Every finding on record at Kansas Veterans Home

The facility had a census of 84 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to ensure staff performed appropriate glove changing and hand hygiene for one resident, Resident (R) 78, when they did not remove their soiled gloves after urinary catheter care and continued to touch other surfaces and resident belongings. Findings included:- On 03/03/26 at 08:35 AM, Certified Nurse Aide (CNA) M donned a clean gown and gloves, and pulled down R78's sweatpants. CNA M informed R78 that she was going to perform catheter care. When CNA M finished, she did not remove her soiled glove and pulled up his sweatpants. CNA M pulled up R78's right pant leg, opened an alcohol wipe, and cleaned the spout of the leg bag. CNA M emptied the urine from the leg bag, used another alcohol wipe on the spout of the leg bag, with the same soiled gloves. CNA M dumped the urine in the toilet, pulled down R78's right pant leg over the catheter bag, adjusted his blankets, and then removed her gloves.On 03/03/25 at 08:45 AM, CNA M stated that it made sense to remove her gloves after catheter care and verified that she had forgotten to do so.On 03/05/25 at 10:36 AM, Administrative Nurse D stated the CNA recognized she should have removed her gloves after catheter care, sanitized her hands, and put on a pair of clean gloves. Administrative Nurse D stated she would provide extra training to the staff.The facility's Hand Hygiene for Staff, Residents, and Volunteers policy, dated 04/15/25, documented all staff members would comply with the current Centers for Disease Control and Prevention hand hygiene guidelines, as effective hand hygiene reduces the incidence of healthcare-associated infections. All personnel received training and competency validation on hand hygiene at the time of employment. If hands are not visibly soiled, an alcohol-based hand sanitizer may be used for routinely decontaminating hands before and after having direct contact with residents. Staff perform hand hygiene before donning gloves and after removing gloves. Staff change gloves during resident care if moving from a contaminated body site to a clean body site.

The facility had a census of 79 residents. The sample included 19 residents. The facility had four medication carts and four treatment carts. Based on observation, interview, and record review, the facility failed to date Resident (R)10, R13, R180, and R62's insulin (a hormone which allows cells throughout the body to uptake glucose) flex pen when opened and outdated and failed to discard expired stock medications. This deficient practice placed the affected residents at risk for ineffective medications. Findings included: - On 04/17/24 at 09:00 AM, observation of the facility's 500 nurse treatment cart revealed the following: R180's Lantus (long-acting insulin) flex pen lacked an open date and discard date. R10's Lantus flex pen lacked an open and discard date. R13'a Fiasp (fast acting) flex pen lacked an open and discard date. On 04/17/24 at 08:20 AM, observation of the facility's 500 nurse medication cart revealed the following: One bottle of acetaminophen (pain medication) 325 milligrams (mg) 100 tablets, expired February 2024. On 04/17/24 at 09:12 AM, observation of the facility's 300 nurse treatment cart revealed the following: R62's Lantus flex pen lacked an open and discard date. On 04/17/24 at 09:14 AM, Licensed Nurse (LN) G verified that Lantus lacked an open date and a discard date. On 04/21/24 at 11:00 AM, Administrative Nurse D verified the nurses were to date the insulin with an opened and discard date. Administrative Nurse D said staff were to discard expired stock medications. Medlineplus.gov directs open, unrefrigerated vials or pens of Lantus and Fiasp can be used within 28 days but after that time they must be discarded. The Medication Administration policy dated 04/22/24, documented that insulin pens would be clearly labeled with the resident's name or other identifying information. The policy documented before administering insulin with an insulin pen, the nurse would verify that the correct pen is used for that resident. The drugs dispensed in the manufacturer's original container would be labeled with the manufacturer's expiration date and the nurse would check the expiration date of each medication before administering it. The policy documented all expired medications would be removed from the active supply, regardless of the amount remaining. The facility failed to date R10, R13, R180, and R62s' flex pen insulin with the date opened and discard date and failed to discard expired stock medications placing the residents at risk for ineffective medication.

The facility had a census of 79 residents. The sample included 19 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported to the facility that staff failed to follow the physician's orders in response to blood glucose monitoring for Resident (R)62, who received insulin (controls the amount of sugar in the blood by moving into the cells). This placed the resident at risk for physical decline and an ineffective medication regimen. Findings included: - The Electronic Medical Record (EMR) for R62 documented diagnoses of diabetes mellitus type two (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), dementia with behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), delusional disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue), bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypertension (high blood pressure), and posttraumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R62 had moderately impaired cognition, and required substantial/maximum assistance with toileting, bathing, dressing, personal hygiene, and transfers. The assessment revealed R62 received insulin and hypoglycemic (a group of medications used to help reduce the amount of sugar present in the blood) medication. R62's Care Plan, dated 02/07/24, initiated on 05/23/23, directed staff to monitor for signs of high and low blood sugars and administer medications as ordered by the physician. The Physician's Order, dated 05/21/23, directed staff to administer Humulog (fast-acting insulin), five units as needed for blood sugar over 250 milliliters (ml) per deciliter (dl). The Physician's Order, dated 08/11/23, directed staff to obtain R62's blood sugar four times per day for monitoring. R62's Treatment Administration Record, dated February 2024, documented the following days R62's blood sugar was above 250 ml/dl and the as-needed Humalog insulin was not administered as ordered. 02/11/24 at 08:27 AM - 293 mm/dl 02/13/24 at 11:57 AM - 258 mm/dl 02/14/24 at 07:36 PM - 275 mm/dl R62's Treatment Administration Record, dated March 2024, documented the following days R62's blood sugar was above 250 ml/dl and the as-needed Humalog insulin was not administered. 03/03/24 at 03:54 PM - 281 mm/dl 03/06/24 at 11:18 AM - 264 mm/dl 03/11/24 at 03:03 PM - 307 mm/dl 03/13/24 at 10:00 AM - 252 mm/dl 03/28/24 at 02:03 PM - 270 mm/dl 03/31/24 at 11:10 AM - 254 mm/dl R62's Treatment Administration Record, dated April 2024, documented the following days R62's blood sugar was above 250 ml/dl and the as-needed Humalog insulin was not administered. 04/16/24 at 11:07 AM - 265 mm/dl The CP's Medication Regimen Review for the months of February and March 2024 lacked evidence the CP identified and reported R62's Humalog was not administered per orders as related to the blood glucose monitoring. On 04/18/24 at 08:30 AM, observation revealed R62 in the dining room eating breakfast. On 04/22/24 at 11:30 AM, Administrative Nurse D stated the CP had not notified her that the insulin was not administered in response to the resident's blood glucose levels as ordered by the physician. The facility's Consultant Pharmacist policy, dated 04/22/23, documented the Pharmacist shall perform monthly reviews of the methods, procedures, storage, administration, disposal, and record-keeping of drugs and biologicals. The findings of irregularities shall be given to the residents attending provider, nursing department, or other departments as appropriate. The resident-specific recommendations are documented in the resident's active medical record. The facility's CP failed to identify and report to the facility that staff failed to follow the physician's orders in response to blood glucose monitoring for R62. This placed the resident at risk for physical decline and an ineffective medication regimen.

The facility had a census of 79 residents. The sample included 19 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to administer medication as ordered by the physician in response to blood glucose monitoring for Resident (R) 62, who received insulin (controls the amount of sugar in the blood by moving into the cells). This placed the resident at risk for physical decline and an ineffective medication regimen. Findings included: - The Electronic Medical Record (EMR) for R62 documented diagnoses of diabetes mellitus type two (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), dementia with behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), delusional disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue), bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypertension (high blood pressure), and posttraumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R62 had moderately impaired cognition, and required substantial/maximum assistance with toileting, bathing, dressing, personal hygiene, and transfers. The assessment revealed R62 received insulin and hypoglycemic (a group of medications used to help reduce the amount of sugar present in the blood) medication. R62's Care Plan, dated 02/07/24, initiated on 05/23/23, directed staff to monitor for signs of high and low blood sugars and administer medications as ordered by the physician. The Physician's Order, dated 05/21/23, directed staff to administer Humulog (fast-acting insulin), five units as needed for blood sugar over 250 milliliters (ml) per deciliter (dl). The Physician's Order, dated 08/11/23, directed staff to obtain R62's blood sugar four times per day for monitoring. R62's Treatment Administration Record, dated February 2024, documented the following days R62's blood sugar was above 250 ml/dl and the as-needed Humalog insulin was not administered as ordered. 02/11/24 at 08:27 AM - 293 mm/dl 02/13/24 at 11:57 AM - 258 mm/dl 02/14/24 at 07:36 PM - 275 mm/dl R62's Treatment Administration Record, dated March 2024, documented the following days R62's blood sugar was above 250 ml/dl and the as-needed Humalog insulin was not administered. 03/03/24 at 03:54 PM - 281 mm/dl 03/06/24 at 11:18 AM - 264 mm/dl 03/11/24 at 03:03 PM - 307 mm/dl 03/13/24 at 10:00 AM - 252 mm/dl 03/28/24 at 02:03 PM - 270 mm/dl 03/31/24 at 11:10 AM - 254 mm/dl R62's Treatment Administration Record, dated April 2024, documented the following days R62's blood sugar was above 250 ml/dl and the as-needed Humalog insulin was not administered. 04/16/24 at 11:07 AM - 265 mm/dl On 04/18/24 at 08:30 AM, observation revealed R62 in the dining room eating breakfast. On 04/22/24 at 09:17 AM, Licensed Nurse (LN) H stated R62 received five units of Humalog insulin if the resident's blood sugar was over 250 mm/dl. LN H said the physician was notified if R62's blood sugar got worse. On 04/22/24 at 11:30 AM, Administrative Nurse D verified R62 did not receive the as-needed insulin as ordered for the above dates and stated she would contact the physician to see if the order could be changed to administer if R62's blood sugar was over 300 mm/dl. The facility's Blood Glucose Monitoring Procedure, dated 12/15/22, documented that staff should verify the order for the procedure and document the blood glucose reading. Staff document any unusual findings and administer prescribed medications, including injections for the treatment of high or low blood glucose. The facility failed to administer medication as ordered by the physician in response to blood glucose monitoring for R62 who received insulin. This placed the resident at risk for physical decline and an ineffective medication regimen.

The facility reported a census of 72 residents. Based on observation, interview and record review, the facility failed to ensure staff disinfected the facility's multi resident use glucometer and failed to ensure staff administered an inhaler, insulin and eye drops to a resident in isolation were sanitized in an effective manner before returning them to the medication cart to prevent cross contamination. Findings included: - Observation, on 08/03/22 at 11:19 AM, revealed Licensed Nurse (LN) L, obtained resident (R)18's blood glucose with a multi-use glucometer (a glucometer that staff used for multiple residents.) Upon completion, LN L proceeded to use an alcohol prep pad to wipe the surface of the glucometer. LN L stated there were antibacterial wipes somewhere, but she thought the alcohol wipe was sufficient to sanitize the glucometer. LN L stated she had four more residents to obtain blood glucose levels from. Interview, on 08/03/22 at 11:30 AM, with Administrative Nurse F, revealed she thought the alcohol wipe or antibacterial wipes available for use were to sanitize the glucometer. Interview, on 08/03/22 at 11:45AM, with Administrative Staff A, revealed staff should follow the manufacturer's recommendations to clean and disinfect the glucometer. Administrative Staff A confirmed the manufacturer's recommendations indicated isopropyl alcohol or a cloth damped with soapy water were acceptable to clean the glucometer, but to disinfect the glucometer a solution of bleach or an approved list of wipes was needed for sanitization. Administrative Staff A stated eight residents on this unit utilized the glucometer. The glucometer manufacturer's recommendations included using a commercially available EPA (environmental protective agency) registered disinfectant detergent of germicide wipe. The manufacturer's recommendations indicated to clean the glucometer with isopropyl alcohol 70-80%, and to disinfect the meter with a dilution of 1:10 bleach solution or a germicide wipe. The facility failed to effectively sanitize this multi resident use glucometer to prevent the spread of infection among the residents' of the facility. - Observation, on 08/04/22 at 09:24 AM, revealed Licensed Nurse (LN) J, donned PPE to administer medications to Resident (R)54 in droplet isolation for exposure to COVID. LN J entered the resident's room and set the resident's inhaler, box that contained [MEDICATION(S)] eye drops (medication to the eye used to treat high pressure in the eye due to [CONDITION(S)] [abnormal condition of elevated pressure within an eye caused by obstruction to the outflow]), [MEDICATION(S)] insulin pens, and [MEDICATION(S)] insulin pens on a paper towel on the resident's bedside table. After the resident used the inhaler, eye drops, and insulin pens, LN J placed them directly on the resident's table. Upon exit of the room, LN placed these medications directly on the medication cart. Interview, on 08/04/22 at 09:40 AM, with LN J, revealed she should sanitize the eye drop box, insulin pens and inhaler with an alcohol wipe. Interview, on 08/04/22 at 10:30 AM with Administrative Nurse F, revealed she would expect nursing staff to sanitize anything that came in contact with a surface in a droplet isolation room with an appropriate sanitizer. The facility's policy for Infection Control and Cleaning of Non-Critical, Reusable Resident Care Equipment, dated 03/03/21, instructed staff to clean equipment immediately after use on residents with contact precautions. Staff were instructed to follow product recommendations for disinfectants/sanitizing agents and instructed staff to clean and disinfect the insulin pens per the manufacturer recommendations. The facility failed to ensure staff disinfected the multi resident use glucometer and failed to ensure staff administered an inhaler, insulin and eye drops to a resident in isolation were sanitized in an effective manner before returning them to the medication cart to prevent cross contamination.

