readmitted to the facility following a hospitalization for pneumonia. No assessments were documented for the resident following an initial assessment when he was readmitted at 3:34 p.m. A nurse's note at 12:40 a.m., documented he was found without respirations and a pulse at 12:20 a.m. The note documented that earlier in the evening he was restless, with profuse sweating and oxygen saturations in the 70's. The Resident Census and Conditions of Residents report documented 44 residents resided in the facility. Findings: Resident #42 had [DIAGNOSES REDACTED]. An admission assessment, dated [DATE], documented the resident was severely impaired in cognitive skills for daily decision making and required extensive assistance from staff with activities of daily living. A nurse's progress note, dated [DATE] at 2:28 a.m., documented, .Resident in westside lobby, having difficulty breathing, showing signs of anxiety, profuse sweating, slurred speech, difficulty comprehending verbal stimuli, VS ,[DATE], 140, 96.6, 24, O2 76%. Notified (name deleted), DON and was informed to have resident transported to (hospital deleted) for eval/treat . A nurse's progress note, dated [DATE] at 4:06 a.m., documented, .Notified at 0455 from (hospital name deleted) that resident had been admitted with dx of right lower lobe pneumonia . A Health Status Note, dated [DATE] at 3:31 p.m., documented, Received report (LPN name deleted), resident was in hosp for pneumonia .Resident arrived to the facility via company vehicle accompanied by (name deleted) CMA .Lung sounds are diminished in all fields anterior and posterior, he does have wheezing noted in the lower lobes bilat. BP is ,[DATE] P 138 T 98.4 r 22 o2 94 on ra. An Admission Summary note, dated [DATE] at 3:34 p.m., documented, .Resident arrived to the facility via company vehicle accompanied by (name deleted) CMA .Lung sounds are diminished in all fields anterior and posterior, he does have wheezing noted in lower lobes bilat .BP is ,[DATE] P 138 T 98.4 r 22 o2 94 on ra . A vitals summary, for the evening shift on [DATE], documented LPN #1 charted vital signs for 20 of the 37 residents. Vital signs for 11 of the residents were charted from 6:02 p.m. to 6:29 p.m. Vital signs for four of the residents were charted from 8:27 p.m. to 10:07 p.m. Vital signs for five of the residents were charted from 12:06 a.m. to 12:19 a.m. The remaining 17 residents had no vital signs documented. No vital signs were documented for resident #42 on these sheets. A nurse's progress note, dated [DATE] at 12:40 a.m., documented, .resident restless, profuse sweating, O2 sat in the 70s. notified (physician's name deleted) to get order for oxygen. Resident stated he was going to bed 2200 (10:00 p.m.). CNAs doing bed check 0020 found resident with head at foot of bed not breathing. CNAs notified this nurse and proceeded to obtain VS of resident. All lung sounds and pulse had ceased. Notified (name deleted) DON, (physician's name deleted), (funeral home name deleted), and all contacts on profile sheet . A nurse's progress note, dated [DATE] at 8:46 a.m., documented, .Expired at 0030 . No assessments were documented for the resident between 3:34 p.m. on [DATE] and 12:40 a.m. on [DATE]. On [DATE] at 8:52 a.m., the DON was asked about the death of resident #42. After reviewing the record, the DON stated from what he could remember the resident died while they were in the process of getting an order for [REDACTED]. The DON stated he was not notified of the situation until after the resident passed that night. At 8:55 a.m., LPN #1 was asked about the death of the resident. He stated he had been waiting for an oxygen order from the physician. He was asked how long he waited for the physician's response after assessing the resident and noting he had an O2 sat in the 70's. The LPN stated it was an hour to two hours. He was asked if he had continued to monitor the resident or attempted to send him to the hospital. He stated, I guess we could have done that. I probably just didn't note that he was feeling better and his O2 was back in the 90's. Sometimes I get busy and it doesn't get done. At 8:59 a.m., the DON was asked when the last assessment was documented. He stated, Not good, last time they have documentation of an assessment was at 2:33 p.m. on the 15th, with the readmission. At 10:13 a.m., the DON provided documentation of an in-service attended by LPN #1 on [DATE] regarding guidelines for nursing documentation. The in-service documented the LPN was educated regarding the required documentation with a change in condition, death in the facility and the monitoring of behaviors and side effects. The DON was asked if the in-service took place due to this incident. He stated no, the in-service was like six hours before it occurred. The DON was then asked if the LPN had just been educated, did he follow any of the information provided in the in-service. The DON stated no, he had not. At 6:38 p.m., CNA #1 was asked the resident's condition on the night of [DATE]. She stated she had assisted the resident to bed around 7:30 p.m. to 8:00 p.m. and he was fine. He got up a little later and that was when he declined. LPN #1 assessed the resident then put a call into the physician to get an order for [REDACTED]. around 80 or 85 percent. CNA #1 was asked if oxygen was administered to the resident that night. She stated no, they never got an order. The CNA continued to explain she assisted the resident back to bed at his request between 10:00 p.m. to 10:30 p.m. then found him not breathing during her midnight rounds. The CNA stated she had left the resident with the head of the bed elevated but when she found him his head was all the way at the foot of the bed. CNA #1 was asked if the resident's vitals were checked after she assisted him to bed the second time and before she found him not breathing. She stated she was not aware of anyone checking them again. She was asked if LPN #1 discussed sending the resident to the hospital. She stated the LPN started to after waiting two hours and the physician had still not responded. They just hated to send him back when he had just returned from the hospital that day. The CNA explained the LPN would try to check on the resident but was not able to because he was so busy. CNA #1 was asked when LPN #1 would do all the charting for the night. She stated he would come on duty, pass all the medications, take vital signs then sit down and do his charting. The CNA explained the LPN was too busy to chart as he went, he would have to sit and document it all at once.

Based on observation, interview, and record review, it was determined the facility failed to implement interventions to aid in the prevention of pressure ulcers and/or provide treatment and services to aid in the healing of pressure ulcers for two (#2 and #37) of three residents who were reviewed for pressure ulcers. Resident #37 was readmitted with a Stage III pressure ulcer. The facility failed to complete timely assessments of the resident's wound, obtain physician's orders for treatment of [REDACTED]. The resident's wound deteriorated to a Stage IV infected pressure ulcer. Resident #2 was admitted without pressure ulcers. The facility failed to provide pressure relieving interventions for the resident's feet and failed to consistenly provide wound care treatments as ordered by the physician. The resident developed multiple pressure ulcers, including two Stage IV pressure ulcers. The facility identified five residents as having pressure ulcers. Findings: 1. A wound physician evaluation for resident #37, dated 07/30/18, documented the resident had a stage III pressure ulcer to the right buttock. It was documented the ulcer measured 1.8 cm x 4 cm. It was documented a depth was not measurable, and the wound bed was covered with 50% granulation tissue and 50% skin. It was documented to treat the ulcer with a silicone foam dressing every three days. Review of the clinical record revealed the resident was sent to the hospital on [DATE]. Resident #37 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A progress note, dated 08/10/18 at 1:47 p.m., documented, .Received call from (hospital name withheld). States res was admitted for [MEDICAL CONDITION] .still has wound to coccyx . A skin observation tool, dated 08/10/18, documented, .wound to coccyx . There were no measurements or descriptors of the ulcer. Review of treatment sheets, dated 08/10/18 through 08/13/18, revealed no documentation a treatment was applied to the pressure ulcer. A nurse's wound note, dated 08/12/18, documented the resident had a stage III pressure ulcer to the right buttock. It was documented the ulcer measured 6.3 cm x 2.9 cm; was 100% covered with slough; [MEDICAL CONDITION] drainage was present; and moderate odor was noted. It was documented the dressing was missing, the ulcer was cleaned with normal saline, and the primary dressing was calcium alginate [MEDICATION NAME]. A treatment administration record for (MONTH) (YEAR) documented, Apply foam w/ silicone border to wound of right buttock. every day shift every 3 day(s) related to Pressure Ulcer of Sacral Region, Stage 3 .Start Date-08/14/2018 0700 . There was no physician's order found for this treatment. An entry on the treatment sheet, dated 08/14/18, documented a foam silicone dressing was applied to the pressure ulcer. A progress note, dated 08/15/18 at 9:01 a.m., documented, .Call placed to PCP about wound to sacrum. Wound noted to have increased purulent drainage. This nurse asked if we could possibly get an antibiotic and new wound care orders for her . A progress note, dated 08/15/18 at 2:20 p.m., documented, .received orders for Bactrim DS BID x 10 days and [MEDICATION NAME] 300 mg BID for 10 days. Received new wound care orders to clean with NS, pat dry, apply Santyl, apply calcium alginate, cover with dry dressing . Review of treatment sheets revealed the treatment was not applied until 08/16/18. A wound note, dated 08/19/18 at 10:21 a.m., documented the resident had a stage III pressure ulcer to the right buttock. It was documented the ulcer measured 5.8 cm x 1.9 cm; the wound bed was 80% covered with slough; moderate [MEDICAL CONDITION] drainage was present; and there was a strong odor. It was documented the edges appeared curled under; and [MEDICAL CONDITION] extended approximately 4 cm around the ulcer. A skin observation tool, dated 08/20/18, documented the resident had a wound to the coccyx. A wound physician evaluation, dated 08/20/18, documented, Stage 3 pressure wound of the right buttock (Resolved on 8/20/2018) Anatomic location of previously existing wound examined today: [MEDICATION NAME] and Resolved. Follow up only as needed . It was also documented the resident had a stage IV pressure ulcer to the sacrum. It was documented the ulcer measured 7.7 cm x 2.4 cm x 1 cm; had undermining of 1.5 cm at 11 o'clock; moderate serous exudate; and the wound bed was covered with 60% thick adherent devitalized necrotic tissue, 20% granulation tissue, and 20% skin. It was documented the ulcer was mechanically debrided. It was documented this was the initial evaluation of this wound. It was documented to treat the ulcer with Santyl, calcium alginate, and cover with a secondary dressing daily. An infection note, dated 08/21/18 at 3:26 p.m., documented, .continues ABT for wound to buttocks .Purulent drainage noted . A wound note, dated 08/21/18 at 6:41 p.m., documented the resident had a stage IV pressure ulcer to the sacrum. It was documented the ulcer measured 6.5 cm x 3.8 cm x 1.2 cm. It was documented there was 1.5 cm undermining and no [MEDICAL CONDITION] was present. It was documented there was 60% thick adherent devitalized necrotic tissue per the wound physician. The resident's care plan, revised 08/21/18, documented a problem related to a stage IV pressure ulcer on the resident's sacrum. The goal was the ulcer would show signs of healing and remain free of infection. Interventions included to administer treatments as ordered by the physician and to monitor, document, and report any changes in the skin status. A significant change assessment, dated 08/22/18, documented the resident was moderately impaired in cognitive skills for daily decision making; required extensive assistance with bed mobility and transfers; and had one stage IV pressure ulcer. A skin observation tool, dated 08/25/18, documented the resident had a wound to the coccyx. A wound note, dated 08/26/18 at 8:05 a.m., documented the resident had a stage IV pressure ulcer to the sacrum. It was documented the ulcer measured 7.6 cm x 5.7 cm x 2.1 cm. It was documented there was 0.6 cm undermining and 2.2 cm tunneling. It was documented the wound bed was 30% granulation, 20% slough, and 50% eschar. It was documented there was a strong odor and moderate serous exudate. It was documented the ulcer was improving. A wound physician evaluation, dated 08/27/18, documented the pressure ulcer measured 7.5 cm x 2.3 cm x 1cm; had 1.4 cm of undermining at 11 o'clock; moderate serous exudate; and the wound bed was 50% thick adherent devitalized necrotic tissue, 30% granulation tissue, and 20% skin. It was documented the wound had improved. It was documented the ulcer was mechanically debrided. It was documented to continue to treat the ulcer with Santyl, calcium alginate, and to cover with a gauze dressing with borders daily. A skin observation tool, dated 08/29/18, documented the resident had a wound to the buttocks. A wound physician evaluation, dated 08/31/18, documented the pressure ulcer measured 7.5 cm x 2.3 cm x 1 cm; had 2 cm of undermining at 7 o'clock; heavy serous exudate; and the wound bed was 50% thick adherent devitalized necrotic tissue, 30% granulation tissue, and 20% skin. It was documented the wound had improved. It was documented the ulcer was mechanically debrided. It was documented to continue to treat the ulcer with Santyl, calcium alginate, and to cover with an ABD pad dressing daily and as needed due to exudate. A skin/wound note, dated 08/31/18 at 4:32 p.m., documented, .(physician name withheld) here to make rounds. Tx to sacrum changed to: Clean w NS, pat dry, apply Santyl to wound bed, cover w/ calcium alginate, then cover w/ ABD pad, and secure w/ tape twice daily . The (MONTH) (YEAR) treatment administration record documented the above treatment was provided twice daily on 09/01/18 through 09/04/18. A wound note, dated 09/02/18 at 11:07 a.m., documented the resident had a stage IV pressure ulcer to the sacrum. It was documented the ulcer measured 6.2 cm x 3.2 cm. It was documented the wound bed was 100% covered with slough; moderate [MEDICAL CONDITION] drainage was present; and there was a strong odor. It was documented the edges appeared curled under. It was documented the ulcer was improving. A skin observation tool, dated 09/05/18 documented the resident had a pressure ulcer to the buttocks. The (MONTH) (YEAR) treatment administration record documented, Clean with NS, pat dry, apply santyl, apply calcium alginate, cover with ABD, and secure w/ tape. every day shift related to Pressure Ulcer of Sacral Region, Stage 4 .Do Not Use [MEDICATION NAME]* - Start Date - 09/25/2018 . The (MONTH) (YEAR) treatment administration record documented this treatment was provided once daily from 09/05/18 through 09/11/18. There was no physician's order to change this treatment from twice a day to once a day. A progress note, dated 09/08/18 at 8:55 a.m., documented, .Clean with NS, pat dry, apply Santyl, apply calcium alginate, cover with ABD, and secure w/ tape. every day shift related to pressure ulcer of sacral region .dressing removed, moderate amount of serosanguineous drainage noted to dressing. Heavy foul odor noted . A wound note, dated 09/09/18 at 10:17 a.m., documented the resident had a stage IV pressure ulcer to the sacrum. It was documented the ulcer measured 5.8 cm x 3.1 cm x 0.4 cm, with 2.3 cm undermining. It was documented the ulcer was deteriorating. The (MONTH) (YEAR) treatment administration record documented, Clean wound to sacrum with dakins solution, apply santyl ointment and calcium alginate, cover with ABD pad and secure in place with dry dressing every day shift related to Pressure Ulcer of Sacral Region, Stage 4 .