The facility reported a census of 72 residents with 20 residents sampled. Based on observation, interview and record review, the facility failed to review and revise the care plan for this dependent Resident (R)17, regarding toileting. Findings included: - Review of the Resident (R)17's electronic medical record (EMR), electronically signed orders under the Orders tab, dated 06/02/22, documented the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The modification of the significant change Minimum Data Set (MDS), dated [DATE], documented the staff assessment of the resident's cognition revealed severely impaired cognition. She had no rejection of care. She required extensive assistance of one staff for toilet use and was frequently incontinent of bladder. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 04/15/22, documented the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS, dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of two, indicating severe cognitive impairment. She had no rejection of care. She required extensive assistance of one for toileting and was frequently incontinent of bladder. The care plan for bowel and bladder, revised 04/23/22, instructed staff to provide peri-care (the cleansing of the genitals) with each incontinent episode. The care plan lacked staff instructions on a toileting plan for this resident. Review of the resident's EMR, under the Tasks tab, from 07/04/22 through 08/01/22, documented the resident required limited to total assistance of one to two staff for toileting and had multiple episodes of bladder continence, as well as bladder incontinence. Review of the resident's EMR, under the Misc (miscellaneous) tab, revealed a Bladder Retraining Record, dated 10/11/22 through 10/13/22, which documented the resident had multiple episodes of bladder continence and incontinence. On 08/03/22 at 11:15 AM, the resident sat in the commons area watching TV, where she remained until 11:59 AM, when Certified Nurse Aide (CNA) NN propelled the resident to the dining room table for lunch. There was no offer to toilet before the meal. At 12:41 PM, CNA M propelled the resident from the dining table back into the commons area where the resident remained until 01:00 PM, when Certified Medication Aide (CMA) S propelled the resident to her room to toilet. The resident's brief observed to be saturated with urine. CMA S provided peri-care and failed to change her gloves after removing the wet brief, providing peri-care and putting on a clean brief. On 08/03/22 at 11:24 AM, CNA M stated staff needed to toilet the resident every two hours. If the resident became restless, then staff knew she needed to be toileted. The resident was able to be continent of urine if staff got her to the bathroom in time. The resident did not have a toileting plan other than for staff to toilet her every two hours. On 08/04/22 at 10:10 AM, CNA N stated staff tried to toilet the resident every two hours. The resident was able to be continent of urine if staff got her to the bathroom in time. On 08/04/22 at 10:29 AM, Licensed Nurse (LN) G stated staff would complete a 72 -hour voiding diary on residents who were a new admission, re-admissions or who had a change in condition. The voiding diaries would help staff develop an individualized toileting plan for residents. LN G stated the staff toilet her every two hours, but the resident had usually been incontinent by that time. The resident did not have a toileting plan, but she could be continent of bladder at times. All nurses were able to review and revise the care plans from their computers. On 08/05/22 at 09:03 AM, Administrative Nurse D stated all residents should have a toileting program individualized to their needs. Staff need to help the residents maintain their continence. The voiding diary should be used to develop an appropriate toileting program for each resident. Nurses should update care plans with any changes in the resident's treatments or condition. The facility policy for Person-Centered Care Planning, revised 09/09/21, included: Any changes in a resident's condition always requires changes to be made in the plan of care either by change in individual approaches or by the addition of new problems to the plan of care. The facility failed to review and revise the care plan for this incontinent dependent resident to include a toileting plan.

The facility reported a census of 72 residents with 20 residents sampled, including two residents reviewed for activities of daily living (ADL)s. Based on interview, observation, and record review, the facility failed to provide two dependent Residents (R)12 and R 42 appropriate assistance with ADLs, regarding R 12 for dirty clothing and R 42 regarding a dirty lap blanket. Findings included: - Review of Resident (R)12's electronic medical record (EMR), under the Med Diag (medical diagnosis) tab, revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The significant change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment. The resident required extensive assistance of two staff for dressing. He had impairment in range of motion (ROM) on both sides of upper and lower extremities. The Activities of Daily Living (ADL) Care Area Assessment (CAA), dated 11/24/21, did not trigger. The Cognitive Loss/Dementia CAA, dated 11/24/21, documented the resident had an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The quarterly MDS, dated [DATE], documented the resident had a BIMS score of 0, indicating severe cognitive impairment. He required total assistance of two staff for dressing and had impairment in ROM on both sides of upper and lower extremities. The care plan for ADLs, revised 07/23/22, instructed staff the resident required one staff assistance for dressing. Review of the resident's EMR under the Tasks tab, from 07/06/22 through 08/03/22, revealed the resident required extensive to total assistance of one to two staff for dressing. On 08/03/22 at 09:51 AM, Certified Medication Aide (CMA) R and Certified Nurse Aide (CNA) Q transferred the resident from his wheelchair to the recliner with the use of a full mechanical body lift. The resident's navy blue t-shirt had food debris around the collar. Staff did not offer to change the resident's shirt or attempt to clean him. On 08/03/22 at 10:10 AM, Licensed Nurse (LN) H cleaned the resident's eyes with a soft cloth. Staff made no attempt to clean the resident's dirty t-shirt and no offer to change his soiled shirt. On 08/03/22 at 02:06 PM, LN H and CMA R propelled the resident into his room to provide peri care. Staff transferred the resident from his geri-chair (a reclined moveable chair) to his bed with the use of the full mechanical lift. The staff provided cares and prepared to transfer the resident back into his geri-chair to return to the commons area. Upon request, staff changed his dirty soiled shirt before taking him back out to the commons area. On 08/03/22 at 09:51 AM, CNA Q confirmed the resident had on a dirty shirt. On 08/03/22 at 02:21 PM, CNA R stated staff should change residents' clothes if they are dirty. On 08/03/22 at 02:21 PM, Licensed Nurse (LN) H stated she had seen the front of the resident's shirt had something on it, but thought it was just discoloration. LN H stated staff should change resident's clothes when they become dirty. On 08/05/22 at 09:03 AM, Administrative Nurse D stated staff should be ensuring all residents are wearing clean clothing. The facility policy for Resident Rights, effective November 24, 2021, included: All residents have the right to be treated with consideration, respect and dignity. The facility failed to ensure this dependent resident had on clean clothing. - Review of Resident (R)42's electronic medical record (EMR), under the Med Diag (medical diagnosis) tab, included a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The significant change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. He required extensive assistance of two staff for dressing and personal hygiene. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 04/01/22, did not trigger. The quarterly MDS, dated [DATE], documented the staff assessment for cognition revealed severe cognitive impairment. The resident required total assistance of two staff for dressing. The ADL care plan, revised 07/02/22, instructed staff the resident required one staff assistance for dressing. Review of the resident's EMR under the Tasks tab, from 07/06/22 through 08/01/22, revealed the resident required total dependance of one staff for personal hygiene and dressing. On 08/03/22 at 07:51 AM, Certified Nurse Aide (CNA) Q propelled the resident to the nurses' desk. The resident's dark blue lap blanket had a large area of dried food on the end of the blanket. On 08/03/22 at 02:28 PM, the resident continued to have the large area of dried food on his blanket. On 08/04/22 at 09:01 AM, the resident sat in his geri-chair ( a reclined moveable chair) in the commons area covered with the dark blue blanket which contained two large areas of dried food. On 08/03/22 at 09:25 AM, Certified Medication Aide (CMA) R stated staff should ensure resident's lap blankets are clean. If they become soiled with food or something, they should be changed, and the dirty blanket taken to the laundry. On 08/04/22 at 09:58 AM, Certified Nurse Aide (CNA) O stated staff need to be sure the residents have clean blankets. CNA O stated the resident's blanket had two large areas of food which had dried. On 08/04/22 at 09:54 AM, Licensed Nurse (LN) I stated staff should ensure the resident's blankets are clean. The staff are responsible for ensuring the residents' have clean clothing and blankets. On 08/05/22 at 09:03 AM, Administrative Nurse D stated it was the expectation for staff to ensure residents have clean lap blankets. The facility policy for Resident Rights, effective November 24, 2021, included: All residents have the right to be treated with consideration, respect and dignity. The facility failed to ensure this dependent resident had a clean lap blanket.

The facility reported a census of 72 residents with 20 residents sampled, including two residents reviewed for Pressure Ulcers (PU). Based on interviews, record review, and observations, the facility failed to promote the prevention of pressure ulcer development for one Resident (R)42, at risk for the development of pressure ulcers. Findings included: - Review of Resident (R)42's electronic medical record (EMR), under the Med Diag (medical diagnosis) tab, revealed the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The significant change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. He required extensive assistance of two staff for bed mobility and used a wheelchair. The resident was at risk for the development of pressure ulcers (PU) (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) and had no unhealed PUs at the time of the assessment. He had a pressure relieving device for his bed and his chair. The Pressure Ulcer Care Area Assessment (CAA), dated 04/01/22, documented the resident had generalized muscle weakness and required staff assistance with transfers and activities of daily living (ADLs). The quarterly MDS, dated [DATE], revealed the staff assessment for cognition revealed severe cognitive impairment. He required total assistance of two staff for bed mobility and transfers. He was at risk for the development of PUs with an unhealed PU at the time of the assessment. The resident had one stage II PU (partial-thickness skin loss into but no deeper than the dermis), which was not present on admission. He had a pressure reducing device for his chair and bed, was on a turning and repositioning program and a nutrition or hydration interventions to manage skin problems. He received PU care. The care plan for skin, revised 07/02/22, instructed staff the resident had expected skin breakdown due to his disease process and his admission to hospice. Staff were to ensure the resident had a pressure relieving cushion in his wheelchair and a pressure relieving mattress. Review of the resident's EMR, under the Assessment tab, revealed Braden assessments (an assessment to predict the risk of the development of PUs), dated 06/23/22 and 04/01/22, which placed the resident at a moderate risk for the development of PUs. Review of the resident's EMR, under the Orders tab, revealed an order to cleanse the open area to the resident's left coccyx with normal saline (NS), apply skin prep (skin protection), and apply a [MEDICATION(S)] dressing (an absorbent foam dressing), every three days until resolved, ordered 07/29/22. Review of the resident's EMR, under the Assessments tab, included Wound Assessment Forms, which documented the following: On 07/21/22, the resident developed a stage II PU to his coccyx (left buttocks area), which measured 0.5 length (L) by 0.3 width (W) by 0.1 depth (D) centimeters (cm). The wound had well defined edges and no drainage. The treatment was to cleanse the area with NS, apply skin prep and apply a [MEDICATION(S)] dressing (a dressing with gel-like properties to absorb excretions from the wound and protect the wound debris and potentially infection causing bacteria), ordered 07/21/22. On 07/28/22, the resident's stage II PU measured 0.5 L by 0.3 W by 0.1 D cms. The wound bed was 100% red/pink and there was no drainage from the wound. The treatment was to cleanse the open area to the left coccyx with NS, apply skin prep and cover with a [MEDICATION(S)] dressing, ordered 07/28/22. On 08/03/22, the resident's stage II PU measured 0.1 L by 0.1 W by 0.1 D cms. The wound had bright red granulation (new vascular tissue in granular form on an ulcer or the healing surface of a wound) tissue and no drainage. There was no change in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] On 08/03/22 at 07:51 AM, the resident sat in his geri-chair (a reclining wheelchair) in front of the nurse's station. The wheelchair had a pressure relieving cushion in place. At 08:00 AM, staff propelled the resident into the commons area and placed him in front of the TV, where he remained until 08:50 AM. At 08:50 AM, Licensed Nurse (LN) H propelled the resident from the commons area to the dining table for breakfast. Certified Medication Aide (CMA) R assisted the resident with his meal. At 09:45 AM, CMA R removed the resident from the dining table and propelled him to the commons area. At 10:25 AM, CMA R and Certified Nurse Aide (CNA) P transfer the resident from his geri-chair to a recliner with the use of a full body mechanical lift. The staff failed to move the pressure relieving cushion from the resident's geri-chair to the recliner and sat the resident down directly onto the recliner without the use of a pressure relieving device. On 08/03/22 at 02:28 PM, CNA Q and CNA P, transferred the resident from his geri-chair to the recliner with the use of the full body mechanical lift. The staff failed to move the pressure relieving cushion from the resident's geri-chair to the recliner and sat the resident down directly onto the recliner without the use of a pressure relieving device. On 08/04/22 at 06:49 AM, LN HH and CNA OO, entered the resident's room to do a dressing change to the open area on his left buttocks area. Staff rolled the resident to his left side and removed the dressing, dated 08/03/22. The open area measured 0.1 L by 0.1 W by 0.1 D. The wound bed was pink and had no drainage. LN HH cleansed the wound with NS and covered the open area with a [MEDICATION(S)] dressing, dated and initialed. On 08/03/22 at 09:25 AM, CMA R stated staff should turn and reposition the resident every two hours due to his pressure ulcers. CMA R stated the resident had a pressure relieving cushion in his wheelchair, but staff did not put the cushion in the recliner when they transferred him because the recliner was foam and he did not need a cushion in the recliner. On 08/04/22 at 09:58 AM, CNA O stated the resident's cushion was to be kept in his wheelchair. Staff did not put the cushion into the resident's recliner because it needed to be kept in the wheelchair. On 08/02/22 at 08:35 AM, LN H stated the PU to the resident's left buttocks developed in house. On 08/03/22 at 02:33 PM, Administrative Nurse E stated the resident did not have a pressure relieving cushion in his recliner because he was not care planned to have one. The recliner seat was not a pressure relieving surface but was foam, which was sufficient. Administrative Nurse E confirmed the PU to the resident's left buttocks developed in house. On 08/04/22 at 09:54 AM, LN I stated the resident acquired the stage II PU to his left buttocks at the facility. The resident had a pressure relieving cushion in his wheelchair, but staff did not transfer the cushion to the recliner when they put the resident in the recliner. On 08/05/22 at 09:03 AM, Administrative Nurse D stated the resident required a cushion in his wheelchair and the recliner due to being at risk for the development of PUs. The facility policy for Skin Injury Protocol, effective October 13, 2020, included: Upon admission, each resident will be evaluated for risk of development of pressure injuries and appropriate interventions for prevention. Interventions for prevention will be evaluated for appropriateness. The facility failed to promote the prevention of pressure ulcer development for this dependent resident at risk for PUs.