-Start Date- 09/12/2018 . There was no physician's order to change the treatment. The (MONTH) (YEAR) treatment administration record documented this treatment was provided from 09/12/18 through 09/27/18. A wound note, dated 09/16/18 at 11:51 p.m., documented the resident had a stage IV pressure ulcer to the sacrum. It was documented the ulcer measured 5.9 cm x 2.4 cm x 1.9 cm, with 3.2 cm undermining. It was documented there was strong odor, sanguineous/bloody drainage, and the edges appeared curled under. A wound physician evaluation, dated 09/17/18, documented the pressure ulcer measured 8 cm x 3 cm x 1.2 cm; had 4.2 cm of undermining at 10 o'clock; heavy serous exudate; and the wound bed was 60% thick adherent devitalized necrotic tissue, 20% granulation tissue, and 20% skin. It was documented the wound had deteriorated. It was documented the ulcer was mechanically debrided. It was documented, .Primary Dressing(s) .Dakins solution apply twice daily for 30 days: dakin's soaked gauze wet to moist, twice daily(.) Secondary Dressing(s) ABD pad sterile apply twice daily for 13 days: more often PRN exudate . The order specified to discontinue the Santyl and Calcium Alginate. Treatment sheets, dated 09/17/18 through 09/23/18, documented the resident's pressure ulcer was cleaned with Dakin's solution; Santyl and calcium alginate were applied; and the ulcer was covered with an ABD pad. It was documented the dressing only occurred once daily. There was no documentation the ulcer was packed with gauze soaked with Dakin's solution. A wound note, dated 09/23/18 at 10:59 a.m., documented the resident had a stage IV pressure ulcer to the sacrum. It was documented the ulcer measured 5.5 cm x 2.0 cm x 1.3 cm, with 4.1 cm tunneling. It was documented the wound bed was 80% covered with slough. A wound physician evaluation, dated 09/24/18, documented the pressure ulcer measured 7 cm x 3.3 cm x 0.9 cm; had 3.2 cm of undermining at 12 o'clock; moderate serous exudate; and the wound bed was 50% thick adherent devitalized necrotic tissue, 30% granulation tissue, and 20% skin. It was documented the wound had improved. It was documented the ulcer was mechanically debrided. It was documented, .Primary Dressing(s) .Dakins solution apply twice daily for 23 days: dakin's soaked gauze wet to moist, twice daily(.) Secondary Dressing(s) ABD pad sterile apply twice daily for 30 days: more often PRN exudate . Treatment sheets, dated 09/24/18 through 09/26/18, documented the resident's pressure ulcer was cleaned with Dakin's solution; Santyl and calcium alginate were applied; and the ulcer was covered with an ABD pad. It was documented the dressing only occurred once daily. There was no documentation the ulcer was packed with gauze soaked with Dakin's solution. On 09/27/18 at 10:19 a.m., LPN #2, an agency nurse, was observed completing the pressure ulcer treatment for [REDACTED]. The surveyor was unable to approximate the size of the ulcer due to the resident's position and the location of the ulcer. Approximately 1 cm above the 12 o'clock position of the ulcer was another smaller ulcer. The smaller ulcer was covered with slough. LPN #2 cleaned the ulcers with gauze soaked with Dakin's solution; put Santyl into the cavity of the stage IV ulcer; placed a sheet of calcium alginate over the ulcers; covered the area with an ABD pad; and then placed a secondary dressing of bordered gauze pads over the ABD pad. She did not pack the stage IV ulcer with gauze soaked with Dakin's solution. LPN #2 stated this was the first time she had completed the dressing as she normally worked the evening shift when she was at the facility. On 09/27/18 at 3:17 p.m., the DON was asked when the resident was readmitted from the hospital. She stated 08/10/18. She was asked what pressure ulcers the resident had when she was readmitted . She reviewed the clinical record and stated the resident had a stage III pressure ulcer on the right buttock. She stated it measured 6.3 cm x 2.9 cm. The DON was asked if that was the same pressure ulcer the resident had at this time. She stated, Yes. She stated there were two ulcers that merged together. The DON was asked what kind of treatment was in place for the ulcer. She stated it looked like the order was to apply foam with a silicone border. She was asked when that treatment started. She stated 08/13/18. She was asked why there was no treatment from 08/10/18 through 08/13/18. She stated the silicone border was to be changed every three days, but she would have to look at the documentation for start up orders. She stated the hospital never sent back wound care orders. She reviewed the clinical record and stated she was not finding any orders on admission. The DON was asked to review the treatment sheets for the first documented treatment to the ulcer. She stated it was not documented on the treatment sheet until 08/14/18. The DON was asked where it was documented there were two ulcers that had merged. She reviewed the clinical record and stated the resident was not seen by the wound care physician until 08/20/18, so that would be the time. The DON was asked when the ulcer on the sacrum was first identified. She reviewed the clinical record and stated that ulcer was first identified in 05/2018, and they had just changed the name of it. The DON was asked if the facility utilized the orders from the wound physician for treatment orders. She stated, Yes. She was asked what the wound physician had ordered as a treatment on 09/17/18. She stated it was ordered to discontinue Santyl and calcium alginate and to use Dakin's twice a day. She was asked to review the treatment sheets for 09/2018 and tell what treatment was done after receiving that order. She stated they had been doing Dakin's and Santyl every day. The DON verified that was not what the wound physician had ordered. A wound note, dated 09/30/18 at 2:16 p.m., documented the stage IV pressure ulcer measured 4.1 cm x 1.7 cm x 0.3 cm, with 0.2 cm undermining. It was documented the wound bed had 40% granulation tissue; no odor; and no drainage. On 10/01/18 at 2:44 p.m., the wound physician was asked who completed rounds with her when she was at the facility. She stated it was usually an agency nurse. She was asked if the DON ever completed rounds with her. She stated she had a few times, when she had been working on the floor as a nurse. The wound physician stated it was difficult with agency staff to get consistency in taking care of the residents' ulcers. The wound physician was asked aobut the wound to the right buttock and the wound to the sacrum. She stated the wound to the right buttock had healed. On 10/01/18 at 4:07 p.m., the DON was asked how often she made rounds with the wound physician. She stated, Myself, only if I am on the floor. She was asked when she had last observed the resident's pressure ulcer. She asked, Myself? She stated, I just monitor wound assessments. She stated she made sure there were treatment orders in place. On 10/01/18 at 4:30 p.m. the wound physician reported the current measurements of the resident's pressure ulcer were 6 cm x 2.7 cm x 0.9 cm, with 6 cm of undermining at 11 o'clock. She reported there was 50% necrotic tissue, 30% granulating tissue, and 20% skin covering the ulcer bed. On 10/01/18 at 5:46 p.m., the corporate nurse provided access to software containing photographs and documentation of the resident's pressure ulcer. The corporate nurse explained how the software worked, stating the nurse took a picture of the ulcer, and then depending on information provided by the nurse, the software would measure the ulcers. She stated there could be some discrepancy in the measurements due to information provided by the nurse. She stated the nurses had to manually input any other descriptors and treatments, and then all that information was recorded in the resident's clinical record as wound notes. She was asked if the nurses measured the ulcers themselves. She stated, No. On 10/02/18 at 3:57 p.m., the corporate nurse and administrator #2 were asked if, prior to the survey, the facility had identified any concerns related to pressure ulcers. The corporate nurse stated, They definitely cover that in the QA. She stated they covered who had wounds, their progression, and tracks and trends. She was asked if there had been any concerns identified. She stated it wasn't documented whether a concern had been identified. She stated it was just listed who had pressure ulcers. On 10/02/18 at 4:09 p.m., the DON was asked if, prior to the survey, the facility had identified any concerns related to pressure ulcers. She stated, We address that in QA meetings. She was asked if a concern or problem had been identified. She stated, We talked about how we had a higher number. She was asked what the facility did about that. She stated she knew at one point they had changed how they were staffing CNAs. She stated they had delegated different duties to make sure residents were getting more fluids and being turned. She stated they assigned one CNA to float. She was asked when those things occurred. She stated, I will have to look. I know it wasn't working, so we went back to not doing that. She was asked what was done when they saw the interventions were not working. She stated, I just continue with my education and inservices. She stated, A lot of it is getting them to do the things they should be doing. She was asked how she monitored after she provided education. She stated, Doing wound audits. She stated she reviewed the documentation to see the progress of the wounds. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident had received hospice services since 06/08/16. The resident's care plan, revised 03/13/18, documented a problem related to the potential for the impairment of skin integrity related to fragile skin. The goal was the resident would maintain or develop clean or intact skin by the review date. Interventions included to avoid scratching and avoid excessive moisture, encourage good nutrition and hydration, monitor for side effects of antibiotics, monitor/document skin injury, and provide wound care per orders. The resident's care plan did not include interventions to prevent the development of pressure ulcers to the feet such as heel protectors, floating the heels, or elevation of the feet. The resident's annual assessment, dated 03/20/18, documented the resident was severely impaired in cognitive skills for daily decision making. It documented she required extensive assistance with bed mobility, transfers, toileting, hygiene, and bathing. It documented the resident was always incontinent of bowel and frequently incontinent of bladder. It documented the resident was at risk for the development of pressure ulcers. It documented the resident did not have a pressure ulcer. The resident's care plan, dated 04/25/18, documented a problem related to a stage IV pressure ulcer on the left lateral foot, a stage IV pressure ulcer on the right heel, a stage II pressure ulcer on the right medial ankle, and an unstageable pressure ulcer on the left lateral ankle. The goal was the resident's pressure ulcers would show signs of healing and remain free from infection by/through the review date. Interventions included to administer medications and treatments as ordered, assess/record/monitor wound healing, educate the resident/family/caregivers, and follow facility policies/protocols for the prevention/treatment of [REDACTED]. Review of the clinical record from 04/25/18 through 06/24/18 revealed the staff had followed the wound care physician's treatment orders for pressure ulcer care. A wound care specialist evaluation, dated 06/25/18, documented the resident had an unstageable pressure ulcer of the right heel with necrosis with light serous exudate. The measurements were documented as 2.1 x 2.7 x not measurable cm. It documented a new order to apply santyl and cover with a dry protective dressing daily. It documented recommendations to include elevation of the legs, float the heels in bed, off-load the wound, reposition per facility policy, low air loss mattress, and a sponge boot. Review of the clinical record from 06/25/18 through 07/02/18 revealed the staff had not applied santyl and covered with a dry protective dressing daily for the pressure ulcer on the right heel per the wound care physician's order. It was documented the staff had applied skin prep to the right heel twice a day. The clinical record did not include documentation the staff had elevated the legs, floated the heels in bed, off-loaded the wound, or applied a sponge boot. Review of the clinical record from 07/03/18 through 07/22/18 revealed the staff had followed the wound care physician's orders for pressure ulcer care. A wound care specialist evaluation, dated 07/23/18 documented the pressure ulcer on the right heel was a stage IV with moderate serous exudate. The measurements were documented as 2.2 x 2.7 x not measurable cm. It documented the wound was surgically debrided of 4.16 cm of devitalized tissue. It documented a new order to discontinue the use of santyl. The new order was to apply mupirocin, cover with a collagen sheet and a dry protective dressing daily. It documented recommendations to include elevation of the legs, float the heels in bed, off-load the wound, reposition per facility policy, and a sponge boot. Review of the clinical record from 07/23/18 through 07/31/18 revealed the staff had not performed the wound care to the pressure ulcer on the right heel per the wound care physician's order. It was documented the staff had applied collagen and covered with a dry protective dressing. It was documented the mupirocin was not applied. The clinical record did not include documentation the staff had elevated the legs, floated the heels in bed, off-loaded the wound, or applied a sponge boot. Review of the clinical record from 08/01/18 through 08/05/18 revealed the staff had followed the wound care physician's orders for pressure ulcer care. A wound care specialist evaluation, dated 08/06/18 documented the pressure ulcer on the right heel was a stage IV with moderate serous exudate. The measurements were documented as 2.0 x 2.4 x not measurable cm. It was documented the wound was surgically debrided of 2.40 cm of devitalized tissue. It documented a new order to use a skin prep to the periwound of the pressure ulcer on the right heel every three days. It documented recommendations to include elevation of the legs, float the heels in bed, off-load the wound, reposition per facility policy, and a sponge boot. Review of the clinical from 08/06/18 through 09/16/18 revealed the staff had not applied skin prep to the periwound of the right heel per the wound care physician's order. The clinical record did not include documentation the staff had elevated the legs, floated the heels in bed, off-loaded the wound, or applied a sponge boot. A wound care specialist evaluation, dated 09/17/18 documented the following: ~ the pressure ulcer on the left lateral foot was a stage IV with light serous exudate. The measurements were documented as 0.6 x 0.6 x 0.5 cm. It documented to discontinue the use of a skin prep. It documented a new order to apply peri-guard and cover with an abd pad daily; ~ the right heel was a stage IV with light serous exudate. The measurements were documented as 1.5 x 0.7 x not measurable cm. It documented to discontinue the following: the collagen sheet, the foam dressing with silicone border, and the use of the skin prep. It documented a new order to apply peri-guard and cover with an abd pad daily; ~ the left lateral ankle had a new unstageable necrosis with light serous exudate. It documented the surrounding tissue was purple/maroon deep tissue injury. The measurements were documented as 0.8 x 0.5 x 0.05 cm. It documented the resident was under palliative care and the responsible party declined debridement of the wound. It documented a new order to apply peri-guard and cover with an abd pad daily; ~ the right ischium had a new shear wound with light serous exudate. The measurements were documented as 0.4 x 0.5 x not measurable cm. It documented the resident was under palliative care and the responsible party declined debridement of the wound. It documented a new order to apply peri-guard every shift; and ~ recommendations were documented to include elevation of the legs, float the heels in bed, off-load the wound, reposition per facility policy, and a sponge boot. Review of the clinical record from 09/17/18 through 09/28/18 revealed the following: ~ the staff had not applied peri-guard and an abd pad to the pressure ulcer on the left lateral foot daily. It was documented the staff had continued the use of a skin prep every shift as previously ordered; ~ the staff had not applied peri-guard and an abd pad to the pressure ulcer on the right heel daily. It was documented the staff had used the collagen and the foam dressing with silicone border every three days as previously ordered; ~ the staff had not applied peri-guard and an abd pad to the pressure ulcer on the left lateral ankle daily. No treatments were documented for the left lateral ankle; and ~ the staff had not applied peri-guard to the shear wound on the right ischium every shift. No treatments were documented for the shear wound on the right ischium. Review of the clinical record did not include documentation the staff had implemented the following interventions recommended by the wound care physician: elevation of the legs, floating of the heels in bed, off-loading the wound, or applying a sponge boot. On 09/25/18 at 8:48 a.m., upon entry to the facility, the resident was observed sitting in her wheelchair with her feet on the floor in the common area near the nurse's station. She was observed to have gauze bandages on both feet. Her toenails were observed to be long and in need of a manicure. The resident's feet were not elevated and she was not wearing footwear. Throughout the survey the resident was never observed to have her legs elevated, the heels floated, the wounds off-loaded, or wearing a sponge boot. On 09/27/18 at 1:39 p.m., the resident was observed laying on her side in bed with her eyes closed. The resident was observed to have a pillow between her knees and a dressing on her right heel. LPN #2 was observed to remove the dressing from the right heel. The pressure ulcer on the right heel was observed with a pink woundbed/edges measuring approximately 1.0 x 0.7 cm x minimal depth with minimal yellow/brown dried exudate observed on the old dressing. The left heel was observed without an open area. LPN #2 was observed to clean the pressure ulcer on the right heel with gauze soaked in normal saline, she dried the wound and covered with collagen and wrapped it with gauze. On 10/02/18 at 10:06 a.m., the DON was asked what risk factors the resident had for the development of pressure ulcers. She stated the resident was incontinent of urine, chairfast most of the time, inadequate nutrition, and decreased mobility. She was asked if the resident was able to reposition her feet. She stated the resident had had quite a bit of change recently. She was asked how much care the resident required for mobility per the assessment dated [DATE]. She stated she required extensive assistance with bed mobility and transfers. She was asked if the resident was able to reposition her feet and legs independently. She stated just because the resident required extensive assistance with mobility did not mean she could not move her legs. She stated she could not answer that question. The DON was asked what interventions were documented in the resident's care plan in 03/2018 related to skin integrity. She stated the use of barrier cream on her bottom and a pressure relieving mattress. She stated those interventions were documented on the treatment administration record. She was asked if the care plan included interventions specific to the resident's feet. She stated no. She was asked why they had not implemented interventions to prevent skin breakdown on the feet. She stated she did not know. She was asked if the resident should have had specific interventions in place to prevent skin breakdown on her feet. She stated yes. The DON was asked when the resident had developed pressure ulcers. She stated on 04/25/18. She was asked what the facility had done to prevent the development of pressure ulcers. She stated barrier cream to the bottom was documented. She was asked if the resident had a specialty mattress upon admission. She stated no, she had the same mattress every resident received on admission. She stated the resident would have received a specialty mattress when she was placed on hospice, but she was unsure when that happened. She was asked if the barrier cream to the bottom was the only intervention in place for the development of pressure ulcers in 03/2018. She stated yes. The DON was asked what treatment the wound physician ordered on [DATE] for the right heel. She stated a dry protective dressing and santyl once daily. She was asked if the staff had performed the dressing change per orders from 06/25/18 - 07/02/18. She stated no. The DON was asked what treatment the wound physician ordered on [DATE] for the right heel. She stated to add collagen to the wound and discontinue the use of the santyl. She stated to continue the dry protective dressing and the use of mupirocin.