The facility reported a census of 72 residents with 20 selected for review, which included one resident reviewed for urinary incontinence and one resident reviewed for urinary catheter. Based on observation, interview and record review, the facility failed to ensure one resident (R)38 received proper catheter maintenance, and one resident (R) 17 received timely toileting opportunities. Findings included: - Review of Resident (R)38's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change Minimum Data Set (MDS), dated [DATE] assessed the resident with normal cognitive function, and required extensive assistance of two staff for bed mobility, transfer, dressing, toilet use, and personal hygiene. The resident had no impairment in functional range of motion of the upper and lower extremities. The resident had a urinary catheter. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 06/20/22, assessed the resident had urinary incontinence due to neuromuscular dysfunction of the bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system) and chronic (persisting for a long period, often for the remainder of the person's life) kidney disease. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential CAA, dated 06/20/22, assessed the resident required increased assistance due to the absence of both legs and increased weakness due to end stage renal disease and congestive heart failure (a condition with low heart output and the body becomes congested with fluid). The Care Plan, reviewed 04/16/21, instructed staff the resident had neuromuscular dysfunction of the bladder (bladder did not empty completely and had increased urge to urinate). The Care Plan lacked interventions for the use of a urinary catheter. Observation on 08/02/22 at 01:08 PM, revealed the resident in droplet precautions due to pneumonia. The resident responded slowly to questions. The resident had a urinary catheter. Observation, on 08/04/22 at 08:02 AM, revealed the resident positioned in bed with red drainage on the bed linen around his groin area and the urinary catheter with the bulb still inflated on the floor beside his bed. Interview on 08/04/22 at 08:02 AM, Licensed Nursing Staff (LN) GG confirmed the resident pulled his catheter out. Since the resident received hospice services, she would notify the physician and hospice for further orders. Observation, on 08/05/22 at 08:02 AM, revealed the urine collection bag and approximately six inches of tubing lay directly on the floor. LN L stated hospice inserted the catheter on 08/04/22, and confirmed the catheter lacked an anchoring device and told Certified Nursing Staff (CNA) MM to apply one. Interview, on 08/05/22 at 08:08 AM, with CNA MM, revealed the previous shift reported the resident attempted to pull on his catheter during the night. Interview on 08/05/22 at 11:01 AM, with Administrative Nurse DD, revealed she would expect staff to ensure the catheter had an anchoring device and keep the urine collection bag off the floor and in a dignity bag. The facility policy Bladder Catheter Procedures, dated 07/07/22, instructed staff to secure the catheter to the resident's leg, place the urine bag and tubing in a dignity bag to prevent embarrassment and avoid letting the drainage bag and tubing touch the floor. The facility failed to ensure staff secured this resident's catheter with an anchoring device, failed to secure the urine collection from touching the floor and failed to apply a dignity bag. - Review of the Resident (R)17's electronic medical record (EMR), electronically signed orders under the Orders tab, dated 06/02/22, documented the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The modification of the significant change Minimum Data Set (MDS), dated [DATE], documented the staff assessment of the resident's cognition revealed severely impaired cognition. She had no rejection of care. She required extensive assistance of one staff for toilet use and was frequently incontinent of bladder. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 04/15/22, documented the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS, dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of two, indicating severe cognitive impairment. She had no rejection of care. She required extensive assistance of one for toileting and was frequently incontinent of bladder. The care plan for bowel and bladder, revised 04/23/22, instructed staff to provide peri-care (the cleansing of the genitals) with each incontinent episode. Review of the resident's EMR, under the Tasks tab, from 07/04/22 through 08/01/22, documented the resident required limited to total assistance of one to two staff for toileting and had multiple episodes of bladder continence, as well as bladder incontinence. Review of the resident's EMR, under the Misc (miscellaneous) tab, revealed a Bladder Retraining Record, dated 10/11/22 through 10/13/22, which documented the resident had multiple episodes of bladder continence and incontinence. On 08/03/22 at 11:15 AM, the resident sat in the commons area watching TV, where she remained until 11:59 AM, when Certified Nurse Aide (CNA) NN propelled the resident to the dining room table for lunch. There was no offer to toilet before the meal. At 12:41 PM, CNA M propelled the resident from the dining table back into the commons area where the resident remained until 01:00 PM, when Certified Medication Aide (CMA) S propelled the resident to her room to toilet. The resident's brief observed to be saturated with urine. CMA S provided peri-care and failed to change her gloves after removing the wet brief, providing peri-care and putting on a clean brief. On 08/03/22 at 11:24 AM, CNA M stated staff needed to toilet the resident every two hours. If the resident became restless, then staff knew she needed to be toileted. The resident was able to be continent of urine if staff got her to the bathroom in time. The resident did not have a toileting plan other than for staff to toilet her every two hours. CNA M stated she should have changed her gloves after she removed the resident's wet brief. On 08/04/22 at 10:10 AM, CNA N stated staff tried to toilet the resident every two hours. The resident was able to be continent of urine if staff got her to the bathroom in time. On 08/04/22 at 10:29 AM, Licensed Nurse (LN) G stated staff would complete a 72 -hour voiding diary on residents who were a new admission, re-admissions or who had a change in condition. The voiding diaries would help staff develop an individualized toileting plan for residents. LN G stated the staff toilet her every two hours, but the resident had usually been incontinent by that time. The resident did not have a toileting plan, but she could be continent of bladder at times. Staff should change their gloves while performing peri-care after removing the soiled brief and putting on a clean brief. On 08/05/22 at 09:03 AM, Administrative Nurse D stated all residents should have a toileting program individualized to their needs. Staff need to help the residents maintain their continence. The voiding diary should be used to develop an appropriate toileting program for each resident. Staff should change their gloves while performing peri-care after removing the soiled brief and putting on a clean brief. The facility policy for Bladder Management, effective 01/01/2000, included: Staff should observe and record the resident's voiding pattern and revise the toileting schedule to meet resident's needs. The Unit Coordinator will develop a toileting schedule based on the resident's voiding pattern identified by the 3-day voiding diary. The facility policy for Perineal Care Procedure, effective April 2, 2019, included: The purpose of the policy was to ensure staff's knowledge to cleanse the perineum to prevent infection and odor. The facility failed to develop an individualized toileting program for this dependent resident.

The facility reported a census of 72 residents. The sample of 20 residents included six residents sampled for respiratory care. Based on observation, interview, and record review, the facility failed to provide appropriate respiratory care in maintaining respiratory equipment to prevent the spread of infection, consistent with standards of practice and person-centered care plan for three Residents. (R)31 related to storage and labeling/dating of oxygen tubing and maintaining distilled water in the humidifier bottle of the oxygen concentrator; R 38 related to labeling/dating oxygen tubing; and R 54 related to storage of the nebulizer kit. Findings included: - Review of Resident's (R)31's Physician Orders, dated 07/18/22, revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) dated [DATE], documented the Brief Interview for Mental Status (BIMS) score of 12 , which indicated moderate cognitive impairment. He required extensive assistance with transfers, and he used oxygen. The quarter MDS, dated [DATE], documented no changes from the above. The Care Area Assessment (CAA), dated 03/17/22, documentation lacked address of the resident's oxygen use. The Care Plan, (CP), dated 06/21/22, directed staff the resident required oxygen therapy. Staff were to provide the resident supplemental oxygen as needed. Provide care and maintenance to oxygen devices per facility protocol. Replace the cannula and concentrator per the facility policy. All tubing should be kept in an infection control bag when not in use to prevent cross contamination. Label/date the oxygen tubing and the humidifier bottle with the date of change/replacement. The Physician Orders, dated 06/06/2022, included Oxygen via nasal cannula at three liters per minute. All tubing to be kept in infection control bag and assess bag for replacement. Replace the O2 tubing, label with date exchanged. On 08/02/22 at 09:49 AM, the oxygen concentrator lacked water in the undated humidifier bottle. The oxygen tubing laid directly on the floor and lacked a bag to store the undated tubing when not in use. On 08/02/22 at 09:49 AM, Certified Nurse Aide (CNA) P, confirmed the above findings. She stated the third shift nurse was responsible for changing out the oxygen equipment weekly and all nursing staff should be checking for the water level in the humidifier bottle as well as the proper storage of the tubing when not in use. CNA P stated she would notify the nurse when the oxygen concentrator's humidifier bottle needed water and the resident needed a bag for the oxygen tubing storage. On 08/02/22 at 10:05 AM, Licensed Nurse (LN) H, entered the resident's room and verified the above findings. She stated the oxygen tubing and humidifier bottle should be labelled with the date the staff replaced it. The humidifier bottle should have distilled water to prevent drying out the resident's airway and there should be a bag available to store the oxygen tubing and cannula when not in use to prevent cross contamination. On 08/04/22 at 11:06 AM, the resident's undated oxygen tubing and cannula was wrapped around the resident's wheelchair (W/C) handle. The w/c lacked a bag to store the oxygen tubing and cannula when not in use to prevent cross contamination. On 08/04/22 at 11:10 AM, Administrative Nurse DD confirmed the resident's undated oxygen tubing and cannula were wrapped around the w/c handle and not stored in a bag to prevent cross contamination. She stated the expectation was that staff should label/date the oxygen tubing and the humidifier bottles and should be changed weekly. The humidifier bottles should have distilled water in the bottle to prevent drying of the resident's airway, and the oxygen tubing and cannula should be stored in a bag when not in use to prevent cross contamination. The facility policy for Oxygen Administration Safety, dated 08/27/2020, documentation included staff to store all cannulas, masks and tubing in a designated storage bag when not in use, nasal cannulas, masks, and tubing would be changed weekly. The storage bag would be changed and dated weekly or more often if needed. Fill the humidifier bottles to the fill line as indicated, using distilled water. Replace humidifier bottles once a week. Humidifier should be labeled with date and time changed. The facility failed to provide appropriate respiratory care in maintaining respiratory equipment to prevent the spread of infection, consistent with standards of practice and person-centered care plan for this resident, who required oxygen. - Review of Resident (R)54's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with normal cognitive function, and required extensive assistance of one person for transfer, dressing, toilet use, and personal hygiene. The resident had no functional impairment in range of motion in the upper and lower extremities. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 04/08/22, assessed the resident required increased assistance with ADL's. The Care Plan, reviewed 07/16/22, instructed staff the resident had [CONDITION(S)] and used supplemental oxygen. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation, on 08/02/22 at 10:30 AM, revealed the resident in contact isolation for exposure to COVID. The resident's nebulizer equipment laid directly on a table with packages of food, papers, neck pillow and generalized clutter. A gallon container of distilled water was positioned directly on the floor in the resident's room. The resident wore oxygen which was connected to an oxygen concentrator with a humidifier (a device filled with water to humidify the oxygen). The oxygen concentrator contained adhesive residue and grime. Observation, on 08/05/22 at 10:45AM, revealed the resident's nasal cannula was draped over the oxygen concentrator and part of the tubing laid directly on the floor, with the oxygen concentrator running and the resident was absent from the room. Interview, on 08/05/22 at 11:50 AM, with the resident, revealed staff used the distilled water to fill his humidifier on the oxygen concentrator. Observation, on 08/05/22 at 12:00 PM, with Administrative Nurse DD, confirmed staff should store the nebulizer equipment in a sanitary manner and the keep the oxygen concentrator clean, with the tubing in the sanitary bag attached to the concentrator. Staff should keep the distilled water off the floor. The facility policy Nebulizer Treatment, reviewed 04/28/20, instructed staff to remove the tubing, wash the components and air dry on a clean cloth and then store the parts in a sealable plastic bag or designated container. The facility policy Oxygen Administration Safety, reviewed 08/27/20, instructed staff to store all cannulas, masks and tubing in a designated storage bag when not in use. Staff instructed to turn off the oxygen if not in use. The facility failed to ensure staff provided oxygen in a sanitary manner and failed to store this resident's nebulizer equipment in a sanitary manner to prevent the spread of infection. - Review of Resident (R)38's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change Minimum Data Set (MDS), dated [DATE] assessed the resident with normal cognitive function . The resident required oxygen therapy. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential CAA, dated 06/20/22, assessed the resident required increased assistance due to the absence of both legs and increased weakness due to end stage renal disease and congestive heart failure (a condition with low heart output and the body becomes congested with fluid). The Care Plan, reviewed 07/30/33, instructed staff the resident received hospice services and supplied the oxygen supplies and concentrator. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 08/02/22 at 01:08 PM, revealed the resident in droplet precautions due to pneumonia. The resident responded slowly to questions. The resident received oxygen through a nasal canula. The oxygen tubing/humidifier was not dated. The oxygen tubing/humidifier remained undated through 08/04/22. Observation, on 08/04/22 at 08:02 AM, revealed the resident positioned in bed. The resident's oxygen tubing was directly on the floor beside his bed. Interview, on 08/05/22 at 10:30 AM, with Administrative Nurse DD, revealed she expected staff to ensure oxygen tubing was changed weekly and dated accordingly. The facility policy Oxygen Administration Safety, reviewed 08/27/20, instructed staff to change the oxygen tubing once a week. The humidifier bottle should be replaced once a week and labeled with date and time changed. The facility failed to date the oxygen tubing and humidifier to ensure staff changed the tubing/humidifier once a week to prevent the spread of infection. In addition, the facility failed to provide appropriate oxygen tubing storage to prevent the spread of infection, for this resident who required oxygen.

The facility reported a census of 54 residents with three residents reviewed for medication administration. Based on record review and interview, the facility failed to ensure that one of the three sampled residents, Resident (R) 1, received medication as ordered by the physician in accordance with professional standards of practice, when the physician ordered to discontinue a medication and the facility continued to administer the medication, from 08/12/21 through 08/20/21. Findings included: - The signed Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 06/26/21, instructed the staff to administer, Aspirin (nonopioid [MEDICATION(S)]) low dose tablet chewable 81 milligrams (mg), give 81 mg by mouth, one time a day, related to [CONDITION(S)] heart disease of native coronary artery without [CONDITION(S)] pectoris (chest pain). Review of the resident's hospital discharge summary, dated 08/10/21, documented a PO stating do not resume home ASA (aspirin) and [MEDICATION(S)] (blood thinner) until neurosurgery follow-up in six to eight weeks. The summary also documented notable medication changes of stopping the ASA and [MEDICATION(S)] due to a subdural hematoma (a bleeding area in the brain region). Review of the resident's August 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview, on 10/28/21 at 11:44 AM, with Administrative Nursing Staff D revealed she assisted with entering the resident's hospital return admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . It was an oversight by nursing staff that the medication did not get discontinued as the physician ordered and the staff continued to administer the medication. The facility policy for Medical Records admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] .to provide guidelines to ensure that admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] .staff will review the following information for accuracy and completeness .3. Medication orders .7. All treatment instructions . The facility failed to ensure the resident received medication as ordered by the physician in accordance with professional standards of practice, when the physician ordered to discontinue a medication and the facility continued to administer the medication, upon hospital return, from 08/12/21 through 08/20/21.

The facility reported a census of 91 residents. Based on observations and interviews, the facility failed to ensure an effective infection prevention program to prevent the spread of infection during room cleaning of 1 isolation room, inappropirate glove use during incontinence care for 1 (#29) resident and resident laundry processing on 4 of the 5 hallways. Findings included: - Observation, on 4-2-19 at 10:30 am, with housekeeping/laundry staff P, revealed the facility contracted to an outside agency for laundry services. Observation of the unit service hallways, at that time, revealed covered carts containing clean laundry lined the wall in the hallways with dirty laundry and trash in covered barrels beside the clean laundry. Staff P stated the clean laundry rooms were kept locked and when the contracted agency delivered laundry they did not unlock the clean laundry room door, but left the laundry in the service hallway. Staff P confirmed the clean and soiled laundry should not be stored in the same hallway. Observation, on 4-2-19 at 11:00 am, with housekeeping/laundry staff P, revealed the facility laundered resident slings for the lifts and pressure relieving boots worn by residents, in two noncommercial high efficiency washers and utilized noncommercial dryers. Staff P stated staff used ordinary laundry detergent, and thought the water temperature was 170 degrees. Staff P stated if there was any isolation laundry it wound be washed separately, but then would be distributed to the general population. Interview, on 4-2-19 at 11:00 am, with maintenance staff L, revealed the water temperature for the washing machines was monitored approximately every 6 months, and thought the last temperature in (MONTH) (YEAR) was 170 degrees Fahrenheit. Observation, on 4-2-19 at 11:00 am, revealed the water temperature of the water in the washing machine (placed on the Hot Water cycle) was 115 degrees Fahrenheit. Maintenance staff L adjusted the water heater temperature, at that time, however, subsequent temperatures did not increase above 115 degrees. The facility policy for laundry services, last reviewed 2-19-19, advised staff linens will be stored and processed in a manner which will prevent odors, contamination of clean linen and spread of disease. The clean linen receiving, holding sorting and distribution areas that exist will be separate from the soiled linen area. Clean linen will be delivered to clean linen rooms. The policy lacked instruction regarding the proper water temperatures necessary for processing linens and resident care equipment soiled with blood and/or body fluids. The facility failed to process laundry in a sanitary manner, including keeping clean and dirty laundry and trash in separate areas, and ensure proper water temperatures for laundering of linens and resident care equipment in a sanitary manner to prevent the spread of infection amongst the residents. - Observation, on 04/02/19 at 11:12 AM, revealed direct care staff F, applied gloves and removed resident #29's sweat pants that were wet with urine and the wet bed pad that was underneath the resident, removed the disposable brief, grabbed the package of wipes using the same gloves, and wiped the skin in the resident's peri area. Then, direct care staff F, grabbed a dry brief and placed under the resident with the same pair of gloves on, grabbed the wipe package, and provided further skin care. Then direct care staff G handed direct care staff F a tube of Periguard ointment and applied the ointment to the resident's peri area. Direct care staff F then removed the one glove used to apply the ointment, fastened the resident's clean disposable brief, placed a clean pair of sweatpants on the resident, placed on the resident's footwear, assisted the resident to sit on the side of the bed, placed a gait belt around the resident, and staff F and G transferred the resident to a wheelchair. Direct care staff F then removed the other glove, took the bags of linens and trash to the soiled utility room, then went to the nurses station. Direct care staff F then washed his/her hands at the sink available at the nurses desk after questioned when was hand hygiene performed. The facility Hand Hygiene policy, revised 2/12/19, instructs the staff to perform hand-washing before and after contact with body fluids even if hands are not visibly soiled, when moving form a contaminated body site to a clean body site during resident care, before and after contact with inanimate objects including medical equipment in the immediate vicinity of the resident, and after removing gloves. The facility failed to perform hand hygiene during incontinence care to prevent cross contamination and reduce the transmission of infection to the residents. -Observation, on 4/3/19 at 8:44 am, revealed custodial staff J, prepared to clean an isolation room. Staff J, donned clean gloves, took the facility spray cleaner (virex II 256), and sprayed the mattress, then wiped the mattress with a clean cloth, removed the mattress and sat it on the floor. Staff J removed dirty gloves, donned new gloves, placed the mattress back on the frame. Took off and disposed of the gloves, donned new gloves and entered the bathroom with powder cleaner (sun flo with bleach), sprinkled the powder cleaner into the toilet and sink. Took a clean cloth and wiped the tank and seat of the toilet and moved to wipe the sink with the same cloth. At that time, the surveyor requested staff J use a clean cloth on the sink. Staff J wiped the sink with a clean cloth. Staff J went out to the cart and changed gloves with no hand hygiene performed. Interview, with custodial supervisor staff P, revealed he/she confirmed the cleaning procedure for an isolation room, proper use of hand hygiene with gloves, and in-services with staff regarding these. The updated hand hygiene policy, dated 2/12/19, advised staff indications for hand-washing before and after contact with fluids or excretions even if hands are not visibly soiled and after removing gloves. The facility failed to provide appropriate cleaning services of an isolation room or proper hand hygiene to prevent the cross contamination and development and/ or spread of communicable disease and infection.

The facility reported a census of 91 residents. The 20 residents selected for review included 5 residents reviewed for presence of written bed hold notice upon transfer to the hospital. Based on record review and interview the facility failed to provide a written bed hold notice for these 5 residents reviewed, including 3 residents (# 53, #295, #5), for two hospitalization s, and 2 residents (#39, #18) for one hospitalization . Findings include: - Review of the following 5 residents medical records revealed lack of the bed hold policy provided to the resident and/or responsible party as follows: 1). Resident #53's, nurses notes, dated 9/17/19, revealed the resident admitted to the hospital overnight for observation. Review of the medical record revealed lack of a written bed hold for the transfer to the hospital. Nurses notes, dated 10/26/18, revealed the resident was sent to ER, then admitted to the hospital. Review of the medical record revealed lack of written bed hold for transfer to the hospital on [DATE]. 2). Resident #295's 8/1/18 and 12/1/18 discharge assessment MDS (minimum data set), revealed the resident transferred to the hospital on these dates. Review of the medical record lacked written bed hold for both transfers. 3). Resident #5's 7/13/18 discharge assessment MDS and the 2/25/19 nurses notes, revealed the resident transferred to the hospital on both of these dates. Review of the medical record lacked written bed hold for both transfers. 4). Resident #39's nurses notes, dated 12/25/18, revealed the resident admitted to the hospital. Review of the medical record lacked written bed hold for the transfer. 5). Resident #18's 2/18/19 discharge assessment MDS, revealed resident #18 transferred to the hospital. Review of the medical record lacked written bed hold for the transfer. Interview, on 4/3/19 at 03:34 pm, with social services staff D, responsible for bed holds, confirmed that bed holds are done only on an annual basis and not when a resident transfers to the hospital. The facility policy for Bed-Hold procedure, revised 10/19/18, instructs that upon admission and when a resident is transferred for hospitalization or for therapeutic leave, a representative of the facility will provide information concerning the bed-hold policy. The facility failed to provide these five residents and/or his/her responsible person with a written bed hold notice, at the time of the residents transfer to the hospital.

The facility reported a census of 91 residents. Based on observation and interview, the facility failed to ensure properly fitting mattresses and bed frames were provided to 14 resident beds to prevent entrapment and/or improper positioning. Findings included: - Observation, on 4-3-19 at 11:00 am, with maintenance staff L and housekeeping staff P, revealed the following beds with gaps between the mattress and headboard or footboard. Six resident beds on hall 400 had a 6 gap between the head board and mattress. One resident bed had a 12 (inch) gap between the footboard and mattress. Four resident beds on 500 hall had a 6 gap at the head of the bed, and one resident bed had an 8 gap at the head of the bed. Two resident beds on 200 hall had a 5 gap at the foot, and 5 gap at the head. Interview with maintenance staff L revealed nursing staff may be replacing the mattresses without measuring the frame. The facility policy for bed rail procedures, revised 8-12-02, advised staff to make sure the mattress fits the bed sufficiently to not leave space for the resident to become trapped between the mattress and the rail. The facility failed to ensure properly fitting mattresses to bedframes to prevent possible entrapment and or improper positioning.