Based on observation, interview, and record review, it was determined the facility failed to provide supervision to prevent/protect residents from eloping for one (#2) of four sampled residents reviewed reviewed for risk of elopement. The DON identified five residents at risk for wandering and elopement. Findings: An undated policy tiled, Missing Residents, documented, .It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the charge nurse immediately . Resident #2 had [DIAGNOSES REDACTED]. A care plan, dated 03/12/16, documented, .The resident is an elopement risk/wanderer .Interventions/Tasks .Distract me from wandering by offering pleasant diversions, structured activities, food, conversation, television, book .Identify pattern of wandering: Is it purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate .Increase frequency of safety checks . A significant change assessment, dated 04/12/16, documented the resident was severely impaired in cognition, had exhibited no wandering behaviors during the seven day look back period, and required supervision with ambulation. A care plan, updated on 04/22/16, documented, Focus .The resident .wanders and not easily redirected/communication deficit .Interventions/Tasks .I have a short attention span and wander . A wandering risk scale record, dated 01/02/17, documented a total score of 11, identifying the resident as a high risk wanderer. A quarterly assessment, dated 01/11/17, documented the resident was severely impaired in cognition, had exhibited wandering behaviors seven days during the seven day look back period, and required limited assistance with ambulation. A kardex report, dated April 2017, documented, .SAFETY .Interventions .MONITOR - Safety Check .Monitor the resident for safety .The resident tends to wander forgetting what he is looking for such as bathroom, chair, drink, staff to frequently ask resident if he needs a restroom (sic) or drink, ask him if he needs to sit down for a break to remind him. Assist resident with these things. When staff notes resident is wandering and seems restless provide him (with) weighted blanket to assist in giving sense of security . A behavior note, dated 04/01/17, documented, .Resident up wandering the hall throughout the night, pulling pants down (and) peeing in the halls, multiple times redirected (and) provided snacks (and) toilet needs . A task safety check report, dated 04/02/17 at 10:00 p.m., documented the resident had received a safety monitoring check. A behavior note, dated 04/02/17, documented, .Up multiple times wandering the halls, rested in increments of 30 minutes to an hour . A wandering risk scale record, dated 04/02/17, documented a total score of 13, identifying the resident at high risk for wandering. On 04/03/17, a task safety check report documented the resident had received safety monitoring checks at 12:00 and 2:00 a.m. A police report, dated 04/03/17 at 5:00 a.m., documented, .Male walking in the rain, making strange noises. Officer request (sic) ambulance for elderly male. Transported to (hospital name withheld) . The website, www.wunderground.com, documented the weather in the Blackwell, Ok. area on 04/03/07 at 5:05 a.m. as follows: Temperature 54.3 degrees F., wind gust of 12 mph, and total precipation accumulation of 1.07 inches. An EMS agency report, dated 04/03/17 at 5:05 a.m., documented, .Ambulance 45 dispatched for an unknown medical. Upon arrival PD was standing outside with the pt on the side of the road. PD had placed emergency blanket on pt. PD stated that a passerby had called in and reported a person walking down the road making cow noises. Pt was soaking wet and skin was cold to the touch and pale. Pt was make (sic) incomprehensible sounds. Pt had one shoe on and the other shoe was nowhere to be found. Pt was placed on stretcher and secured with straps. Once in ambulance pt clothes were removed and pt was covered with blankets. Pt had 2+ edema in lower extremities. Pt had contusions and abrasions to both lower legs and knees. Tympanic temp was 97.6. BP was elevated at 187/92. 20g (sic) IV was started in the left AC. BG was 190. Warm normal saline drip was started. Lung sounds were clear. Pupils were PEARL. Pt was transported to (hospital name withheld) and care was transferred to nursing staff . An initial incident report form, dated 04/03/17, documented, .(at) (5:25 a.m.) the morning of 4/3/17, the facility (name withheld) received a call from local police department that (resident #2) was found outdoors at the corner of (location withheld). That is 3 blocks south of (facility name withheld). Police reported that (resident #2) told them who he was when asked. He was wet and muddy. Rain was ending from night time, lawns muddy. Police called for an ambulance. (Resident #2) was transported to local ER for further evaluation .Upon arrival to (hospital name withheld), he was evaluated. He was wet, muddy, had scrapes on his knees, shins and hands bilaterally. No further injuries or treatment needed. Doctor in ER diagnosed (resident #2) at that time for exposure and hypothermia and ordered to kept (sic) him for 24 hours observation through out (sic) the day and night of 4/3/17. Nurses on duty alerted at (5:25 a.m.), then did a visual check of all residents at facility. They proceeded to check all exits from building, all doors alarmed. Administrator, D.O.N. and maintenance notified by (6:00 a.m.). (Resident #2's) responsible party, POA was notified. Staff coming on and off duty (at) (6:00 a.m.) were notified of elopement and told to continue to be vigilant of residents whereabouts and to assure no one follows you out a door at any time during your shift. When maintenance staff arrived, a recheck of all exit doors and alarms was done. All showed to be in working order and alarmed . An emergency room record, dated 04/03/17 at 5:35 a.m., documented, .Temp 94.1 .Pulse 73 .Resp 22 .B/P 199/59 .Pulse Ox 93 .History of Present Illness .pt found naked walking along the road. The patient is a resident at the nursing home. They were not aware he had left the facility. The patient presents now is a [AGE] year-old white male. Patient is well-known to this examiner. Patient is a resident at the (facility name withheld). Patient was found walking down the street near a creek. Patient was essentially naked wearing had (sic) just a remnant of a diaper and one sock. Patient has history of long-term dementia. The patient was brought to the hospital for evaluation. The nursing home was unaware that he had left the facility in the middle of the night in the middle of a pouring down thunderstorm. I've assumed the care of the patient at (7:00 a.m.) . An order summary report, dated 04/05/17, documented: ~ Behavior charting for: anxiety and wandering, every day and night shift, start date 09/30/16; and ~ Safety check every hour, start date 04/05/17. On 04/05/17 at 10:45 a.m., the resident was observed in the common area, sitting in a recliner with his eyes closed. He was within view of nursing staff. An interview was attempted with the resident but he was found to be non-interviewable. On 04/05/17 at 2:15 p.m., CNA #1 was asked how he was made aware of the number of residents in the facility at the beginning of his shift. He stated the CNAs completed room rounds at shift change. He stated the charge nurses also informed CNAs of resident census. He was asked what the policy was regarding a missing resident. He stated the charge nurse would be notified and all staff would begin to search for the resident. He was asked if all the exit doors had an alarm. He stated yes except for the two doors leading outside to the courtyards. He was asked if the courtyards were kept locked. He stated yes. He was asked how he was made aware a resident was at risk for elopement. He stated the charge nurse would inform the staff. He stated the information was located in the residents' plan of care. He was asked if the residents' plan of care was always made available to him. He stated yes. He was asked if he had ever seen a resident trying to exit the facility. He stated he observed some of the residents going to the doors, but had not observed any residents getting out the doors unless accompanied by a family or staff member. He was asked if he was aware of any residents that had exited the facility without staff knowledge. He stated he had heard the incident involving resident #2. He stated he did not know what had happened, only that the resident had eloped. CNA #1 was asked if he provided care to resident #2. He stated yes. He was asked if the resident exhibited wandering behaviors. He stated yes. He was asked what interventions he used when he observed the resident wandering. He stated he would redirect him, keep him in sight, offer snacks, or take him to the bathroom. He was asked if resident #2 had attempted to elope before the incident on 04/03/17. He stated no. He stated he was surprised when he heard the resident had eloped. On 04/05/17 at 2:30 p.m. CNA #2 was asked how she was made aware of the number of residents at the beginning of her shift. She stated the charge nurses would inform her. She stated the CNAs completed room rounds during shift change. She was asked what the policy was regarding a missing resident. She stated the charge nurse would be notified and all staff would begin to search for the resident. She stated at least one staff member would be sent to search outside. She stated if the resident was not found the charge nurse would notify the administrator, DON, and police department. She was asked if all the exit doors had an alarm. She stated yes, except for the two doors leading outside to the courtyards. She was asked if the courtyards were kept locked. She stated yes. She was asked how she was made aware a resident was at risk for elopement. She stated the charge nurse would inform the staff. She stated the information was located in the residents' plan of care. She was asked if the residents' plan of care was always made available to her. She stated yes. She was asked if she had ever seen a resident trying to exit the facility. She stated no. She was asked if she was aware any residents had exited the facility without staff knowledge. She stated she had heard resident #2 had eloped. CNA #2 was asked if she provided care to resident #2. She stated yes. She was asked if the resident exhibited wandering behaviors. She stated yes. She was asked what interventions were utilized when she observed the resident wandering. She stated she would try to redirect him or walk with him until he got tired. She was asked if resident #2 had attempted to elope before the incident on 04/03/17. She stated no. She stated she was shocked when she heard the resident had eloped. On 04/05/17 at 2:39 p.m., EMSA worker #1 was asked if he was on duty the morning resident #2 had eloped. He stated yes. He was asked if the resident was clothed when the ambulance arrived. He stated yes. He stated when the EMS crew arrived the resident had a blanket around him. He stated when they had the resident in the ambulance they removed his clothes because they were wet and muddy. On 04/05/17 at 3:00 p.m., LPN #1 was asked how she was made aware of the number of residents in the facility at the beginning of her shift. She stated through shift reports and making room rounds. She was asked what the policy was regarding a missing resident. She stated the charge nurse would be notified and all staff would begin to search for the resident. She stated at least one staff member would be sent to search outside. She stated if the resident was not found the charge nurse would immediately notify the administrator, DON, and police department. She was asked if all the exit doors had an alarm. She stated yes, except for the two doors leading outside to the courtyards. She was asked if the courtyards were kept locked. She stated yes. She was asked how she was made aware a resident was at risk for elopement. She stated on admission. She stated she observed the resident's ambulation status and if they were exit seeking. She was asked if she had ever seen a resident trying to exit the facility. She stated no. She was asked if she was aware any residents had exited the facility without staff knowledge. She stated yes. She stated she was on duty the night resident #2 had eloped. She was asked if the resident exhibited wandering behaviors. She stated yes. She stated it was not uncommon for the resident to ambulate to her unit and sit with her. She was asked if she had observed the resident during her shift. She stated yes that she had observed him at around 2:00 a.m. in the library area, sitting in a recliner. She was asked if she had documented the time she had observed him. She stated no. She stated she had also observed one of the CNAs assisting him to his room around 3:00 a.m. She was asked if resident #2 had attempted to elope before the incident on 04/03/17. She stated no. She stated she was surprised that he had gotten out of the facility. On 04/05/17 at 3:40 p.m., the DON was asked how often the nursing staff made room rounds. She stated at least every two hours. She was asked if the room rounds were documented. She stated only for residents whose orders included safety checks. She was asked how staff were made aware of the number of residents present in the facility at the beginning of their shifts. She stated through nursing reports and room rounds. She was asked what the policy was regarding a missing resident. She stated once a resident had been discovered missing the charge nurse was to be notified and all the staff were to immediately begin a search. She stated at least one staff member was assigned to search outside. She stated the charge nurse was to notify the administrator, the DON, and the police department. She was asked how staff were made aware a resident was at risk for elopement. She stated the information would be available in the resident's kardex. She was asked if all nursing staff had access to the information. She stated yes. She was asked if resident #2 had attempted to elope before the incident on 04/03/17. She stated no. She was asked how many residents had eloped in the past year. She stated she was only aware of resident #2. She was asked what interventions had been implemented for resident #2. She stated safety checks had been increased from every two hours to every hour. On 04/05/17 at 4:30 p.m., the administrator was asked what information she had obtained in her investigation of resident #2's elopement. She stated she had interviewed all night staff who stated the resident had been observed sitting in a recliner on (unit name withheld) between 3:00 and 3:30 a.m. She stated a CNA who had worked the night shift stated she had parked her car in the parking lot just outside the unit where resident #2 was last seen. The CNA had stated she had gone out to her car to get her lunch between 3:00 and 3:30 a.m. The administrator was asked if she had determined how resident #2 eloped. She stated she believed the resident eloped when the CNA had gone out to her car. The administrator was asked what had been implemented to ensure other residents would not elope. She stated the maintenance supervisor was providing one-on-one inservice to staff regarding the use of the exit doors. She stated signs had been posted at all exit doors in order to alert anyone exiting the building to be aware of residents in close proximity. She was asked how many residents had eloped in the past year. She stated only the incident with resident #2. She was asked if resident #2 had attempted to elope before the incident on 04/03/17. She stated no. She stated she was shocked when she heard he eloped.