The facility reported a census of 91 residents. The 20 residents selected for review included 2 residents reviewed for skin conditions. Based on observation, interview, and record review, the facility failed to provide prompt, appropriate treatment for [REDACTED].#12 and 58) reviewed for skin wounds. Findings included: - Record review, of physician progress notes [REDACTED].#58, included [DIAGNOSES REDACTED]. The quarterly MDS (minimum data set), dated 2/15/19, assessed the resident of having a BIMS (brief interview of mental status) score of 13, had a skin tear present, was receiving application of dressings and ointments, and received an anticoagulant (a medication that thins the blood) for 7 days of the MDS assessment period. The skin CAA (care area assessment), dated 8/27/18, revealed the resident required assistance with mobility and was at risk for skin breakdown related to immobility, incontinence, and chronic disease process. The care plan, dated 2/18/19, instructed the staff to follow the facility policies/protocols for the prevention/treatment of [REDACTED]. The care plan further instructed that the blood thinner he/she takes can cause increased bruising and to monitor skin routinely. Record review, of the skin observation tool, dated 3/18/19, revealed no skin conditions noted. Observation, on 03/28/19 01:40 PM, revealed the resident to have 3 steri-strips in place to the left forearm. The resident interview, at that time, confirmed there was a wrap that was removed yesterday, there was a pus like fluid on the sore, the area was cleaned, and the steri-strips were left in place. Furthermore, the area happened a couple of weeks ago when his/her shirt sleeve caught his/her watch and caused a tear. Record review, of nurses note, dated 3/31/2019 at 03:22, revealed the resident complained of his/her left leg bleeding, a skin tear was present that measured 5cm x 3cm, was cleansed with saline wound flush, and a DuoDerm (a wafer type moisture-retentive wound dressing used for partial and full-thickness wounds leaking fluids) thin spot was applied. The Treatment record, dated 3/2019, revealed a code of 9 for the skin assessment due on 3/25/19 and lacked a treatment order for left forearm and left leg. The skin observation tool, dated 4/1/19, revealed the resident skin to be dry, warm, and intact; and no new skin conditions observed. Observation, on 4/2/19 at 2:00 pm, revealed steri-strips in place to left forearm. Observation, on 4/3/19 at 07:56 am, revealed the dressing in place to the left shin that lacked a date, time, and initials. Steri-strips remained in place to left forearm. Interview, on 4/3/19 at 07:58 am, with administrative nursing staff B, confirmed the dressing on the left shin lacked a date, time, or initials and should have a treatment order in place. Staff B also confirmed the left forearm should be monitored and placed on the treatment record, and skin areas should be on the treatment record and assessed with [REDACTED]. Interview, on 4/3/19, at 8:10 am, with administrative nursing staff B, confirmed a treatment order for the left leg and the left forearm were not in place. Observation and interview, on 4/3/19 at 8:15am, revealed administrative nursing staff B assessed the left forearm, steri-strips had been removed, and he/she confirmed the area to the left forearm was healed. Furthermore, he/she confirmed a thin duoderm was present to the resident's left leg. Staff B removed the dressing and cleansed with wound wash, the wound lacked drainage but was open. Staff B dried the area with gauze and measured the wound to be 0.5cm in length and 0.3cm in width. Observation and interview, on 4/3/19 at 8:22am, of administrative nursing staff B, confirmed the treatment order per the wound protocol standing orders was to clean the area, apply triple antibiotic ointment and cover. Then, staff B, gathered supplies and provided treatment to the left leg. Interview, on 4/3/19 at 9:59 am, confirmed that the code 9 on the treatment record for the skin assessment on 3/25/19, means other, see progress note. Review of the progress notes, dated 3/25/19-3/31/19, did not reveal any information regarding skin assessment on 3/25/19. The facility dressing change policy, dated 1/14/11, indicated to document dressing change as required, noting condition of wound; and to write the date, time, and initials on the dressing. The facility standing protocols, dated 3/13/19, reveals instructions for minor cuts and scrapes, to cleanse the area, may apply triple antibiotic ointment once and apply dressing; do not repeat the triple antibiotic on subsequent days. The facility failed to provide appropriate treatment of [REDACTED]. -Review of resident #12's physician order [REDACTED]. peripheral nerves that spreads toward the center of the body). The annual MDS (minimum data set), dated 9/28/19, assessed the resident with a BIMS (brief interview for mental status) score of 15 indicating little or no impairment (13-15), that resident was at risk for pressure ulcers. The resident had pressure relieving device in chair and ointment or medication applied. The resident received [MEDICAL TREATMENT]. The quarterly MDS, dated [DATE], assessed the resident with a BIMS score of 8 indicating moderate cognitive impairment (8-12), that the resident was at risk for pressure ulcers, had open lesion(s) other than pressure ulcers, rashes, or cuts, moisture associated skin issue. The resident receives the application of non surgical dressing, ointment, or medication, and has a pressure relieving device in chair. The resident recieved [MEDICAL TREATMENT]. The CAA's (care area assessment) for ADL's (activities of daily living), dated 9/28/19, indicated the resident required staff assistance with ADL's due to weakness/chronic disease processes, LE (lower extremity) amputation. The resident is often tired and may refuse bathing particularly due to chronic disease process and [MEDICAL TREATMENT]. The care plan, dated 12/28/18, directed staff that resident needed assistance with ADL's. That the resident has impaired physical activity, and does not like more than 2 people in the room when providing his/ her cares. Observation, on 04/01/19 at 1:06 pm, of a dressing change revealed licensed nursing staff C, donned gloves, removed the dressing to the left upper arm revealing a [MEDICAL TREATMENT] shunt, discarded gloves, performed hand hygiene, donned clean gloves, feels thrill (a fine vibration felt which reflects the blood flow by a [MEDICAL TREATMENT] resident's shunt), listens to bruit (blowing or swishing sound heard which reflects the blood flow with a [MEDICAL TREATMENT] resident's shunt), removed gloves, no hand hygiene, new gloves donned and dressing on the residents back was removed, cleansed and a new dressing applied with same gloves on. Staff C then asks the resident the questions on the facility [MEDICAL TREATMENT] check list sheet. Staff C acknowledged that hand hygiene should occur before and after donning/removing gloves, and gloves should be changed from site to site, and from removing a dressing to cleansing a wound, and again when applying a clean dressing. The updated facility policy on dressing changes, dated 1/14/11, states open dressing pack, put on first pair of disposable gloves, remove soiled dressing and discard, dispose of gloves, wash hands, put on second pair of disposable gloves, apply cleansing solution, apply dressing, remove gloves. The updated hand hygiene policy, dated 2/12/19, advises staff indications for hand-washing before and after contact with fluids or excretions, mucous membranes, non intact skin, and wound dressings, even if hands are not visibly soiled after removing gloves. The facility failed to ensure proper hand sanitization and glove change during this resident's dressing change to prevent cross contamination and the spread of infection.

The facility reported a census of 91 residents with 20 residents selected for review which included 3 residents reviewed for pressure ulcers. Based on observation, interview and record review the facility failed to ensure proper hand washing and glove use during dressing changes for 2 ( #48 and #74) of the 3 residents reviewed, and failed to ensure uncompromised pressure relieving measures for 1 (#78) of the 3 residents reviewed. Findings included: - Review of resident #78's physician order [REDACTED]. to the insulin) and osteomylitis (local or generalized infection of the bone and bone marrow). Review of the significant change MDS (minimum data set), dated 12-7-18, assessed the resident with a BIMS (brief interview for mental status) score of 13, indicating normal cognitive function, inattention that fluctuated, no behaviors, total dependence for bed mobility, transfers, toileting and personal hygiene, independent with eating. This MDS assessed the resident with no range of motion impairment in the upper extremities, and impairment in the lower extremities, at risk for pressure ulcers, 1 stage 1, 4 stage 3, with 2 present upon admission, 1 stage 4 and 2 arterial/venous ulcers, with interventions of pressure relieving device in bed, chair, turn and reposition program, dressing changes. The CAA (care area assessment), for pressure ulcers, dated 12-7-18, advised staff good nutrition and hydration to promote healthier skin, to identify and document potential causative factors and eliminate/resolve where possible, Prevlon boots for pressure relief to heals bilaterally, to turn upon rounds, and the resident will position him/herself on his/her back and staff advised to reposition as often as needed to help relieve pressure off of pressure areas. The resident to have a pressure relieving air mattress. The care plan, updated 3-12-19, advised staff when repositioning and transferring the resident to protect against the effects of external mechanical forces such as pressure, friction and shear. The care plan advised staff to provide Prevlon boots for pressure relief, pressure relieving air mattress, pressure relieving cushion to chair. A hospice wound care note, dated 1-14-19, advised staff to provide a low air loss mattress, with setting at 150 pounds, alternating pressure, ensure fewest layers in between the resident and mattress, to reposition every 2 hours as tolerated with advisement that the resident was a hospice resident, and these chronic pressure ulcer wounds were present for over a year due to immobility, with goals to prevent infection and prevent new areas of breakdown. The Braden score ( a scale to determine a resident's risk of developing pressure related injuries) evaluated the resident with a score of 12 on 5-31-18 (10-12 high risk), 9 on 8-27-18 (<9 severe risk), 12 on 11-24-18, 11 on 2-24-19. Review of the wound assessments, dated 12-25-18 revealed a right heel SDTI (suspected deep tissue injury) with measurements of 2.7 by 4.3 by 1 cm (centimeter) depth, 75% (percent) necrotic (dead) and 25 % [MEDICATION NAME] tissue, with Prevlon boots, alternating pressure mattress and side rails for positioning. (pressure relieving mattress and Prevlon boots on care plan dated 11-8-17). The wound assessment dated , 3-31-19, revealed the right heel pressure ulcer, identified as ulcer #7, with the date of development (blank), stage 3 with measurements of 4 by 5 cm, depth 1.5 cm, with 4.2 centimeter tunneling from 11:00 o'clock to 3:00 o'clock. Review of the wound assessments, dated 12-3-18 , revealed the ball of the left foot pressure ulcer, identified as ulcer #9, SDTI, (identified on 11-16-18), with measurements of 3.9 by 8.8 cm. no depth (with boots as intervention in place). The wound assessment, dated 3-31-19, revealed left foot ulcer measurements of 2.3 by 4 cm with a depth of 0.39 cm, 25 % necrotic/slough. Observation, on 4-3-19 at 9:30 am, revealed the resident positioned in bed with his/her head of the bed elevated at approximately a 45 degree angle. Interview, on 4-3-19 at 9:30 am, with the resident revealed the wounds have been present for years. The resident stated staff repositioned the him/her frequently and used pillows for positioning and comfort. The resident stated he/she could use his/her hands and arms but did not have the use of his/her legs due to illness ([MEDICAL CONDITION]). The resident further stated that he/she did not always allow staff to reposition him/her. Observation, on 4-3-19 at 10:29 am, revealed the resident sitting in bed, with the head of the bed elevated at approximately a 45 degree angle. Licensed nursing staff M removed the blankets covering the resident's feet to reveal the resident's left foot (enclosed in a pressure relieving boot directly in contact with the foot board of the bed. The resident's pressure relieving boot contained an egg crate-like foam padding. Licensed nursing staff M stated, at that time, these were not the resident's usual pressure relieving boots as they had been sent to laundry for cleaning. Staff M proceeded to provide wound care to the resident's left foot, and measured the left foot pressure ulcer as 2.5 cm in length by 1.1 by 1.2 which contained gray/yellow slough and the area below the resident's toes as 4 by 3 cm which contained tissue red in color, beefy constancy with 2 white areas of a structure (tendon like-structures). Staff M cleansed the areas with wound cleanser, applied skin prep to the peri wound, applied hydrogel an ABD (large thick gauze dressing) and wrapped the entire foot with kerlix (a stretchy type of gauze). Staff M questioned the resident if he/she felt any pain or discomfort during the dressing change and manipulation of the resident's feet, and the resident stated he/she did not feel anything in his/her feet. Staff M removed the dressing with an area of approximately 5 centimeters saturated with serous drainage from the resident's right foot and measured the area on the resident's right heel as 6 by 3.8 cm with a depth of 1.2 cm and tunneling 4.5 cm in an area from 11:00 o'clock to 3:00 o'clock. Staff M cleansed the wound with wound cleanser, applied Mesalt packing to the tunneling, and placed silver alginate on the beefy red wound bed. Staff M reapplied the pressure relieving boots to both feet. Staff M stated at that time he/she would continue with dressing changes to the resident's back, periarea and coccyx and hips, but the resident decline surveyor observation of these wounds. Observation, on 4-3-19 at 12:19 pm, revealed the resident positioned in bed with the head of the bed elevated approximately 45 degrees, as the resident ate fruit cocktail. The resident's bilateral feet were contained in the egg crate lined boots. The resident's left foot was positioned directly on the the footboard. Interview, on 4-3-19 at 12:19 pm with direct care staff G, revealed he/she repositioned the resident approximately at 11:30 am, but the resident routinely repositioned the pillows him/herself, placing the resident on his/her back. Interview, on 4-3-19 at 1:15 pm, with licensed nursing staff M, confirmed the resident often removed and repositioned pillows which resulted in change in position. Staff M confirmed the resident did slide down in the bed, but thought the pressure relieving boots would help distribute the pressure of the footboard. Staff M stated the resident's usual pressure relieving boots were in the wash, but did find them in the clean laundry, at that time. Interview, on 4-3-19 at 1:15 pm, with direct are staff U stated he/she would apply the newly found (resident's usual) pressure relieving boots, at that time. Observation, on 4-3-19 at 1:25 pm, revealed the resident positioned sitting upright in bed at approximately a 45 degree angle. The resident's feet were encased in the newly found pressure relieving boots, and staff M was able to get his/her hand between the boot and the foot board, however the foot was up against the metal bar holding the footboard on the bed frame. Interview, on 4-3-19 at 1:30 pm, with administrative nursing staff A, revealed the facility usually ordered pressure relieving boots but did not have specific brand name (Prevlon) pressure relieving boots available. Staff A stated he/she would advise staff to observe the resident's foot position hourly to prevent pressure against the foot board. The facility policy for pressure ulcers, revised 5-25-16, advised staff a resident having a pressure ulcer receives the necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing. The facility failed to provide presssure ulcer care in a manner to promote healing of the resident's left heel pressure ulcer when staff failed to ensure the resident's feet did not push up against the bed foot board which in turn reduced the effectiveness of the pressure relieving boots. - Review of resident # 74's physician order [REDACTED]. The annual MDS (minimum data set), dated 11-16-18, assessed the resident with a BIMS (brief interview for mental status) score of 6 indicating severe cognitive deficit, verbal behaviors 1-3 days, required extensive assistance with bed mobility. The resident had no impairment in range of motion in upper or lower extremities, at risk for pressure ulcers with 2 unstageable pressure ulcers, pressure reducing device in bed, and on a turn and repositioning program. The CAA (care area assessment), dated 11-16-18, for pressure ulcers, assessed the resident with 2 SDTI (suspected deep tissue injury to bilateral heels). The care plan, updated 3-12-19, advised staff the resident had SDTI to bilateral heels, advised to turn and position the resident, avoid positioning the resident on his/her back to limit pressure to the coccyx, pressure relieving boots to feet bilaterally, and low air loss mattress. Resident requires extensive assist with ADL's (activities of daily living). The physician's orders [REDACTED]. Observation, on 4-1-19 a 7:50 am, revealed the resident positioned in bed with bilateral off loading boots. Licensed nursing staff O prepared to provide wound care to the resident. Staff O washed his/her hands, donned gloves, removed the resident's dressing, staff O then, wearing the same gloves, cleansed the area with wound cleanser, removed gloves and performed hand hygiene. Staff O then applied new gloves and applied [MEDICATION NAME] to the resident's foot/toes then took the gloves off, did not perform hand hygiene, put on another pair of gloves, and applied [MEDICATION NAME] (swabs) to the left heel ulcer, changed gloves, staff O did not wash his/her hands, donned another pair of gloves and placed the ABD (thick gauze dressing) on the wound, and wrapped the foot with [MEDICATION NAME] (a type of strechy gauze). Direct care staff O measured the left foot eschar at 3.4 by 3.3 cm (centimeter) and an area on the left heel inner side measured 1.5 by 1 cm with gray eschar (dead skin and tissue). Interview, on 4-1-19 at 8:30 am, with licensed nursing staff O revealed the resident admitted (11-7-17) to the facility with pressure ulcers on his/her left lateral ankle and great toes, and had pressure relieving boots and air mattress in place at that time. Interview, on 4-2-19 at 2:24 pm, with administrative nursing staff, Q revealed the resident had a barriatric bed with a pressure relieving mattress, and pressure relieving boots when first admitted . Staff Q stated at the time of the development of the pressure ulcer on the left heel, the resident was on [MEDICATION NAME] for severe pain, as a result the [MEDICATION NAME], the resident had compromised healing. Staff Q stated the integrity of the pressure relieving boot was examined and the new pressure relieving boots were applied as was a change in bed and low air loss mattress. Interview, on 4-1-19 at 2:55 pm, with consulting medical staff R, revealed the resident at high risk for pressure ulcer development due to diabetes, [MEDICAL CONDITION] (abnormal condition affecting the blood vessels) and immoblitiy. The facility policy for hand hygiene, dated 3-12-19, advised staff to wash hands before and after contact with body fluids, excretions, mucous membranes, non-intact skin, and wound dressings even if hands are not visible soiled. Staff advised to wash hands after removing gloves. The facility policy for dressing changes, revised 1-14-11, advised staff to put on first pair of disposable gloves, removed soiled dressing and dsicard, wash hands and put on second pair of disposable gloves. The facility failed to ensure staff provided a dressing change with proper hand hygiene and glove changes to promote healing and prevent cross contamination and development of infection to the resident's pressure ulcer. - Review, of resident #48's, signed physician order [REDACTED]. The quarterly MDS (minimum data set), dated 11/9/18, assessed the resident with BIMS score of 11, indicating moderate cognitive deficit (8-12), requiring extensive assist of 2 with personal hygiene, total dependence of 2 with toilet use, dressing, bed mobility and transfers. The resident had one stage 2 pressure ulcer with pressure reducing devices in bed and wheelchair. Resident on a repositioning/ turning program. Had pressure ulcer care, application of dressing, and ointment or medication. The annual MDS (minimum data set), dated 2/8/19, revealed BIMS (brief interview for mental status) score of 10, indicating moderate cognitive deficit (8-12), required limited assist of 1 with personal hygiene, extensive assist of 2 with toileting, dressing, and bed mobility. The resident was always incontinent of bowel and bladder. The resident had two pressure ulcers with pressure reducing devices in the wheelchair and on the bed. The resident was on a turning/ repositioning program. Had nutrition/ hydration interventions in place. Pressure ulcer care, application of dressing and ointment or medication. The CAA (care area assessment) for pressure ulcers, dated 2/8/19, assessed the resident had two pressure ulcers both being treated with [MEDICATION NAME] (dressing that absorbs drainage and contains a low level of silver that aids in killing bacteria) and [MEDICATION NAME] border (foam dressing) changed every other day. The care plan, revised 3/12/19, advised staff the resident required assist of 1-2 with mobility, dressing, toileting, bed mobility, and transfers. To monitor, assess, and record wound measurements weekly. The resident had depression, and resistance to care. Staff advised to educate the resident and give explanations of care given, and keep consistency in care, timing and staff as much as possible. The physicians order sheet, dated 11/28/18, advised staff the resident was to wear pressure relieving boots during the day, reposition every 2 hours, and out of his/her wheelchair every 2 hours. A wound assessment note, on 11/6/18, identified a stage 2 pressure ulcer above the anal area measuring 0.25 by 1.3 cm (centimeters). At this time resident had in place pressure relieving devices in the wheelchair, a ROHO (specialized pressure reducing cushion), and in bed, a low air loss mattress. With last noted measurement, on 3/20/19, of 1 by 0.5 cm and 0.1 cm in depth (improved). Physicians order sheet, dated 3/20/19, instructed staff to pack the above anal wound with [MEDICATION NAME] (a collagen), cover with foam dressing and change every other day and as needed. Observation, on 04/01/19 at 08:40 am, revealed the resident sat at the dining room table in the wheelchair. At 09:00 am, the resident observed sitting in his/her wheelchair, eating am meal, at 09:21 am the resident is observed moving him/ herself down the hall in the wheelchair. At 09:37 am the resident is observed sitting in the wheelchair in his/her room actively watching the TV (television), at 09:55 am the resident is observed sitting in the wheelchair watching the TV. At 10:09 am, the resident is observed in his/her own room watching the TV, at 10:25 am, the resident continues in the wheelchair watching TV. At 10:40 am, the resident is observed in the wheelchair in his/her room watching the TV, at 10:55 am the resident continues to sit in the wheelchair watching the TV. At 11:10 am, the resident had been observed sitting up in the wheelchair for two and a half hours. Staff informed at that time. Staff I stated that the resident refused to be repositioned. At 11:25 am, staff I entered the resident's room and offered to reposition the resident, he/ she refused offer of assistance to laydown in the bed or move to the recliner. Interview, on 4/1/19 at 11:25 am, revealed the resident stated yes he/she was having pain to his/her buttocks, but declined to lay down in the bed or move to the recliner. At that time, staff I did not notify the charge nurse. Interview, on 4/1/19 at 11;25 am, with licensed nursing staff C revealed staff I did not notify charge nurse of the residents refusal to lay down. Resident agrees to move to the recliner for staff C. Staff C goes to find help for position change of the resident. Staff C returned to inform the resident that he/ she will be put in the bed following lunch. The resident was then taken, in the wheelchair, to the dining room for the noon meal. Staff C stated the resident will be laid down right after the noon meal. Observation, on 4/1/19 at 12:30pm, the resident observed sitting in the wheelchair (now for 3 hours and 20 minutes) in his/her room. Nursing staff F and I, use the lift to move the resident into the bed, they use caution with the residents limbs and head, so as to not harm the resident. Staff F was requested to assess the resident's buttocks and there was no redness noted, dressing to coccyx is clean, dry and intact. Observation, on 4/1/19 at 2:05 pm, revealed staff C performed wound care to the resident's pressure ulcer above the anal area. Staff C washed his/ her hands and obtained supplies. Applied gloves while he/ she explained the procedure to the resident, uncovered the resident and opened the brief, removed the old dressing. Staff C obtained wound measurements of 1.5 by 0.3 cm, and 0.1 cm in depth. Wound was cleaned, and collagen was cut & placed in the wound, the wound was then covered. All with the same gloves in place. Interview, on 4/2/19 at 3:40 pm, with staff A, revealed the resident had pressure relieving devices on the bed and in the wheelchair, frequent position changes, and protein supplements in place prior to the resident acquiring the most recent pressure ulcer above the anal region. Interview, with staff N, revealed staff are educated and reviewed by competencies upon hire and annually for hand hygiene. Staff N states in-services are given monthly. Interview, with staff U, reveals staff are educated, and that the correct procedure of glove use is to change gloves when moving from dirty to clean following hand hygiene. Updated pressure ulcer policy, dated 5/23/16, advises staff a resident having a pressure ulcer receives the necessary treatment and services to promote healing, prevent infection and prevent new ulcers from forming. Updated hand hygiene policy, dated 2/12/19, advises staff indications for hand-washing before and after contact with fluids or excretions, mucous membranes, non intact skin, and wound dressings, even if hands are not visibly soiled. After removing gloves. The facility failed to provide proper repositioning in a timely manner for the resident to promote healing and prevent development of further pressure ulcers. In addition, the facility failed to provide wound dressing treatments with proper hand hygiene to promote healing of the pressure ulcer and prevent infection.

The facility reported a census of 91 residents, with 20 residents selected for review, including 6 residents reviewed for accidents. The facility reported 1 resident at risk for elopement on one hall with an automatic exit door with a non functioning key pad and alarm. Based on observations and interviews, the facility failed to ensure a door monitoring system to ensure this 1 residents did not exit the building without staff knowledge. Furthermore, the facility failed to provide appropriate interventions for 1 of the 6 residents reviewed (#47) who experienced a fall during transfer from the wheelchair to the bed. Findings included: - Observation, on 4-3-19 at 10:30 am, on one hall, revealed one of the double wooden doors between the unit and hallway containing the exit door, was open and the automatic door to exit the building opened without the use of a keypad, and did not alarm when opened. Interview with direct care staff G, on 4-3-19 at 10:30 am, revealed he/she did not know the exit door opened without the code, and did not alarm. Staff G stated maintenance would need to repair the door. Interview, on 4-3-19 at 1:30 pm, with licensed nurse M revealed 1 resident at risk for elopement. Interview, on 4-3-19 at 1:30 pm, with administrative nursing staff T, confirmed 1 resident at risk for elopement on this unit. Staff T stated the administrator would have an action plan for monitoring this door that opened without a code, and did not alarm when opened. Staff T stated the door did have a camera monitor and this displayed at the nurses' desk. Interview, on 4-3-19 at 1:30 pm, with maintenance staff L, revealed the contractors that worked on the door on Friday, 3-29-19, disengaged the key pad and alarm to the exit door. Staff L stated he/she would connect the alarm to sound, and contacted the contractors to complete the maintenance of the door on 4-4-19. Staff L stated, after 8:00 pm. the doors automatically locked. Interview, on 4-3-19 with administrative staff W revealed staff monitored the 1 resident at risk for elopement on this unit, and the key pad functioned between the hours of 8:00 pm and 7:00 am. Staff provided an action plan, at that time, to ensure safety during the time of key pad inactivation, and nonfunctioning alarm system. The facility policy for door monitoring, revised 12-10-08, advised staff until the electronic monitoring system is functional, team members working in the facility will implement a plan to ensure that no resident exits the building without the awareness of knowledge of nursing staff members by continuously monitoring each exit door visually. The facility failed to maintain a door monitoring system on one exit door to ensure the 1 resident at risk for elopement did not exit the building without staff knowledge. - The POS (Physician order [REDACTED]. The annual MDS (Minimum Data Set), dated 7-15-18, documented the staff assessment for cognition revealed the resident had severly impaired cognition. He/she rerquired extensive assistance of 2 for bed mobility and transfers and had limitation on both sides of the upper and lower extremities. The resident had one non-injury fall since and 2 or more injury (except major) falls since the prior assessment. The significant change MDS, dated [DATE], docuemnted the resident had severe impairment in cognition. He/she required extensive assistance of 2 for bed mobility and transfers, and had functional limitation in range of motion of upper and lower extremities. He/she had one injury fall (except major), and two or more non-injury falls since the prior assessment. The CAA (Care Area Assessment) for falls was incomplete. The care plan, dated 2-24-19, for falls, instructed staff the resident had a short attention span. Reveiw of the fall assessments, dated 12-14-18, 12-17-18, and 1-16-19, revealed the resident was at a high risk for falls. Nurses notes, dated 1-23-19, evidenced the resident fell while transfering him/herself from the wheelchair to the bed. Staff initiated an intervention to place body pillows for positioning in his/her bed (not an appropriate intervention for a fall during transfer). On 4-02-19 at 3:16 p.m., licensed staff Y, stated an intervention needed to be initiated as soon as possible following a fall. Staff need to find the root cause of the fall to prevent further falls. On 4-02-19 at 3:19 p.m., licensed staff Z, stated the intervention for body pillows on 1-23-19, was not an approprite intervention for the fall. On 4-02-19 at 3:34 p.m., administrative nursing staff A, stated the fall intervention on 1-23-19 was not approrpiate. The policy for resident assessment, dated 6-1-18, instructed staff to develop a care plan to describe services furnished to attain the resident's highest practicable physical, mental, ann psychosicial well being. The facility failed to provide approrpiate fall interventions for this resident, to prevent further falls.