Based on observation, record review and interviews, it was determined the facility failed to ensure one (#2) of four sampled residents who were reviewed for accidents was safely transferred using available equipment to prevent falls. This resulted in an actual harm related to the resident received a fracture to her C1 vertebrae, laceration to her face and knee and a deviated septum. The facility denitrified 8 residents who used wheelchairs with foot pedals. Findings: A nursing procedure policy titled, Wheelchairs and Rock-N-Go Wheelchairs .To provide safe and comfortable transportation for non-ambulatory residents .Use of Standard Wheelchair .Adjust the footrests as needed . Resident #2 had [DIAGNOSES REDACTED]. A significant change assessment, dated 03/04/16, documented the resident's cognition was severely impaired, required extensive assistance of two staff members for transfers and toilet use. The assessment documented the resident required extensive assistance of one staff member for ambulation and she used a walker and wheelchair for mobility. A quarterly assessment, dated 06/04/16, documented the resident's cognition was severely impaired, she required extensive assistance with two staff members for bed mobility, transfers and with toilet use. The assessment documented the resident required extensive assistance of one staff member for locomotion on and off the unit, dressing and personal hygiene. An orientation checklist, dated 06/13/16, documented CNA #3 reviewed the transfer policy and procedures. A nurse staffing information sheet, documented CNA #3 was oriented by RA #1, CNA #4, and CNA #1 A care plan, initiated on 06/18/15, documented the resident had limited physical mobility related to weakness. Interventions included the resident used a wheelchair and a wheeled walker for locomotion. There were no interventions documented for the use of foot pedals on her wheelchair. A nurse's note, dated 07/15/16 at 3:00 p.m., documented, Observed resident on floor in hallway in front of hall bathroom. Staff was pushing resident out of bathroom in wheelchair, they went over the transition piece on floor and resident tipped out of wheelchair, hitting her head and left knee on floor. Lacerations to L (left) knee (size 7 cm x 1 cm x 0.2 cm), mid forehead (2.7 cm x 0.2 cm x 0 cm), and bridge of nose (1 cm x 0.1 cm x 0 cm). No other skin issues noted at this time .verbalizes pain to head, knee, and back .Resident did not have foot pedals attached to wheelchair at the time of incident. Resident was wearing socks and shoes, Family and physician were notified. Physician gave new order to send to ER (emergency room ) for eval/tx (evaluation and treatment) for lacerations to see if they need stitches . A nurse's note, dated 07/15/16 at 5:00 p.m., documented, Returned to facility via facility vehicle with staff. At ER, placed 11 stitches to left knee and 5 stitches to forehead . A nurse's note, dated 07/16/16 at 11:06 a.m., documented, Family here at 10 am to see resident, they are concerned that her back is hurting and her left knee. Gave her Tylenol per orders at 6:30 a.m. and gave Ibuprofen @ 10:15 a.m. with some relief noted, Family is wanting her have an x-ray done of her back and left knee to make sure there is nothing wrong .Called (Name deleted physician) and received order to send to ER . A nurse's note, dated 07/16/16 at 3:00 p.m., documented, Resident returned to facility with new dx (diagnoses) of C1 fracture-stable . A nurse's note, dated 07/17/16 at 7:30 p.m., documented, Sent to ER via facility vehicle per Dr. order for evaluation. Because of deteriorating status from fall on 07/15/16 . A nurse's note, dated 07/17/16 at 9:48 p.m., documented, Granddaughter called stated they are admitting her due to dehydration and deviated septum. On 07/20/16, CNA #3 documented the fall for resident #2. She documented, .She was sitting forword (sic) so I told her to lean Back she Did so I started to take her Back to her Room, she started sitting forward again as I was going over transision (sic) she came out of chair and landed face first on the floor. The care plan, initiated on 07/26/16, documented the resident had an actual fall on 07/15/16 which resulted in a serious injury related to leaning forwards/poor balance. New interventions included to use a Hi-Back wheelchair instead of a regular wheelchair for comfort to support neck and a cervical collar was to be worn at all times related to a C1 fracture. The care plan documented to use a total lift for transfers until her knee heals. At 900 a.m., the resident was observed in her room in a regular wheelchair leaning forward. The family members were observed to repeatedly encourage the resident to sit upright. At 9:25 a.m., CMA #1 and CNA #2 were observed to transfer the resident from the wheelchair to the toilet using the sit to stand lift. The resident was observed to lean forward and the staff repeatedly encouraged the resident to sit upright. The resident was observed to lean forward while on the toilet. The facility staff again encouraged the resident to sit upright. After toileting the resident, she was transferred with the sit to stand lift back to the regular wheelchair. The resident was observed to lean forward in the wheelchair. The facility staff again encouraged the resident to sit upright. At 9:45 a.m., the resident was asked about the fall on 07/15/16. The resident stated, All I know is I hurt my head and my knee. She was observed in her wheelchair leaning forward. The family gently pushed up on the resident's forehead to encourage the resident to sit upright. On 08/17/16 at 1:45 p.m., certified medication aide (CMA) #1 was asked about the fall for resident #2. She stated the resident leaned forward in her wheelchair. She was asked what assistance the resident needed for transfers. She stated for a while she was a 2 staff member assist and then she started getting weaker and complained of her back hurting and we started to use the sit to stand lift about 2 - 3 months ago. She was asked how the resident sat in her wheelchair. She stated most of the time she was straight but she did lean forward and to the side. She was asked if there were any interventions in place to prevent falls. She stated no not at that time for the foot pedals. She was asked if it is protocol for foot pedals to be on a wheelchair if the resident can not wheel themselves. She stated yes, she could not hold her feet up so she needed the foot pedals. She was asked if the CNA who was assisting the resident should have known to place the foot pedals on the wheelchair before transporting to the hall bathroom. She stated yes. She had been here approximately a month and a half and her preceptor should have trained her on that. She was asked if it was care planned for the foot pedals to be on the wheelchair. She reviewed the care plan and stated no. She was asked if it should be. She stated yes. She was asked if there were new interventions implemented after the fall. She stated the resident was placed in a hi back wheelchair. She was asked where the hi back wheelchair was at this time. She stated she left for a 3 day weekend and when she came back it was gone. She further stated she had asked the nurse where it was and no one knew. At 2:03 p.m., CNA #1 was asked how long she had worked with resident #2. She stated for the last couple of months. She was asked what was the level of assistance the resident needed to transfer. She stated, at first the resident was a two person assist but she just would not stand anymore so they had to start using the sit to stand lift. She was asked if the resident could propel herself in the wheelchair. She stated, No she can not. She was asked if the resident leaned forward in the wheelchair. She stated she leaned forward a lot. She would place her hand on the resident's shoulder to keep her in the wheelchair. She was asked if the foot pedals were to be used on the wheelchair. She stated the foot pedals were supposed to be on the wheelchair when transferring the resident to help with positioning. She was asked if she witnessed the residents fall on 07/15/16. She stated no, she was in a room down the other hall. She stated she knew she came out of the bathroom and she did not have the foot pedals on the wheelchair at the time. She was asked if the fall could have been prevented if the foot pedals were on the wheelchair. She stated, Yes. At 2:10 p.m., RN #1 was asked if the resident could propel herself in the wheelchair. She stated she had not known the resident to move herself. She was asked about the physical positioning of the resident in the wheelchair. She stated she frequently leaned forward in the wheelchair and was reminded to sit upright several times a shift. She was asked if the resident's fall was witnessed. She stated she came out of the end room and saw the resident fall out of the wheelchair as she came out of the bathroom across the threshold. She was asked if the foot pedals were to be on the wheelchair when the resident was being transferred. She stated they have been used for this resident. She was asked if the fall could have been prevented if the foot pedals were on the wheelchair at the time of the fall. She stated, It is hard to say. She was asked who completed the investigation after the resident's fall out of the wheelchair. She stated she did the immediate investigation and the pedals were not on the wheelchair. She was asked if the care plan addressed the foot pedals on the wheelchair. She looked at the care plan and stated, it is not on the care plan for the use of the foot pedals. She was asked if it should have been on the care plan. She stated yes. At 4:10 p.m., the assistant director of nurses (ADON) was asked who monitored the training of new CNA's. She stated she and the director of nurses (DON). She was asked how they ensured the staff know are informed if foot pedals were to be in place on wheelchairs. She stated it should have been known to use the foot pedals when transferring the resident that can not move themselves. The ADON was asked who reviews the falls and determines the root cause of the fall. She stated the interdisciplinary team which included the DON, herself, the administrator, social services and if therapy is involved. She was asked what the root cause of the fall was determined after the fall on 07/15/16. She stated the DON performed the investigation and she is not her and does not know where she put her documentation. She further stated that the resident was receiving restorative therapy. She was asked what new interventions were put into place after the fall. She stated they placed the resident in a hi back wheelchair. She was informed of the observations of the resident being seated in a regular wheelchair and was asked where the hi back wheelchair was at this time. She stated that was a good question. At 4:30 p.m., the RA #1 was asked if the resident should have foot pedals on the wheelchair. He stated yes, her feet hang down. He was asked if the foot pedals had been used on the resident's wheelchair. He stated yes, he had hit his legs on them a couple of times.