The facility reported a census of 91 residents. The sample included 20 residents, including 3 sampled residents reviewed for urinary catheter (tube inserted into the bladder to drain urine into a collection bag). Based on interview, record review and observation, the facility failed to handle the catheter tubing and collection bag in a clean, sanitary manner to prevent infections, for 1 (#2) of the 3 residents reviewed. Findings included: - The POS (Physician order [REDACTED].#2 had [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set), dated 12-14-18, documented the resident had a BIMS (Brief Interview for Mental Status) score of 3, indicating the resident had severely impaired cognition. He/she required extensive assistance of 2 for toileting and had an indwelling urinary catheter. The admission MDS, dated [DATE], documented the resident had a BIMS score of 8, indicating the resident had moderately impaired cognition. He/she required extensive assistance of 2 for toileting and had an indwelling urinary catheter. The CAA (Care Area Assessment) for indwelling urianry catheter, dated 3-16-18, documented the resident had [MEDICAL CONDITION] with a lower urinary tract obstruction (blockage). The care plan, dated 1-07-19, for urinary catheter, instructed staff to perform catheter care daily. On 4-01-19 at 10:52 a.m., the resident rested in his/her bed with the catheter collection bag laying directly on the floor. On 4-01-19 at 2:30 p.m., the resident rested in his/her bed with the catheter collection bag laying directly on the floor. On 4-01-19 at 3:58 p.m., the resident rested in his/her bed with the catheter collection bag laying directly on the floor. On 4-02-19 at 8:53 a.m., the resident ate breakfast in the dining room. The catheter tubing laid on the floor beneath the wheelchair. On 4-02-19 at 9:15 a.m., direct care staff H stated there should be a hook on the bed frame to hang the catheter bag from, otherwise the bag would lay on the floor. On 4-02-19 at 9:25 a.m., direct care staff K stated the catheter collection bag should not be on the floor without a dignity bag. On 4-02-19 at 1:47 p.m., licensed nursing staff X stated the catheter collection bag should never be on the floor. On 4-02-19 at 3:34 p.m., administrative nursing staff A stated the catheter bag should not be on the floor, at any time. The facility policy for Catheter Care procedure, dated 6-1-18, lacked instruction to staff to ensure the catheter collection bag and tubing were kept off the floor to prevent cross contamination and the development of infections. The facility failed to ensure staff handled this resident's catheter collection bag and tubing in a clean, sanitary manner, to prevent cross contamination and the development of infections.

The facility reported a census of 117 residents, with 3 residents selected for review related to resident to resident altercations. Based on observation, record review, and interview, the facility failed to provide adequate supervision and/or assistive devices to prevent the occurrence of a resident to resident altercation which resulted in 1 resident (#1) who required transfer to the emergency room for a [MEDICAL CONDITION] which required staples and another resident (#2) who sustained skin tears on his/her right wrist, left hand, and right upper arm and a scratch on the nose. Findings included: - Resident #1's, signed physician orders, dated 6/8/18, documented the resident admitted on [DATE], with the following [DIAGNOSES REDACTED]. The annual MDS (minimum data set), dated 11/3/17, revealed the resident had a BIMS (brief interview for mental status) score of 1, indicating severely impaired cognition. The resident had a mood score of 0, indicating without mood/depression. The resident with hallucinations and delusions. The resident with the behavior of wandering and behavior of this type occurred 1-3 days. The resident required supervision with ambulation and his/her balance was steady. The resident received an antidepressant (a treatment to prevent and/or treat depression) medication. The quarterly MDS, dated [DATE], revealed there was not any change from the quarterly MDS, dated [DATE]. The CAA (care area assessment), for behavior dated 11/4/17, advised the resident was at risk for potential decline due to dementia. The care plan which addressed elopement, initiated on 11/16/14, related to a [DIAGNOSES REDACTED]. Staff were to invite the resident to sit with other resident's in the T.V. (television) room when the resident seemed anxious and wanted to leave. 11/23/15 - the resident resided on a secured unit due to his/her wandering and elopement risk. 12/26/17 - redirect the resident to avoid conflict with other residents. The plan of care lacked any interventions prior to 7/5/18, following a resident to resident altercation, which addressed the resident's wandering behavior, his/her inability to find his/her own room, or his/her tendency to go into other residents rooms. 07/05/18 (following the altercation) - keep a sign outside the resident's room to help him/her locate the correct room. The care plan lacked instruction to staff for monitoring the resident to ensure he/she did not go into another resident's room. A progress note, dated 6/22/18 at 7:03 AM, advised the resident was up most of this shift wandering, and asked the staff where his/her ride was. The resident remained confused and tearful until around 4:30 AM, when he/she went to bed. A progress note, dated 7/5/18 at 7:14 PM, identified the resident involved in a resident to resident altercation. A staff member observed the resident on the floor in the hallway with a trail of blood coming from resident #2's room. The resident had a laceration (wound to the skin) on the top of his/her head, on the right side, with excessive bleeding. The charge nurse covered the wound with a pressure dressing. Staff called EMS (emergency medical services) at 5:45 PM. EMS arrived at 6:00 PM and the resident was transferred by ambulance to the hospital. The EMS (emergency medical services) report, dated 7/5/18, documented upon arrival at the facility at 6:04, the resident was sitting up in a folding chair in the hallway. A staff member was holding pressure on top of his/her head to control the bleeding. There was approximately 100 ml (milliliters) of blood on the floor that another employee was cleaning. The resident was alert and oriented to name and place, and suffered from dementia. The resident had 3 lacerations to the top of his/her head, and lip. While at the facility, EMS staff observed a trash can that was used as the weapon to hit the resident and had approximately a 1.5inch lip on the bottom that still had hair and blood stuck to it. The progress note, dated 7/5/18 at 9:30 PM, revealed the resident returned from the hospital with a simple laceration of the scalp and a facial contusion (injured tissue or skin, or a bruise) on the left cheek. The physician orders [REDACTED]. A progress note, dated 7/5/18 at 8:35 PM, in #2's clinical record documented the resident involved in a resident to resident altercation. The resident stated another resident (#1) was in his/her bed. A staff member observed resident (#2) follow injured resident #1 out of his/her room. Resident #2 had a skin tear on the right wrist, A 3 cm (centimeter) scratch on the right nostril, A 2.75 cm by 1 cm. skin tear on the left hand, and a skin tear on the right upper arm. The resident was put on 1 to 1 staff supervision, with staff. A progress note, dated 7/6/18 at 6:02 PM, in resident #2's clinical record documented the resident continued with 1:1 monitoring, without behaviors, and was then transferred to a behavior unit. On 8/8/18 at 11:37 AM, observation revealed resident #1 ambulated in the hallway independently, and his/her gait was steady. The sign which designated where the resident's room was, was lying between the wall and the hand rail, leaning forward, and not easily seen/read. On 8/8/18 at 12:51 PM, observation revealed resident #1 was attempting to lay down in resident #2's bed, when direct care staff M walked by and assisted the resident to walk back to his/her own room and get in bed. The sign continued to lay between the wall and the hand rail, leaning forward. At 1:15 PM, the resident was lying in his/her bed. The sign with the resident's name on it, was hanging upside down on the right side of the doorway. At 2:40 PM, no change with the sign. At 3:47 PM, the resident continued resting in his/her bed. The sign continued to be upside down on the wall, beside the door. On 8/9/18 at 9:30 AM, the sign with the resident's name on the wall by the door, was hanging upside down. The resident was seen resting quietly in his/her bed. On 8/8/18 at 12:52 PM, direct care staff M stated he/she did not believe resident #1 had been going into resident #2's room lately, but he/she had several times before the altercation. On 8/8/18 2:29 PM, licensed nursing staff D stated resident #2 reported resident#1 was in his/her bed. Resident #2 went to wake up resident #1 who attacked him/her first, but he/she would not admit to hitting resident #1 with the trash can. He/she believed resident #2 startled resident #1. The staff that evening did not hear the scuffle, he/she was at the desk, and looked up and saw resident #1 on the hallway floor. The physical behavior was out of character for resident #2. Staff D called EMS (emergency management staff) to transfer resident #1 to the hospital due to the laceration to his/her head. Staff D made sure the two residents stayed separated. Resident #2 had some skin tears, and staff D provided treatment. Resident #2 was 1:1 with staff that night, and has been also since he/she came back from the behavior unit. A sign was placed on resident #1's door that sticks out, so he/she would know where his/her room was. Staff D stated he/she felt resident #1 knew where his room was. On 8/8/18 at 3:30 PM, direct care staff H stated at the time of the altercation, he/she heard another staff member call out, and then observed resident #1 trying to stand up, he/she was covered in blood, and staff H stood by him/her until the nurse came. The resident stated he/she fell , in the hallway. However, a little later staff H went into resident #2's room, and observed blood on the floor, and the metal trash can had hair on it. The resident had an indentation on his/her head from the trash can. Staff H stated he/she thought resident #2 became upset with resident #1 lying in his/her bed. After the event occurred and staff separated the resident's, resident #2 was placed on 1:1 with staff. On 8/8/18 at 4:12 PM, direct care staff I stated at the time of the altercation, in the middle of supper he/she looked down the hallway and observed resident #1 on the floor, staff I went down the hall, and saw all the blood, and he/she called for the charge nurse. The door to resident #2's room was shut when he/she looked. Staff I stated he/she remembered opening the door later and saw all the blood in the room. Resident #1 stated resident #2 hit him/her with a trash can, and later resident #2 stated yes, he/she hit resident #1 because the other resident was in his/her bed. The resident used to wander into resident #2's room and get into bed a lot. Resident #1 would get upset when he/she woke the resident up. Staff try to monitor the residents from going into others room. Staff placed a sign with the resident's name by his/her door to try to get his/her attention to go into his/her room, after the altercation. On 8/9/18 at 9:13 AM, direct care staff K stated if staff wake resident #1 up he/she would be confused as to why he/she was being woke up in what the resident thought was his/her bed. The resident would become agitated when trying to get him/her out of the wrong bed. He/she would leave the resident alone and try again later. The resident liked to go into resident #2's room/bed. He/she tried to keep an eye on resident #1 to make sure the resident did not go into other residents rooms. Staff are to keep the sign by the resident's door where the resident can see it, but staff K did not think the sign helped, and he/she took the sign down. On 8/9/18 at 1:57 PM, licensed administrative staff C stated he/she was not aware the resident was going into resident #2's room, except for that one time, however, when the resident did wanderer into other residents rooms, he/she could be easily redirected by taking his/her hand and leading the resident to his/her own room. The facility policy and procedure, Behavior Management for Residents with Dementia, dated 08/13/18, was developed after the incident. The facility failed to develop and implement a plan to adequately provide supervision and or assistive devices to manage resident #1's repetitive wandering behavior. The resident wandered into resident #2's room and went to bed. This behavior lead to a resident to resident altercation, in which resident #1 experienced a [MEDICAL CONDITION] which required staples and resident #2 experienced skin tears on the arms/hands and a scratch on his/her nose.