Based on observation, record review and interviews, it was determined the facility failed to intervene to prevent/reduce unintended severe weight loss for three (#2, 8 and #12) of eight sampled residents whose clinical records were reviewed for significant/severe weight loss. Resident #2 experienced a 15.2% weight loss over a 6 month period. The resident's physician had not been notified of the severe weight loss during the 6 month period, no nutritional interventions had been initiated for over 3 months and the problem of unintended severe weight loss had not been care planned resulting in actual harm to the resident. The facility identified 15 residents who had experienced significant/severe weight loss. The facility identified 60 residents resided in the facility. Findings: The facility's Best Practice Protocols for Nutrition Intervention policy and procedure documented: POLICY All residents will be screened for nutritional risk upon admission, annually and when there is a significant change in condition. A clinically appropriate intervention will be implemented within 5 days so that the resident's risk can be addressed in a timely fashion . PROCEDURE The following interventions will be implemented within 5 days of identification of risk .these interventions will be care planned. The dietitian will review all interventions and make appropriate changes if necessary. Weight Loss-significant, unplanned .4 (ounce) health shake with meals .med pass supplement .weekly weights until weight is stabilized .care plan. 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The clinical record documented the resident's weights were as follows: 11/19/16 - 203.6 pounds 12/01/16 - 186.9 pounds (a severe weight loss of 8.2% in 12 days) 01/02/16 - 189.8 pounds 02/03/16 - 187 pounds (a severe weight loss of 8.15% in 90 days) 03/06/16 - 176.2 pounds (a severe weight loss of 5.77% in 30 days 04/01/16 - 175.7 pounds 05/01/16 - 172.6 pounds (a severe weight loss of 7.7% in 90 days and 15.2% in 180 days) There was no documentation in the clinical record which indicated the resident's physician had been notified about the severe weight loss of 8.2% in 12 days as of 12/01/16. The care plan, dated 12/08/15, addressed problems related to the resident's ADL self-care deficit, limited physical mobility and cognitive impairment. The care plan did not address the resident's severe weight loss and/or interventions initiated to prevent further weight loss. A nutrition/dietary note, dated 12/11/16, written by the dietary manager, documented the resident was needing a lot of assistance with eating. The note documented the resident would be moved to the assisted dining room to be assisted and monitored. An MDS note, dated 12/14/16, written by the MDS coordinator, documented the resident's weight remains stable. Nurses' notes documented the resident was hospitalized for [REDACTED]. The resident's weight record documented his weight was 189.8 pounds on 01/02/16 and 196.1 pounds upon re-admission on 01/26/16. Nurses' notes documented the resident fell and fractured his hip and was hosptalized on [DATE]. He was re-admitted to the facility on [DATE]. The resident's weight record documented his weight was 189.8 pounds on 01/02/16 and 187 pounds upon re-admission on 02/03/16. A physician's orders [REDACTED]. There was no documentation in the clinical record which indicated the resident's physician had been notified of his severe weight loss of 8.15% in 90 days as of 02/03/16. The significant change assessment, dated 02/09/16, documented the resident had severe cognitive impairment; required limited assistance with eating; required extensive assistance with other ADLs; was 72 inches tall and weighed 187 pounds. The nutritional risk assessment, dated 02/09/16, written by the consultant dietician, documented the resident was at high nutritional risk second to significant weight loss .Suggest .health shakes and give 3 (ounces) med pass supplement (3 times daily), along with large meat servings. A weight change note, dated 03/01/16, documented the resident's physician was faxed to inform that resident has had a 7.1 (pound) weight loss since last month. A health status note, dated 03/08/16, documented a call had been made to the resident's physician to report dietary recommendations for health shakes with meals, large meat servings to all meals and MedPass 3 ounces 3 times daily between meals. A health status note, dated 03/08/16, documented the physician had ordered health shakes with meals, large meat servings with all meals, and MedPass 3 ounces three times daily between meals. A nutrition/dietary note, dated 03/10/16, written by the consultant dietician, documented the resident's weight was down 5.8% in one month. The note documented he was receiving shakes and MedPass supplements for weight loss and large meat portions for low [MEDICATION NAME]. The note documented clarification was needed for the MedPass order. A physician's orders [REDACTED]. An orders administration note, dated 04/22/16, documented the resident had fallen and his physician was notified. The note documented he had a 3% weight loss since the last weight. A nutrition/dietary note, dated 04/22/16 written by the consultant dietician, documented the resident's weight was 169.5 (pounds), down 16.7% in 5 months, down 13.6% in 3 months. Major weight change was between 01/26 and 2/21. In hospital from 01/30-2/2. 2 (ounces) Med pass supplement give (3 times daily) after meals and receives health shakes with meals. Eating 76-100% of (low concentrated sweets) diet . A physician's orders [REDACTED]. A nutrition/dietary note, dated 05/10/16, written by the dietary manager, documented: .Resident receiving a mightyshake with meals for continued weight loss, as well as Medpass 2.0 and Large meat servings with meals. Resident's current weight is 172.6 (pounds) (-7.5% comparison weight on 2/3/16 (at) 187. (pounds)) and (-10% change with comparison weight on 11/19/15 (at) 203.6 (pounds)) .Intake is 76-100% . There was no documentation in the clinical record which indicated the resident's physician had been notified of his severe weight loss of 7.7% in 90 days and 15.2% in 180 days as of 05/01/16. The quarterly assessment, dated 05/11/16, documented the resident had severe cognitive impairment; required supervision with eating; required extensive assistance with other ADLs; and weighed 173 pounds. On 05/24/16 at noon, the resident was observed during lunch. He was not provided a health shake during the meal. On 05/24/16 during the evening meal, the resident was observed eating supper. He was not provided a health shake with the meal. A nutrition/dietary note, dated 05/24/16 at 5:53 p.m., written by the consultant dietician, documented: Weight review: 172.6 (pounds), down 7.7% in 3 months and 15.2% in 6 months. Largest weight loss occurred in late January and early February-was in hospital twice during that period of time .Eating 76-100% of (low concentrated sweets) diet with large meat servings. Also receiving 2 (ounces) of med pass supplement (3 times daily) between meals and health shakes with meals .Continue (plan of care). On 05/25/16 at 7:30 a.m., the resident was observed during breakfast. He was not provided a health shake during the meal. The clinical record was reviewed for physician's visits. The most recent physician's visit was dated 02/26/16. The resident's current weight was documented as 172.0 and the previous month's weight was documented as 169.1. The resident's actual severe weight loss was not addressed. On 05/25/16 at 2:55 p.m., during an interview with the director of nurses (DON), assistant director of nurses (ADON) and corporate nurse, the surveyor stated the resident had experienced a severe weight loss of 8.2% from 11/19/15 to 12/01/15. The surveyor asked if the physician had been notified about the severe weight loss. The DON reviewed the clinical record and stated, No. The surveyor asked if any interventions had been initiated to prevent further weight loss. The ADON stated the resident had been moved to the assisted dining room. The surveyor asked if any nutritional interventions had been initiated. The ADON stated, No. The surveyor stated the resident had experience a severe weight loss of 8.15% from 11/19/15 to 02/03/16 and asked if the physician had been notified about that severe weight loss. The ADON reviewed the clinical record and stated, No. The surveyor asked if any interventions had been initiated to prevent further weight loss. The DON reviewed the clinical record and stated, No. The surveyor stated, as of 05/01/16, the resident had experienced a severe weight loss of 7.7% in 90 days and 15.2% in 180 days and asked if the physician had been notified of that severe weight loss. The DON reviewed the clinical record and stated, No. The surveyor asked if severe weight loss was a change in condition of which the physician should be notified. The DON stated, Yes. The surveyor reported the consultant dietician had suggested the resident receive health shakes in the nutritional risk assessment, dated 02/09/16. The surveyor asked if the suggestion was acted upon. The DON stated, No. She stated the consultant dietician had recommended health shakes with meals on 03/09/16. The surveyor asked if the administration of a health shake with meals was documented anywhere during any time period in the clinical record. The DON reviewed the clinical record and stated, I don't see it. The surveyor reported a health shake had not been served to the resident at lunch or supper on 05/24/16 or at breakfast on 05/25/16. The surveyor asked if the resident's severe weight loss over a 6-month period had been care planned. The ADON reviewed the care plan and stated, No. The surveyor asked if the resident had been seen by his physician at any time since 02/26/16. The DON reviewed the clinical record and stated, No. At 3:40 p.m., the DM was asked how she monitored the residents for weight loss. She stated she did the admission assessments and the dietician checked them and added to them as needed. She also did the quarterly assessments unless she noticed something that needed to be brought to the dietician's attention. She was asked if she monitored the residents weights on a monthly basis. She stated she did not monitor the residents weight, the dietician did that. She would then follow the dietician's recommendations. She was asked how she knew the residents received their health shakes. She stated the nurses would pass them out because they were documented on the MARs. Then the CNAs were told they did not have to worry about the shakes because dietary was supposed to pass them out but no one had told her. No one was making sure the health shakes were passed out for a couple of months. She was asked if she had notified anyone of the resident's 8.2% weight loss in 30 days in December 2015. She stated she had not because she did not monitor the weights. At 3:45 p.m., the consultant dietician was asked how she monitored the residents nutritional status. She stated she went through the weights, the wound tracking, scheduled MDS and relied on the dietary manager to let her know about new admissions. She knew who the tube feedings were because she charted on them every month. She was asked how often she monitored the residents. She stated she was in the facility one day a month and would chart remotely when able. She looked at the initial weight and then the monthly weights from the weight reports done by the 5th of every month. She stated her priorities were wounds, admissions, significant change in conditions and tube feeders. She was asked who she turned her dietary recommendations in to. She stated she gave them to the DM and requested she give them to the DON and the administrator. She was asked who was responsible to followup with her recommendations. She stated she had asked the DM to follow up with nursing in a timely manner or within 7 days, to send off to the physician or call as a followup. She was asked if significant weight loss was identified and no recommendations were made for three months, would this be considered timely interventions. She stated probably not, but she would need more information. She stated if a resident triggered for significant weight loss then it should be addressed. She stated there would be a notation by her in a note or an assessment. Significant weight loss should be addressed. At 4:10 p.m., the consultant dietician was asked if she could remember resident #2. She stated she did. She stated he had a weight loss on 12/13/15 but she might not have caught it because it didn't trigger. She stated the first weight in January 2016 didn't show a weight loss but there was an 8% loss the beginning of February 2016 which triggered in March. She made recommendations for the weight loss at that time. 2. Resident #8 had [DIAGNOSES REDACTED]. The significant change assessment, dated 04/20/16, documented the resident had severe cognitive impairment; required supervision with eating; required extensive assistance or was dependent upon staff for ADLs; was 60 inches tall and weighed 104 pounds; had experienced significant weight loss not prescribed by a physician; had no nutritional interventions; and received hospice services. The care plan, dated 04/22/16, documented the resident had problems related to impaired cognition, requiring extensive staff assistance with ADLs, and falls. The care plan did not address the resident's severe weight loss and/or any interventions which had been initiated to slow/prevent further weight loss. The clinical record documented the resident's weights were as follows: 10/21/15 - 120 pounds 11/01/15 - 116.3 pounds 12/01/15 - 117.8 pounds 01/01/16 - 118.0 pounds 02/01/15 - 121.2 pounds 03/01/16 - 114.0 pounds (a severe weight loss of 5.9% in 30 days) 04/01/16 - 104.1 pounds (a severe weight loss of 8.68% in 30 days, 11.77% in 90 days and 13.25% in 180 days) 05/01/16 - 90.4 pounds (a severe weight loss of 13.16% in 30 days, 25.4% in 90 days and 22.2% in 180 days) A nutrition/dietary note, dated 03/01/16, written by the dietary manager, documented the resident's weight was 114 pounds, a -5% change in 30 days and a healthshake with meals would be requested. A weight change note, dated 03/01/16, written by the ADON, documented the resident had a weight loss of 7.2 pounds from 02/01/16 - 03/01/16, and the physician had been notified by fax. A nurse's progress note, dated 03/03/16, documented the resident was admitted to a hospital with a [DIAGNOSES REDACTED]. A nurse's progress note, dated 03/08/16, documented the resident was readmitted to the facility and was to receive hospice services. The resident's weight upon re-admission was not documented in the clinical record. The comprehensive nutritional assessment, dated 03/10/16, completed by the consultant dietician, documented the resident was at high nutritional risk due to (diagnosis) of protein calorie malnutrition .can suggest shakes with meals. The assessment did not address the resident's severe weight loss of 5.9% in 30 days. A nutrition/dietary note, dated 03/11/16 at 11:05 a.m., written by a LPN, documented the resident had eaten less than 50% of her breakfast, was fed by a nurse and had consumed 100% of two healthshakes. The consultant dietician's nutritional recommendations, dated 03/24/16, did not mention the resident's severe weight loss or recommend interventions to slow/prevent further weight loss. There was no documentation in the clinical record which indicated the resident received a healthshake with meals at any time during the month of 03/2016. There was no documentation in the clinical record which indicated the resident's physician had been notified about her severe weight loss of 8.68% in 30 days, 11.77% in 90 days and 13.25% in 180 days as of 04/01/16. A health status note, dated 04/15/16, written by the DON, documented: Received dietary recommendation of health shake, they declined due to hospice status. A nutrition/dietary note, dated 04/21/16, written by the dietary manager, documented the resident noted to have increasing weight loss and increasingly poor appetite. Eats meals in the assisted dining room with assistance from nursing staff. Recommend a Healthshake with each meal. Will continue to monitor weight loss. The consultant dietician's nutritional recommendations, dated 04/22/16, did not mention the resident's severe weight loss or recommend interventions to slow/prevent further weight loss. The comprehensive nutritional assessment, dated 04/22/16, completed by the consultant dietician, documented the resident was at high nutritional risk second to significant weight loss, (diagnosis) of (protein calorie malnutrition .(Oral) intake was declining so now receiving health shakes with meals and intake has improved of late .(Continue plan of care.) The consultant dietician's nutritional recommendations, dated 04/22/16, did not mention the resident's severe weight loss or recommend interventions to slow/prevent further weight loss. An orders administration note, dated 04/24/16, written by a CMA, documented: Healthshakes with meals for supplement (due to) decreased intake . A physician's orders [REDACTED]. There was no documentation in the clinical record which indicated the resident's physician had been notified about her severe weight loss of 13.16% in 30 days, 25.4% in 90 days and 22.2% in 180 days, as of 05/01/16. An orders administration note, dated 05/15/16, written by a CMA, documented: Mightyshake with meals for Poor appetite . Resident #8's clinical record was reviewed for physician visits. No physician visit had been documented since 02/26/16, which was prior to the severe weight loss. The facility's Diet Type Report, dated 05/23/16, found in a binder on a drink/supplement cart in the assisted dining room, documented resident #8 was to be served a Mightyshake supplement with meals. On 05/24/16 at 8:35 a.m., the surveyor observed the resident as she ate breakfast in the assisted dining room. No health shake was served to the resident at any time during the meal. On 05/24/16 at 12:50 p.m., the surveyor observed the resident as she ate lunch in the assisted dining room. No health shake was served to the resident at any time during the meal. The surveyor asked CNA #2, who was sitting at a U-shaped table supervising/assisting resident #8 and 3 other residents, who was responsible for serving residents their health shakes. He stated staff served the health shakes. The surveyor asked how staff knew which residents were to receive health shakes. The CNA stated, There's a list and pointed to the binder which contained the Diet Type Report. The surveyor asked which residents at that table were to be served supplements. He stated 2 of the residents were served supplements with meals. Resident #8 was not one of the 2 residents he named. A nutrition/dietary note, dated 05/24/16 at 2:40 p.m., written by the consultant dietician, documented: Weight Review: 90.4 (pounds), down 13.2% in one month, down 22.9% in 6 months. Was in hospital from 3/3 to 3/8 for pneumonia so weight loss on 4/1 understandable. Not sure why resident has weight loss this month-intake of (mechanical) soft with nectar liquids improved to 76-100% nearly every meal. She had [MEDICAL CONDITION] at one time but last note of such was 3/12. A healthshake was suggested but was not implemented due to resident on hospice care but has one ordered presently .Since resident has had further weight loss, can suggest 2 (ounces) med pass supplement (3 times daily) between meals. On 05/25/16 at 9:40 a.m., in an interview with the DON and corporate nurse, the surveyor reported the resident had experienced a severe weight loss of 5.9% in 30 days as of 03/01/16 and the dietary manager had recognized the severe weight loss and recommended a health shake with meals on 03/01/16. The surveyor asked if the recommendation for a health shake with meals had been acted upon. The DON reviewed the clinical record and stated, No. The surveyor asked if any additional interventions had been initiated to prevent further weight loss. She stated, Not that I've seen. The surveyor asked if the resident's weight had been obtained upon re-admission to the facility on [DATE], following hospitalization for pneumonia. The DON reviewed the clinical record and stated, No. The surveyor asked if it was the facility's policy to weigh a resident upon re-admission. The DON stated it was and acknowledged the facility did not know how much, if any, weight the resident had lost while in the hospital. The surveyor reported, as of 04/01/16, the resident had experienced a severe weight loss of 8.68% in 30 days, 11.77% in 90 days and 13.25% in 180 days and asked if the physician had been notified about the severe weight loss. The DON stated, I don't see a note. The surveyor asked if the severe weight loss was a change in condition of which the physician should be notified. She stated, Yes. The surveyor reviewed the health status note, dated 04/15/16, where the DON had documented a dietary recommendation for a health shake to be served with each meal and they declined the recommendation. The surveyor asked who they were. The DON stated she had called hospice and they would have called their physician. She stated it would have been the hospice physician who declined the recommendation for the health shake with meals. The surveyor asked if the facility charged hospice for health shakes. She stated, No. The surveyor asked if the resident was supposed to be allowed to continue to lose more weight because she received hospice services. The DON stated, No. The surveyor reviewed the resident's severe weight loss of 13.16% in 30 days, 25.4% in 90 days and 22.2% in 180 days as of 05/01/16. The surveyor asked the DON if the resident's physician had been notified of the severe weight loss as of 05/01/16. She reviewed the clinical record and stated, No. The surveyor asked if the severe weight loss was a change in condition of which the physician should be notified. The DON stated, Yes. The surveyor asked if the administration of health shakes with meals, ordered on [DATE], was documented anywhere in the resident's clinical record. The DON and the corporate nurse both reviewed the clinical record and stated, No. The surveyor asked if the resident's severe weight loss had been addressed in the care plan. The DON reviewed the care plan and stated, No. On 05/25/16 at 3:45 p.m., the surveyor informed the DON and ADON the last physician's progress note was dated 02/26/16 and asked if the resident had been seen by her physician since 02/26/16. The ADON stated the resident had been in the hospital from 03/03/16 to 03/08/16. The surveyor asked if the resident had been seen by her physician since 03/08/16. The ADON reviewed the clinical record and stated, No. 3. Resident #12 had [DIAGNOSES REDACTED]. The quarterly assessment, dated 04/11/16, documented the resident had severe cognitive impairment and required supervision for all activities of daily living. The care plan, most recently revised 07/11/13, documented .focus .resident prefers to eat meals in her room .goal .I will consume at least 50% of all of my meals and maintain consistent weight .interventions/tasks .Monitor my weight per facility policy. Notify my physician of 5% weight loss or gain in one month or 10% in 180 days .Assess my response to diet and request order from my physician for any modification needed . The resident's weight records documented the resident's weights as follows: 11/2015 - 159.6 12/2015 - 152.8 01/2016 - 157.3 02/2016 - 163.4 03/2016 - 155.9 04/2016 - 158.8 05/2016 - 148.8 (a severe weight loss of 6.3% in one month and 8.9% in 3 months) A dietary progress note, dated 05/24/16, documented the consultant dietitian noted a 6.1% weight loss in one month. She refused the Ensure so it was discontinued on 02/21/16 and was eating 76-100% of her meals. She was not sure why there was a weight loss and if further weight loss occurred would consider supplementation if the resident approved. The clinical record was reviewed and no order was documented for a dietary supplement and the physician was not contacted related to a significant weight loss in May. The registered dietician's tracking sheet, dated May 2016, documented .30 day weight loss .(resident name deleted) . On 05/26/16 at 3:55 p.m., LPN #1 was asked when the residents were weighed. She stated they were weighed once a month and the computer flagged any significant weight loss. If significant weight loss was flagged, the nurse was suppose to notify the physician. She was asked what she would consider excessive weight loss. She stated five to ten pounds in a month and 10 to 15 pounds in three months. On 05/31/16 at 12:50 p.m., LPN #1 was asked if she took care of resident #12. She stated she did. She was asked how she addressed weight changes. She stated the CNA got the weights, wrote them down and gave them to her to put in the computer. She was asked what did she do if there was a significant weight loss. She stated she contacted the physician and saw if the resident had supplements. If they didn't, she would make a recommendation it to the physician. She was asked if she or anybody else contacted the physician about the resident's significant weight loss in May. She stated no, we didn't contact the physician. She was asked what was done about the significant weight loss. She stated nothing. She stated, Nothing, she couldn't find anything in the computer that was done. She was asked did she consider a 10 pound weight loss in one month significant. She stated yes. She was asked who was responsible to notify the physician about significant weight loss. She stated the floor nurse or whoever found it should call or fax the physician. She was asked if she would revise the care plan if she found a significant weight loss. She stated yes, the floor nurse, or whichever nurse found the weight loss should revise the care plan, but it wasn't done.

Based on record review and interview it was determined the facility failed to notify the physician of a significant weight loss for five (#2, 8, 10, 11, and #12) of 13 sampled residents whose clinical records were reviewed for weight loss. The Resident Census and Conditions Report, dated 05/24/16, documented 60 residents resided in the facility. Findings: 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The clinical record documented the resident's weights were as follows: 11/19/16 - 203.6 pounds 12/01/16 - 186.9 pounds (a severe weight loss of 8.2% in 12 days) 01/02/16 - 189.8 pounds 02/03/16 - 187 pounds (a severe weight loss of 8.15% in 90 days) 03/06/16 - 176.2 pounds (a severe weight loss of 5.77% in 30 days 04/01/16 - 175.7 pounds 05/01/16 - 172.6 pounds (a severe weight loss of 7.7% in 90 days and 15.2% in 180 days) There was no documentation in the clinical record which indicated the resident's physician had been notified about the severe weight loss of 8.2% in 12 days as of 12/01/16. The care plan, dated 12/08/15, addressed problems related to the resident's ADL self-care deficit, limited physical mobility and cognitive impairment. The care plan did not address the resident's severe weight loss and/or interventions initiated to prevent further weight loss. There was no documentation in the clinical record which indicated the resident's physician had been notified of his severe weight loss of 8.15% in 90 days as of 02/03/16. The significant change assessment, dated 02/09/16, documented the resident had severe cognitive impairment; required limited assistance with eating; required extensive assistance with other activities of daily living (ADLs); was 72 inches tall and weighed 187 pounds. There was no documentation in the clinical record which indicated the resident's physician had been notified of his severe weight loss of 7.7% in 90 days and 15.2% in 180 days as of 05/01/16. The quarterly assessment, dated 05/11/16, documented the resident had severe cognitive impairment; required supervision with eating; required extensive assistance with other ADLs; and weighed 173 pounds. The clinical record was reviewed for physician's visits. The most recent physician's visit was dated 02/26/16. The resident's current weight was documented as 172.0 pounds and the previous month's weight was documented as 169.1 pounds. The resident's actual severe weight loss was not addressed. On 05/25/16 at 2:55 p.m., during an interview with the director of nurses (DON), assistant director of nurses (ADON) and corporate nurse, the surveyor stated the resident had experienced a severe weight loss of 8.2% from 11/19/15 to 12/01/15. The surveyor asked if the physician had been notified about the severe weight loss. The DON reviewed the clinical record and stated, No. The surveyor stated the resident had experience a severe weight loss of 8.15% from 11/19/15 to 02/03/16 and asked if the physician had been notified about that severe weight loss. The ADON reviewed the clinical record and stated, No. The surveyor stated, as of 05/01/16, the resident had experienced a severe weight loss of 7.7% in 90 days and 15.2% in 180 days and asked if the physician had been notified of that severe weight loss. The DON reviewed the clinical record and stated, No. The surveyor asked if severe weight loss was a change in condition of which the physician should be notified. The DON stated, Yes. The surveyor asked if the resident had been seen by his physician at any time since 02/26/16. The DON reviewed the clinical record and stated, No. 2. Resident #8 had [DIAGNOSES REDACTED]. The significant change assessment, dated 04/20/16, documented the resident had severe cognitive impairment; required supervision with eating; required extensive assistance or was dependent upon staff for activities of daily living (ADL); was 60 inches tall and weighed 104 pounds; had experienced significant weight loss not prescribed by a physician; had no nutritional interventions; and received hospice services. The care plan, dated 04/22/16, documented the resident had problems related to impaired cognition requiring extensive staff assistance with ADLs and falls. The care plan did not address the resident's severe weight loss and/or interventions which had been initiated to slow/prevent further weight loss. The clinical record documented the resident's weights were as follows: 10/21/15 - 120 pounds 11/01/15 - 116.3 pounds 12/01/15 - 117.8 pounds 01/01/16 - 118.0 pounds 02/01/15 - 121.2 pounds 03/01/16 - 114.0 pounds (a severe weight loss of 5.9% in 30 days) 04/01/16 - 104.1 pounds (a severe weight loss of 8.68% in 30 days, 11.77% in 90 days and 13.25% in 180 days) 05/01/16 - 90.4 pounds (a severe weight loss of 13.16% in 30 days, 25.4% in 90 days and 22.2% in 180 days) A weight change note, dated 03/01/16, written by the ADON, documented the resident had a weight loss of 7.2 pounds from 02/01/16 - 03/01/16, and the physician had been notified by fax. There was no documentation in the clinical record which indicated the resident's physician had been notified about her severe weight loss of 8.68% in 30 days, 11.77% in 90 days and 13.25% in 180 days as of 04/01/16. There was no documentation in the clinical record which indicated the resident's physician had been notified about her severe weight loss of 13.16% in 30 days, 25.4% in 90 days and 22.2% in 180 days, as of 05/01/16. Resident #8's clinical record was reviewed for physician visits. No physician visit had been documented since 02/26/16, which was prior to the severe weight loss. On 05/25/16 at 9:40 a.m., in an interview with the DON and corporate nurse, the surveyor reported, as of 04/01/16, the resident had experienced a severe weight loss of 8.68% in 30 days, 11.77% in 90 days and 13.25% in 180 days and asked if the physician had been notified about the severe weight loss. The DON stated, I don't see a note. The surveyor asked if the severe weight loss was a change in condition of which the physician should have been notified. She stated, Yes. The surveyor reviewed the resident's severe weight loss of 13.16% in 30 days, 25.4% in 90 days and 22.2% in 180 days as of 05/01/16. The surveyor asked the DON if the resident's physician had been notified of the severe weight loss as of 05/01/16. She reviewed the clinical record and stated, No. The surveyor asked if the severe weight loss was a change in condition of which the physician should have been notified. The DON stated, Yes. On 05/25/16 at 3:45 p.m., the surveyor informed the DON and ADON the last physician's progress note was dated 02/26/16 and asked if the resident had been seen by her physician since 02/26/16. The ADON stated the resident had been in the hospital from 03/03/16 to 03/08/16. The surveyor asked if the resident had been seen by her physician since 03/08/16. The ADON reviewed the clinical record and stated, No. 3. Resident #11 was admitted on [DATE] with [DIAGNOSES REDACTED]. The admission assessment, dated 03/30/16, documented the resident was cognitively impaired and required assistance of one person for her ADLs including eating. The weights and Vitals Summary, dated 05/23/16, documented, .128 (pounds) (Wheelchair) -10.0% change (Comparison Weight 03/23/2016, 149 lbs, -14.1%, -21.0 lbs) -3.0% change over 30 day 6(s) (Comparison Weight 04/27/2016, 141.6 lbs, -9.6%, -13.6 lbs) -5.0% change {Comparison Weight 04/27/2016, 141.6 lbs, -9.6%, -13.6 lbs) -7.5% change (Comparison Weight 03/23/2016, 149.0 lbs, -14.1%, -21.0 lbs) MDS: -5.0% change over 30 day(s) (Comparison Weight 04/27/2016, 141.6 lbs, -9.6%, -13.6 lbs) There was no documentation in the clinical record of the physician having been notified of the significant weight loss. On 05/26/16 at 11:50 a.m., the DON was asked when was the physician to be notified when there was a change in the resident's condition. She stated immediately. She was asked who was to notify the physician when a resident had a significant weight loss. She stated it was done by the nurse when she documented the monthly weights. 4. Resident #10 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident's weights were as follows: 02/12/16 wt.133.5 lb. 03/30/16 wt. 119.9 lb, -10.18% 4/4/16 wt.123.9 lbs, + 4 lb; 4/14/16 wt. 118.2 lbs, -3%; 4/20/14 wt. 114.3 lbs, -3%; 5/2/16 wt. 110.1 lbs, -3%; Weight loss from 04/04/16 through 05/02/16 was -11.1%. There was no documentation of the physician being notified of the resident's significant weight loss. On 05/26/15 at 1:15 p.m., the DON was asked if the physician had been notified of the resident's significant weight loss of 10.18% and 11.1%. She reviewed the records and stated, No. 5. Resident #12 had [DIAGNOSES REDACTED]. The Weights and Vitals Summary, dated 05/02/16, documented .148.8 -3.0 change from last weight (Comparison Weight 04/01/2016, 158.8 lbs, -6.3%, -10.0 lbs) . MDS: -5.0% change over 30 day(s) (Comparison Weight 04/01/2016, 158.8 lbs, -6.3%, -10.0 lbs) . There was no documentation located of the physician being notified of the significant weight loss. On 5/31/16 at 12:50 p.m., LPN #1 was asked what she would do if there was significant weight loss. She stated she would contact the physician and see if the resident had supplements. If they didn't, she would recommend it to the physician. She was asked if she or any other person contacted the physician about the significant weight loss in May. She stated no, they didn't contact the physician.

Based on observation, clinical record review, review of policy and procedure, and staff interviews, it was determined the facility failed to: a. assess and monitor pressure ulcers initially and on a routine basis for two (#10 and #20) for two sampled residents with pressure ulcers; and b. provide wound care as ordered for one (#10) of two sampled residents with pressure ulcers. The facility identified one resident who had a pressure ulcer. This resulted in actual harm to resident #10, who developed an unstageable pressure ulcer to his left lateral heel with eschar present and pain related to the wound. Findings: 1. Resident # 10 was admitted to the facility with [DIAGNOSES REDACTED]. A nurse's note, dated 10/30/12 for the 7-3 shift, documented, "Non Sting Skin Prep to red area on L outer foot et Red area R great toe." A physician's orders [REDACTED]. Diagnosis: [REDACTED]. A quarterly assessment, dated 11/26/12, documented the resident was not at risk for developing pressure ulcers. The assessment also documented the resident did not have one or more unhealed pressure ulcers at stage 1 or higher. A comprehensive assessment, dated 02/26/13, documented the resident was not at risk for developing pressure ulcers. The assessment also documented the resident did not have one or more unhealed pressure ulcers at stage 1 or higher. A nurse's note, dated 04/08/13 for the 11-7 shift, documented, "CNA doing bed ck (check) + found a lrg (large) round area - drk (dark) purple on inside - light purple on outside on L heel. Applied skin prep + wrapped it c [MEDICATION NAME] + roll gauze, + tape...Order written + faxed." A nurse's note, dated 04/08/13 at 10:15, documented, "Dr (name deleted) notified..." A physician's orders [REDACTED]." A nurse's note, dated 04/08/13 for the 3-11 shift, documented, "Bath this evening. Tol well L heel noted to be dark purplish in color et being tx q shift Daily. No problems." An update to the care plan, dated 04/08/13, documented, "Skin tear To L heel adm TX as ordered q shift." This was an update to a problem documented as, "Onset Date 02/28/2013...I am frequently incontinent of bowel and bladder and am at a risk for skin breakdown..." A nurse's note, dated 04/18/13 for the 3-11 shift, documented, "...Drsng (dressing) (change) to L heel. Dark, purple are(sic) lateral outer foot. Soft to 'mushy' feel. Cries out in pain to touch. Takes med PO (without) problem..." A nurse's note, dated 04/19/13 for the 3-11 shift, documented, " ...C/O L heel pain 9/10 med c [MEDICATION NAME] 50mg 1 tab. Drsng (changed) to L heel. Cleansed as ordered..." A nurse's note, dated 04/20/13 at 5:15 a.m., documented, "...Drsg change done, outer L heal (sic) black, cold to touch, 0 drainage noted, 0 odor @ 5:15 a.m. Res hollering out states 'You're cutting my leg off.' This nurse responds 'No, I'm changing the drsg.' Res replies 'Oh, Ok, well it feels like it.' [MEDICATION NAME] 50mg 1 given po for L foot pain. 6:15 am Res states 'Yes my foot still hurts.' Res refuses to scale pain began cursing this nurse. res states 'No that pill didn't work'." A nurse's note, dated 04/20/13 at 10:00 a.m., documented, "New order or order (changed) to left heel clean (with) N.S. apply Skin Prep. Wrap (with) Foam Dressing, roll gauze. Secure (with) tape q Shift until healed." A nurse's note, dated 04/20/13 for the 3-11 shift, documented, "...L foot (with) clean drsng applied. Tol procedure well. L heel site (with) dark purplish area on lateral/back heel..." An update to the care plan, dated 04/20/13, documented, "(L) heel - Apply skin prep as ordered q shift till healed." A nurse's note, dated 04/21/13 at 1:15 a.m., documented, "Drsg change done to (L) foot, heel black area noted soft, (no) open areas. Res hollering out during procedure states 'That hurts.' Res unwilling to rate pain on a scale. [MEDICATION NAME] 50mg 1 given po. 215am When res questioned about heel pain res replies 'It still hurts.' 'Yes it feels better'." A nurses note, dated 04/21/13 for the 3-11 shift, documented, "Drsng (changed) to (L) heel as ordered. Tender to touch. Area remains dark, purplish to black on lateral back heel. Hollered out c drsng (change). Did not tolerate (change) well..." A nurse's note, dated 04/22/13 at 5:15 a.m., documented, "Res c/o L foot pain states 'It hurts really, really bad.' [MEDICATION NAME] 50mg 1 given po. Res noted in bed hollering out 'Ouch'." Treatment documents from November 2012 to March 2013 were reviewed, no documentation was found to show the treatment to the left heel was done by staff. A weekly pressure ulcer QI log, dated 04/26/13, documented the resident had a facility acquired unstageable pressure ulcer on her left heel that measured 1.6 x 2.3cm, with no depth, odor or drainage. The treatment was documented as, "Preppies and foam". A weekly pressure ulcer QI log, dated 05/03/13, documented the resident had a facility acquired unstageable pressure ulcer on her left heel that measured 2.0 x 2.3cm, with no odor or drainage. The treatment was documented as, "Preppies and guaze wrap." A weekly pressure ulcer QI log, dated 05/09/13, documented the resident had a facility acquired unstageable pressure ulcer on her left heel, with no odor or drainage. The wound was not measured. The treatment was documented as, "Preppies & foam wrap." On 05/15/13 at 1:30 p.m., LPN #1 was observed to provide wound care to the resident's left heel. The left heel pressure ulcer measured approximately 2cm wide and 4cm in length. The center area was approximately 1x1cm. The wound was black from the center of the plantar surface of the heel to the lateral and medial edges to include the posterior heel. The inner part of the pressure ulcer had a dark gray color surrounding the center area. The pressure ulcer was observed to have an opaque gray color to the very center of the ulcer. The wound was observed to be closed. The wound was cleaned with normal saline, the area was patted dry, a foam dressing was placed on the wound and secured with gauze wrap and tape. The physician's orders [REDACTED]. LPN #1 failed to apply the skin prep to the wound as ordered. On 05/15/13 at 2:15 p.m., the DON was asked where documentation was kept for residents who currently had pressure ulcers. She provided a book titled wound assessments. The documents did not have any information recorded of the resident's pressure ulcer from October 2012 to March 2013. At 2:20 p.m., the DON was asked how she would classify the wound to the resident's left heel. She stated it would be an unstageable pressure ulcer. She was asked if the wound was measured each time it was assessed. She stated unstageable pressure ulcers were not measured. At 4:30 p.m., the DON was asked where documentation of dressing changes performed by the nurses were kept. She stated the treatments would be documented on the treatment sheets. She was then asked why there were not treatments of the resident's wound care documented from the month of October 2012 through the month of April 2012. She stated, " I don't know, I can't answer that." At 5:30 p.m., the DON was asked if any initial measurements were taken in October 2012 when the resident's heel was observed to have a reddened area. She stated because the area was just red, there were not any measurements taken at the time. She was asked if there were any measurements taken of the resident's pressure ulcer on the left heel on 04/08/13. She stated she was not made aware of the problem until 04/20/13. She was asked if there were any measurements taken of the ulcer on the left heel on 05/09/13. She stated measurements were not taken of an unstageable wound. 2. Resident #20 was admitted to the facility with [DIAGNOSES REDACTED]. A significant change assessment, dated 04/15/13, documented the resident was independent in cognitive skills for daily decision making. He required extensive assistance from staff with bed mobility, transfers, locomotion, dressing, toilet use and bathing. He was occasionally incontinent of bowel and bladder. A care plan, initiated 04/16/13, documented: "...Focus I am at risk for skin breakdown r/t occasionally incontinent of both bladder and bowel and limited mobility... Goals I will remain free from skin breakdown r/t incontinence and limited mobility through the review...5-5-13 Clean open area to R buttock c NS apply silver excalginate cover c foam drsg q day and prn until healed..." A telephone order, dated 05/05/03, documented, "...clean open area on R buttock c N/S apply silver Excalcinate cover c foam dressing q day and prn. Diagnosis: [REDACTED]. A treatment sheet for May 2013 documented, "...clean open area on R buttock c N/S apply silver Excalcinate cover c foam dressing q day + prn until healed. DX: open area 2 cm x 1..." The treatment sheet documented the treatment had been done on May 5 through May 14. A daily skilled nurse's note, dated 05/05/13 for the day shift, documented, "...Pressure ulcer R buttock...Noted this am open area on R buttox (sic) 2 x 1 new order writen (sic)..." A daily skilled nurse's note, dated 05/06/13 for the day shift, documented, "...Pressure ulcer R buttock...area to Rt buttock, Tx done per order area is 2cm x 1cm...c [MEDICATION NAME] tissue, present, (no) necrotic tissue present." Daily skilled nurses' notes, dated 05/07/13, 05/08/13, 05/09/13, 05/10/13, 05/11/13, 05/12/13, and 05/13/13, documented, "...Pressure ulcer R buttock..." On 05/15/13 at 6:00 p.m., the facility wound assessment book was reviewed. There was no documentation to indicate the resident had a wound. At 6:10 p.m., the DON was asked if the resident had a wound. She stated, "I looked at it in the afternoon of the 5th after the nurse told me about it. It was not open, just red where he had an old wound." At 6:15 p.m., an open area was observed on the resident's right upper buttocks which measured approximately 0.5 cm x 0.5 cm in size. The DON was asked about the open area. She stated, "That's not the one I looked at. That one is new."

Based on record review and interview, it was determined the facility failed to ensure one (#2) of two sampled residents were transfered per manufacturer's specifications and warnings with a sit to stand lift. The resident suffered a fall that resulted in a spiral fracture to the distal third of the right femur. The resident could not withstand a surgical repair. Documentation from the hospital indicated the physician stated this was a probable terminal fracture. This resulted in an immedicate jeopardy situation. Findings: The facility's undated policy and procedure on the use of portable lifting machines documented, "...place the sling, fan-folded, along the back of the resident; make sure the top of the sling is at the head of the resident and the bottom at the resident's knees...attach the hooks to the sling...attach the sling to the lift...instruct the resident to fold both arms across his/her chest if possible..." The manufacturer's manual for the Vera-Lift II sit to stand lift, dated 05/2008, documented, "...Warning Although one person can perform patient transfers, certain patients or situations may require the help of one or more additional staff members...The above information must be recorded in the patient's record and must be communicated to the staff...The patient's arms must be on the outside of the back belt. Fasten the inner safety belt snuggly...Standing Transfer with Crossed Straps...Connect the back belt to the lift arm hooks snuggly: a) Cross one back belt white strap through the loop closest to the back belt on the other white strap. b) Connect the right side white back belt loops to the left lift arm hook and connect the left side white back belt loops to the right lift arm hook using the same loop on both sides of the back belt. c) Remove the colored straps from the Velcro pocket under the patient's arms and connect the colored straps straight (not crossed) to the lift arm hooks using the same loop on both sides of the back belt. (The upper or lower lift arm hooks may be used for short to medium height patients. The upper hooks should be used for tall patients as this will help the patient to stand erect on the Vera-Lift II.)..." Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 05/15/12, documented the resident was cognitively intact, required extensive assistance of one person for bed mobility, locomotion on and off the unit, dressing, toileting, personal hygiene, and bathing. It was documented the resident required extensive assistance of two people for transferring. The assessment also documented the resident was only able to stabilize with staff assistance during surface to surface transfers. The care plan, last updated 05/17/12, documented a problem, "...Risk for falls r/t visual deficit and mobility deficit..." The goal was, "...resident will not experience fall qd through review date..." Approaches included, "...assist resident as needed with transfer..." Another problem was, "...requires extensive assist with performing ADLs/bathing/transfers..." The goal was, "...resident will be able to perform adls/transfers safely with assist thru next review..." Approaches included, "...Perform ADLs/transfers for resident as needed...assist with transfers as needed c sit to stand...use of lift for transfers..." A nurse's note, dated 07/28/12 at 7:30 a.m., documented, "...At (7:30 a.m.) nurse called to resident room was told by CNAs that while transferring resident from bed to w/c using sit to stand the strap came off one side. CNA had to assist resident to set down on floor. Resident did not fall. Resident c/o knee pain right side. Nurse did assessment no discoloration (sic) or bruising noted. Did ROM resident c/o of pain could not put any wt on (right) leg when stood up nurse told resident need to call Dr get order to go to hospital to get X-ray. Resident stated 'No. I will not go to hospital.' Resident repeated this statement x 2 to nurse. Nurse put cold pack on resident (right) knee. Resident toke (sic) one tyl 3 for pain at 7:40. Vital signs then taken O2 91%, T 98.1, P 63, R 16, B/P 143/75. Then resident went to dining room ate breakfast nurse called (physician name withheld)...nurse called resident (family member name withheld)...Stated this is fine do what she wants if she said don't want to go to hospital keep her at home..." At 11:50 a.m., it was documented, "...nurse called to room. Resident not responding sitting on commode (sic) in bathroom. Nurse started talking to resident rubbing face. Resident responded. Vital signs taken B/P 73/53, P 52, O2 sats 83%. Nurse called (physician name withheld)...received orders to send her to (hospital name withheld emergency room ) per ambulance. Nurse call 911 nurse called resident (family member name withheld). CNA transferred (sic) resident from comode (sic) to w/c. Resident became limp...CNA lifted resident transferred to gurney..." A hospital history and physical, dated 07/28/12, documented, "...Evidently, the nursing was trying to transfer her. Somehow, she was dropped on her right, landing on her right knee. Complained of pain and swelling in her right knee. Originally, she refused to come to the emergency room for evaluation, but she had a vasovagal episode getting up to the commode, became diaphoretic , sweaty and less responsive and the patient was transferred to the emergency room . On evaluation, she was found to have a spiral fracture of the distal third of the femur on the right side...She has a long history of severe osteoarthritis..." A physician's hospital progress note, dated 07/31/12, documented, "...Due to the patient's nonambulatory status, and her poor health condition, she is not a candidate for surgery for [REDACTED]. On 08/09/12 at 10:45 a.m., resident #2 was asked if she remembered the incident with the lift when she fell and broke her leg. She stated yes. The resident was asked if she remembered the staff fastening the lift straps under her arms. She stated, "She was in a hurry. She was getting me up for breakfast." When asked if the staff crossed the straps in front of her, resident #2 stated, "I'm too short. I've asked them not to because the straps hit me right in the face." On 08/09/12 at approximately 10:00 a.m., CNA #1 was asked to describe how she used the sit to stand lift with resident #2 and the events surrounding the fall with resident #2. CNA #1 stated she put the "deal" around the middle, straps over/under the arms, and strap behind the legs. CNA #1 was asked if she crossed the straps in front of the resident as the manufacturer instructed. She stated no because the resident did not want the straps to be crossed because they hit her in the face. CNA #1 stated, "Her (resident #2) knees buckled and she went down." CNA #1 stated she did not know if the resident fainted. She stated the harness remained attached to the lift. CNA #1 stated, "She hollered when I laid her down, not when she was lowered." CNA #1 stated the resident normally held her hands on the top of lift but this time she let go. On 08/09/12 at approximately 10:15 a.m., CNA #2 stated the resident would not use the velcro strap on her lower legs. She stated the resident would refuse. CNA #2 stated, "She won't let you criss cross the top. She throws a fit." CNA #2 stated, "That's what they told me so I never did it (cross the straps)." CNA #2 stated the resident would get aggravated if staff did not do what she wanted. On 08/09/12 at 2:45 p.m., the administrator was asked if the lift had been checked to ensure it did not malfunction. She stated yes, the lift had been checked and it did not malfunction. The administrator was asked if the staff had been inserviced regarding proper use of the lift and notifying their supervisor if a resident verbalized they did not want the lift used per manufacture guidelines. She stated the two staff members on the east unit had been inserviced. When asked if the entire nursing home staff had been inserviced, she stated, "No." The administrator was asked if she was aware of the resident's specific requests/directives to staff insisting that the sling straps not be crossed as recommended by the manufacturer. She stated, "No, I didn't know." She stated she was unaware of the resident's request until after the fall occurred and that she would have intervened and either explained to the resident she must let the straps be crossed for safety or stop using the equipment. The administrator stated the two staff members involved in the incident were inserviced and made to do return demonstrations. When asked if other staff had been inserviced and made to do return demonstrations, the administrator stated, "I never thought about that." The administrator was asked if she was aware of the resident moving her arms inside of the sling and reaching forward to grab the bar in the middle of the lift. She stated, "No." On 08/09/12 at 3:05 p.m., the DON was asked who was inserviced on proper use of the sit to stand lift after the incident with resident #2. The DON stated the two staff members (CNAs #1 and #2), who were the staff on the resident's hall the day of the accident were the ones inserviced. When asked if she thought the rest of the staff should have been inserviced, the DON stated it was the subject of their next inservice on 08/10/12. The DON was asked if she knew there were two failures involving the lift during the incident. She stated no. The DON was informed the straps were not crossed during the lift and that the resident brought her arms inside the straps during the transfer. The DON stated staff did not report to her the resident was insisting the straps on the sling not be crossed until after the incident but she was unaware the resident was bringing her arms inside the sling during the transfer. The DON stated she did not think to broaden the investigation to obtain further information about how the lift was being used. The DON was shown the manufacturer's manual on the sit to stand lift and was asked if she had ever seen the manual. She stated, "No, I've never seen this book." Immediate Jeopardy Identified On 08/09/12 at 3:40 p.m., an Immediate Jeopardy situation was determined to exist due to the facility's failure to ensure a resident was transfered per manufacturer's specifications and warnings with a sit to stand lift. Resident #2 fell and sustained a spiral fracture of the distal third of the femur on the right side. Documentation from the hospital indicated that due to the resident's condition the physician stated this was a probable terminal fracture. Facility Plan of Removal for Immediate Jeopardy On 08/08/12 at 6:10 p.m., an acceptable plan of removal was accepted. The plan of removal documented, "Hillcrest Manor will ensure that all residents are transferred safely when using any mechanical lifts to transfer positions. Hillcrest Manor has identified 12 total residents who utilize mechanical lifts to assist with transfer. Hillcrest Manor is currently contacting each of the 48 direct care staff via telephone to report for in-service. Any staff member who is not able to attend the immediate in-service will be placed on administrative leave until they are in-serviced. Each direct care staff member will be in-serviced immediately (8/9/2012) on how to properly use each of the lifts before they are allowed to use them with the residents and will also be in-serviced on communicating resident preferences to the Administrator, DON or ADON according to the manufacturer's direction prior to direct care staff be ginning their respective shifts. An additional in-service will be held on August 21st utilizing instructional videos provided by the manufacturer. Additionally, direct care staff hired after 8/9/2012 will be in-serviced on the proper use of these devices before they are allowed to use these devices and on effective communication. Education and training in safe transfers and the use of mechanical lifts is ongoing." Immediacy Removed The IJ was removed on 08/10/12 at 1:15 p.m., when the last employee inservice was completed. The deficient practice remained at a level of isolated actual harm that was not immediate jeopardy. The facility's administrator provided documentation ensuring all staff had been inserviviced on the facility's policy and procedures for the mechanical sit to stand lift. Staff membes were interviewed on 08/10/12, in regard to their knowledge of the inservice; to ensure their understanding of the proper usage of the sit to stand lift.

***Supplemental*** Based on record review, and interview, it was determined the facility failed to ensure indwelling urinary catheters were not used without medical justification for one (#9) of three sampled residents with a catheter. The resident developed a urinary tract infection with a fever of 103.9 degrees Fahrenheit and penile [MEDICAL CONDITION]. This had the potential to affect three residents identified by the facility with an indwelling urinary catheter. Findings: Resident #9 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment, dated 03/28/12, documented the resident was independent in cognitive skills for daily decision making. He required extensive assistance by staff with transfers, dressing and bathing. He was occasionally incontinent of bladder. A nurses's note, dated 03/30/12 at 2:18 p.m., documented, "This nurse noted @ noon meal res incont of bladder. Clothes were urine soaked noted lg (large) puddle of urine (down) w/c...call placed to (named physician) ..." A physcian's order, dated 03/30/12, documented "...insert foley...[DIAGNOSES REDACTED]. A physcian's order, dated 04/02/12, documented "...send U.A. for urinalysis (with) C & S (culture and sensitivity) [DIAGNOSES REDACTED].I (urinary tract infection) to hospital then [MEDICATION NAME](Ciproflaxin) 500 mg 1 po bid x's 15 days..." A nurse's note, dated 04/02/12 on the 7:00 a.m. to 3:00 p.m., shift, documented, "...around noon resident was chilling temp was 101.9. resident was assisted to bed wife @ bedside. Resident stopped chilling temp was 103.9." At 6:15 p.m., a nurse's note, documented " ...Res temp 103.1 ..." A doctor's progress notes, dated 04/03/12, documented "...febrile response to catheter..." A nurse's note, dated 04/04/12 at 11:30 a.m., documented, "call placed to Dr. office re: penal (sic) [MEDICAL CONDITION]" A physcian's order, dated 04/04/12 at 12:00 p.m., documented "...DC foley catheter..." A nurse's note, dated 04/04/12 at 10:00 p.m., documented, '...DC'd foley catheter ...res tol well. urine - dk tea colored (with) mucous noted in foley bag..." A diagnostic lab report, dated 04/05/12, documented "culture urine...result Escherichia coli." On 05/10/12 at 9:20 a.m., the ADON was asked where the justification for an indwelling catheter would be documented. She stated, "We just write it on our notes no form." She was then shown the clinical record for the resident. She looked at the record and stated, "There should have been documentation." At 9:45 a.m., the DON was asked what was the medical justification for the foley catheter. She stated, "In the nurse's notes and orders it's for incontinence."

Based on observation and interview, it was determined the facility failed to maintain the kitchen in a sanitary manner as evidenced by: a. Staff not washing their hands after they picked up a plastic lid off the floor and scratched their head. They did not wash their hands and continued to work in the kitchen area. b. Three dry cereal storage containers had a plastic cup left inside the bin. c. A dry flour storage bin had a plastic measuring cup left in the flour. d. Twenty plate covers were stacked wet. e. Snacks were stored undated and left open to air in a drawer. This had the potential to affect 74 residents who received food prepared in the kitchen. Two residents received hydration and nutrition solely through a feeding tube. Findings: A policy titled, "Hand Washing and Glove Use", documented, "Policy Guidelines for handwashing and glove use to promote safe and sanitary conditions throughout the dietary department must be followed. Procedure handwashing 1. Handwashing is a priority for infection control. 2. Hands must be washed prior to beginning work, after using the restroom, after smoking, when working with different food substance i.e. raw chicken to fresh fruit, and following contact with any unsanitary surface i.e. touching hair, sneezing, opening doors, dirty dishes, etc. 3.Washing procedure (See Handwashing Flow Chart on following page) a. Wet hands. b. Apply soap. c. lather, vigorously rubbing hands together for approximately 20 seconds. d. rinse hands to remove soap and debris. e. Dry hands with a disposable paper towel. Turn off water. f. Discard papertowel in a foot pedal trash can..." On 02/27/12 at 11:25 a.m., dietary aide #2 was observed to have dropped a plastic lid on the floor. After picking up the lid she continued to complete her serving task without washing her hands. At 11:26 a.m., dietary aide #2 was observed scratching her head. She then continued with her task without washing her hands. At 12:36 p.m., dietary aide #2 was observed taking 20 plates from the dish machine and stacked them wet. She placed the wet dishes onto a tray by the steam table for use during the evening meal. Three dry plastic cereal storage containers had a plastic cup for a scoop left in the bin. The flour bin had a plastic measuring cup in the flour. In a kitchen drawer, individual snacks had been placed into sandwich baggies. Five vanilla wafers, one cookie, and one bag of goldfish. No dates were found on the snacks. The snacks were open to air. At 12:41 p.m., dietary aide #2 was asked if she is to stack dishes wet. She stated, "No. They should be left to air dry but I did not have any room over there." On 02/28/12 at 1:10 p.m., dietary aide # 2 was asked if she should have washed her hands after picking up the lid she dropped on the floor. She stated, "Yes". She was asked if someone should wash their hands after scratching their head. She stated, "Yes". She was asked why scoops should not be left in the containers. She stated, "It allows for germs to get on the food". Dietary aide # 1 was asked if one should leave any kind of scoop in the plastic bins. She stated, "No. I don't know why those are in there." When asked why not. She stated, "It a way to cross contaminate." On 02/29/12 at 2:20 p.m., the administrator and the consulting dietitian were informed of the kitchen observation findings. The administrator stated, "It sounds like we need to do some inservices."

Based on observation; review of clinical records; and staff, family, and resident interviews; it was determined the facility failed to assess, monitor, and intervene in the management of pain for one (#5) of one sampled resident who had a physician's orders [REDACTED]. Findings: Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. An admission assessment, dated 06/06/11, documented the resident was cognitively intact. She was independent with dressing, eating, hygiene and required limited assistance with ambulation. A physician's orders [REDACTED]. A MAR, dated December 2011, documented, "[MEDICATION NAME] 25mcg/hr patch TD 72...apply patch topically every 72 hrs..." The MAR indicated [REDACTED]. The patch had not been changed on December 16th. A [MEDICATION NAME] ([MEDICATION NAME]) removal sheet documented a patch was removed on December 1, 4, 7, 10, 13, 25, 28 and 31. The form documented no patch was located (on the resident) on the 22nd. The resident's individual patient's narcotic record, documented [MEDICATION NAME] 25mcg/hr removed 12/1/11, 12/04/11, 12/10/11, 12/13/11, 12/19/11, 12/22/11, 12/25/11, 12/28/11 and 12/31/11. A fax, dated 12/16/11, documented, "...fax urgent (checked)...from (LPN #2)...subject need script faxed...resident name (resident #5)...drug refill request [MEDICATION NAME], drug dose 25mcg, drug use apply top (topically) (change) q 72 (hours)...patch is due to be changed this am please send ASAP..." The fax confirmation documented the fax was sent at 10:04 p.m. on 12/15/11. A drug order sheet documented, "[MEDICATION NAME] 25mch/hr...received 10 (amount)...12/19/11..." On 02/28/12 at 9:55 a.m., LPN #2 was asked when the medication was received. She stated, "On the 19th. The physician was out of the office. No other physician in the office would write the script (prescription)." On 02/28/12 at 4:30 p.m., the resident was asked if she remembered any time she did not get her pain patch changed. She stated, "Yes. In December it took about a week when they ran out." On 02/29/12 at 1:00 p.m., the resident was asked what her pain was like when she did not get her patch changed. She stated, "10+." At 1:25 p.m., the family of the resident was asked if they noticed any difference in the resident when she didn't have her patch changed. She stated, "She was hurting more than usual and missed some Christmas activities at church." On 03/01/12 at 9:00 a.m., the pharmacy who provided the [MEDICATION NAME] patch was called. The pharmacist was asked when the medication was ordered and picked up. She stated, "It was filled on the 19th and picked up on the 19th." A pharmacy ticket, documented [MEDICATION NAME]es were picked up from the pharmacy on 12/19/11. At 9:55 a.m., LPN #2 was asked her process for reordering [MEDICATION NAME]es. She stated, "When one is left in the box I call or fax the physician for a script and request till we get a script." At 10:00 a.m., the DON was asked if the facility had a back up plan if the attending physician could not be reached for a script. She stated, "No." At 1:30 p.m., the ADON was asked if there was a policy on reordering [MEDICATION NAME]es. She stated, "No but the pharmacy consultant says usually two to three days before running out." On 03/02/12 at 9:45 a.m., the administrator provided a letter which documented, "...if the facility is unable to receive a written hard script for one of our residents the medical director has agreed to provide assistance in writing a script for the resident needing assistance..." At 10:00 a.m., LPN #7 was asked her process for reordering [MEDICATION NAME]es. She stated, "I call the the doctor when the resident is down to two patches. That gives me two days to request for a hard script to be sent to the pharmacy." At 10:25 a.m., LPN #9 was asked her process for reordering [MEDICATION NAME]es. She stated, "I order [MEDICATION NAME]es when the resident is down to two patches."