The facility reported a census of 122 residents including 26 selected for review. Based on observation, interview and record review, the facility failed to ensure staff provided assistance to resident # 60, when drinking hot coffee, and sustained a second degree burn (a burn involving the first and second layer of skin which may blister and be painful) when he/she spilled the coffee onto him/herself. Furthermore, the facility failed to follow the fall care plan interventions for residents #100 and #62 who sustained falls. Findings included: - Review of resident # 60's physician orders, dated 4-11-18, revealed [DIAGNOSES REDACTED]. The admission MDS (minimum data set), dated 7-17-17, assessed the resident with a BIMS (brief interview for mental status) score of 10 , indicating moderate cognitive impairment, required 1 person extensive assistance for eating, and had impairment of range of motion on one side of the upper and lower extremities. The CAA (care area assessment), dated 7-17-17, for activities of daily living, assessed the resident required extensive assistance due to left sided [MEDICAL CONDITION]. The quarterly MDS, dated [DATE], assessed the resident with moderate cognitive impairment, required extensive assistance of 1 person with eating, and had limitation in range of motion on one side of the upper and lower extremities. The quarterly MDS, dated [DATE], assessed the resident with severe cognitive impairment, required limited assistance of 1 person with eating and had limitation in range of motion on one side of the upper and lower extremities. The care plan initiated on 7-19-17, advised staff the resident required extensive assistance of 1 staff to eat and required nectar thick consistency fluids. The care plan, updated 1-24-18, advised staff the resident likes to drink coffee and staff to ensure to use a cup with a lid to prevent injuries. The care, plan updated 4-4-18, advised staff the resident was not to have hot liquids/meals/snacks while in bed and must be sitting upright in a chair. Staff to provide a sippy cup with lid in place. The resident obtained a burn from dropping the coffee and due to it being thickened, caused prolonged contact with the resident's skin. The physician's orders [REDACTED]. A nurses' note, dated 4-4-18 at 1:35 am (late entry) documented inflammation surrounding blisters to the resident's left lateral thigh with measurements of 23 cm (cenitimeter) by 5 cm red area with 3-5 small blister areas within. A nurses' note, dated 4-4-18 at 8:48 am, documented the resident spilled coffee on 4-4-18. Direct care staff advised the resident to sit upright when drinking and were not to give hot beverages when the resident was in bed. A physician's note, dated 4-4-18, documented the resident sustained [REDACTED]. Observation, on 5-31-18 at 9:19 am, revealed the resident used his/her right hand to feed himself breakfast from a plate with a plate guard. The resident had thickened orange juice and water. Observation, on 5-31-18 at 9:51 am, revealed the resident lacked movement in his/her left upper and lower extremities. The resident lay in bed and revealed 5 areas of redness approximately 5 by 2 cm, on his/her left thigh. Interview, with the resident, at that time, revealed he/she remembered spilling hot coffee on him/herself, and burning his/her skin. The resident stated he/she was left handed and could not use his/her left hand or leg but now could use his/her right hand for most tasks since having the stroke. Interview, on 5-31-18 at 4:46 pm, with administrative nursing staff E, revealed a direct care staff Q gave the resident a thickened cup of coffee while he/she was in bed and left the resident unattended and the resident spilled the coffee onto his/her thigh. Staff E stated nursing staff updated the care plan to inform other staff the resident must sit in a chair to have hot liquids. Observation, on 5-31-18 at 12:22 pm, revealed the hot water temperature from the hot water dispenser (from which the water came from to make the resident's coffee) at 171.2 degrees Fahrenheit. The US Dept of Health and Human Services, Mass Casualties: Burns, 3-25-14, indicate that a water temperature of 155 degrees Fahrenheit requires 1 second contact time for a third degree burn to occur. Interview, on 5-31-18 at 4:59 pm, with direct care staff Q revealed on 4-4-18, the resident requested a cup of coffee, so staff Q checked the diet for the resident, and made him/her a sippy cup (with a spout and hole for a straw) of thickened coffee, using the prepackaged thickened coffee and water from the automatic coffee dispenser. Staff Q stated he/she gave the resident the coffee in his/her right hand, and the over bed table was on the resident's left side. Staff Q stated he/she did not stay with the resident while he/she drank the coffee. Staff Q stated the resident tried to place the cup on the bedside table and the cup fell from his/her hand and spilled through the spout and straw onto his/her left thigh, causing a burn. Interview, on 6-1-18 at 9:50 am, with administrative nursing staff A confirmed the resident's care plan indicated the resident required 1 staff extensive assistance with meals, and the direct care staff should stay with the resident when eating/drinking. Staff A confirmed the resident sustained [REDACTED]. Interview, on 6-1-18 at 10:51 am, with consulting medical staff Z, confirmed the resident sustained [REDACTED]. Staff Z confirmed the resident had [MEDICAL CONDITION] in his/her left side upper and lower extremities. The facility policy for feeding procedure, revised 3-26-12, advised staff to develop a plan of care based on the resident's strengths. The competency checklist, developed 4-2018, advised staff to access the Kardex (for resident information) in the direct care staff Kiosk electronic documentation system to determine resident needs. The facility failed to ensure staff provided extensive assistance for drinking hot liquids for this resident with range of motion deficits on his/her dominant side, and moderate cognitive impairment, to prevent the resident from spilling hot coffee on him/herself, which resulted in second degree burns. - The POS (physician's orders [REDACTED].#62, documented the resident had a [DIAGNOSES REDACTED]. The annual MDS (Minimum Data Set), dated 7-14-17, documented the staff assessment for cognition revealed the resident was severely impaired. The resident required extensive assistance of 2 staff for transfers, bed mobility and toilet use. The resident's balance while moving on and off the toilet and for surface-to-surface transfers was not steady, and he/she was only able to stabilize with staff assistance. The resident had functional limitation in ROM (Range of Motion) of the upper and lower extremities and used a wheelchair. The resident had 2 or more non-injury falls since the prior assessment. The CAA (Care Area Assessment) for falls, dated 7-14-17, documented the resident was at risk for decline due to dementia (progressive mental disorder characterized by failing memory, confusion). The quarterly MDS, dated [DATE], documented the resident had a BIMS (Brief Interview for Mental Status) score of 0, indicating the resident had severely impaired cognition. The resident required extensive assistance of 2 staff for bed mobility and transfers and had 1 non-injury fall and 2 or more injury (except major) falls since the prior assessment. The care plan for falls, dated 4-06-18, instructed staff to transfer the resident with extensive assistance of 2, ensure the alarms were in working order, staff were to place the resident's shoes in the closet, and keep his/her bed in the lowest position. Staff were to assist the resident with toileting and going to bed following meals to prevent self transfers. Review of the resident's fall assessments, revealed the resident was at a high risk for falls. review of the resident's medical record revealed [REDACTED]. The documented intervention was to follow the fall protocol. On 5-31-18 at 3:37 p.m., licensed nurse H stated, staff did not initiate a new intervention for the fall on 5-28-18. On 6-01-18 at 9:15 a.m., licensed staff C stated, staff did not document an intervention for the fall on 5-28-18. On 6-01-18 at 12:38 p.m., administrative staff A stated, nurses are to update the care plans immediately with a new intervention when there was an incident. The facility policy for accidents, dated 9-05-17, included: A licensed nurse will review and revise the care plan with updated interventions as it relates to the accident and/or incident. The facility failed to implement an intervention following a fall for this dependent resident at high risk for falls and a history of injury falls. - The POS (physician's orders [REDACTED].#100 had [DIAGNOSES REDACTED]. The annual MDS (Minimum Data Set), dated 8-18-17, documented the staff assessment for cognition as severely impaired. The resident required extensive assistance of 2 staff for bed mobility, transfers, toilet use, and walking in room. The resident's balance was not steady and he/she was only able to stabilize with staff assistance. He/she had no limitation in functional ROM (Range of Motion) and used a wheelchair for locomotion. The resident had no falls since the prior assessment. The CAA (Care Area Assessment) for falls, dated 8-18-17, documented the resident was at risk for decline due to [MEDICAL CONDITION]. The quarterly MDS, dated [DATE], documented the resident had a BIMS (Brief Interview for Mental Status) score 0, indicating the resident was severely cognitively impaired. The resident required extensive assistance of 2 staff for bed mobility, transfers, toilet use, and walking in room. The resident's balance was not steady and he/she was only able to stabilize with staff assistance. He/she had no limitation in functional ROM (Range of Motion) and used a wheelchair for locomotion. The resident had no falls since the prior assessment. The care plan, dated 1-26-18, instructed staff the resident had a bed exit alarm to alert the staff when he/she attempted to get up. Staff were to ensure he/she wore appropriate footwear and there was a floor mat at bedside. The bed was to be kept in the lowest position with a concave (having an outline or surface that curves inward) mattress and the resident was to have an alarm in his/her wheelchair. review of the resident's medical record revealed [REDACTED]. review of the resident's medical record revealed [REDACTED]. The documented intervention was to follow the fall protocol. On 5-30-18 at 2:00 p.m., the resident rested in his/her bed. The floor mat was in place and the bed alarm was in proper working condition. On 5-31-18 at 3:37 p.m., licensed nurse H stated, staff did not initiate a new intervention for the fall on 2-07-18. On 6-01-18 at 9:15 a.m., licensed staff C stated, staff did not document an intervention for the fall on 2-07-18. On 6-01-18 at 12:38 p.m., administrative staff A stated, nurses are to immediately update the care plans with a new intervention when there was an incident. The facility policy for accidents, dated 9-05-17, included: A licensed nurse will review and revise the care plan with updated interventions as it relates to the accident and/or incident. The facility failed to implement an intervention following a fall for this dependent resident at high risk for falls and a history of injury falls.

The facility reported a census of 118 residents. Based on observation, interviews and record review, the facility failed to provide adequate supervision and assistive devices for 1 (#01) of 3 sampled residents to prevent a fall. The resident fell and fractured a hip. Findings included: - The facility electronic record face sheet evidenced the facility readmitted resident #01 on 7/15/16. The physician listed Parkinson's Disease (slowly progressive neurologic disorder) and dementia (progressive mental disorder characterized by failing memory and confusion) as diagnoses. The annual MDS (minimum data set) assessment, dated 7/7/17, documented the resident with severe cognitive deficit and unable to complete the brief mental interview, in need for extensive assist with bed mobility and transfers, and limited assist with walking. No falls were documented. The 7/22/17 CAA (care area assessment) included: cognition, resident displays confusion at times, is difficult to understand due to speaking in a whisper. For activities of daily living, the resident required extensive assist of 2 staff with toileting. The resident at risk for falls due to immobility and need for assistance with ADLs (activities of daily living). A fall risk assessment, dated 9/5/17 completed by the facility, scored the resident at a 10, high risk. The assessment documented the resident with a balance problem while standing or walking and a history of 1-2 falls in the past 3 months. The care plan, dated 1/10/17, included the resident required extensive assist x 2 staff for toileting. He/she is able to make needs known and will ask for assist when needed. On 2/22/17, the care plan included, resident needs to be reminded that he/she needs more assist and needs to use the call light. The resident had severe cognitive impairment. Keep call light within reach and use call light when the need arises. On 7/30/17 the care plan update included, resident to have bed and chair alarm in place at all times for fall prevention intervention. Per the facility investigation, on 9/16/17 at approximately 6:55 P.M., direct care staff C returned to the residents' room and found the resident, on the floor on his/her left side, by the restroom door. On 10/6/17 at 3:20 P.M., staff C verified staff placed the resident on the toilet approximately 10 minutes prior to his/her fall on 9/16/17. Staff gave the resident the call light and then left him/her per usual on the toilet. Staff C acknowledged it was routine practice to leave him/her alone on the toilet and the resident previously utilized the call light. The resident reported he/she activated the call light before getting up. On 10/6/17 at 8:10 A.M., administrative staff A acknowledged the facility tested the call light on 9/16/17 at 3:30 P.M. and found it working appropriately. Therefore the cognitively impaired resident failed to activate the call light. Per nurses notes on 9/16/17, licensed nursing staff B immediately assessed the resident and noted the resident without pain or limited range of motion. The following shift, direct care staff E noted a large hematoma to the resident's lateral left hip. The resident could bear weight without pain. The facility notified the physician of the fall and he/she advised the nursing staff to monitor the resident throughout the night. At approximately 6:00 A.M., the resident complained of pain. Licensed nursing staff D notified the physician and received orders to send the resident to the emergency room for evaluation. The resident admitted to the hospital with [REDACTED]. On 10/16/17 at 8:10 A.M. administrative staff A acknowledged the facility investigated the incident and determined the root cause of the fall was the unattended resident attempted to self-transfer. The new intervention in place included not to leave the resident on the toilet unattended. Observation on 10/16/17, throughout the day at various times, revealed the resident sat in the wheelchair or lift recliner with a personal alarm in place at all times. The facility personal alarms policy, dated 10/17/17, developed after the 9/16/17 fall included, the use of personal alarms were utilized only to alert staff of potentially unsafe transfers attempted by a resident. Residents would benefit from the use of personal alarm devices then unsteady or weak during ambulation, unsteady or weak during transfers and unsafe attempts to transfer or ambulate without calling for assistance. The facility lacked a policy related to safety of confused residents, identified at risk for falls, being left unattended on the toilet. The facility personal alarms policy, dated 10/17/17 included, the use of personal alarms are to be utilized only to alert staff of potentially unsafe transfers attempted by a resident. Residents would benefit from the use of personal alarm devices then unsteady or weak during ambulation, unsteady or week during transfers and unsafe attempts to transfer or ambulate without calling for assistance. The facility failed to provide adequate supervision and assistive devices for this confused resident with a fall history, to prevent this fall. The resident sustained [REDACTED].

The facility reported a census of 110 residents with 25 selected for review, including 4 residents reviewed for accidents. Based on observation, interview and record review, the facility failed to develop and implement interventions to prevent falls for 1 of the 4 residents, #121, who sustained a fall with a head laceration requiring emergency room care and staples. Findings included: - Review of resident #121 physician order [REDACTED]. The admission MDS, dated [DATE], assessed the resident with a BIMS (brief interview for mental status) score of 5, indicating severe cognitive impairment with disorganized thinking. The resident required limited assistance with bed mobility, transfers toilet use and personal hygiene. The resident's balance was unsteady. The resident had impairment on one side upper and lower extremities and utilized a wheelchair and walker for mobility. The resident was frequently incontinent of bladder, and was not on a trial toileting program. The resident received diuretic (a medication used to remove fluid from the body through the kidneys, causing increased urination) therapy 7 of the 7 days look back period. The resident sustained [REDACTED]. The 30 day MDS, dated [DATE], assessed the resident with a BIMS score of 5, required limited assistance with bed mobility transfer, toilet use and personal hygiene, received 7 days of diuretic and antidepressant therapy in the 7 day look back period had unsteady balance and sustained no falls since admission. The CAA (care area assessment), dated 2-23-16, for activities of daily living, assessed the resident required assistance from staff to complete most of his/her activities of daily living. The CAA for falls, dated 2-23-16, assessed the resident with a fall prior to admission and a fall score of 15, but the CAA did not indicate what this score meant. The CAA for cognitive loss, dated 2-23-16, advised staff the resident had [DIAGNOSES REDACTED]. The CAA for urinary incontinence, dated 2-23-16, assessed the resident as frequently incontinent of urine due to his/her disease process and required limited assistance of one staff for toileting needs. The care plan, reviewed 3-4-16, advised staff the resident required limited assistance by 1 staff for toileting, and transferring, with limited physical mobility, required limited assistance of 1 staff for ambulation, and utilized a walker and wheelchair for longer distances. The care plan advised staff the resident was at high risk for falls related to gait balance problems and contracture (abnormal permanent fixation of a joint) to the right knee. The care plan advised staff to keep the resident's call light within reach and encourage the resident to use it for assistance as needed. The resident needed prompt response to all requests for assistance and utilized a walker with 1 staff assistance. Staff were advised the resident was to wear shoes and provide nonskid socks when ambulating and/or in bed. This care plan advised occupational and physical therapy to evaluate and treat. The resident needed a safe environment with even floors free from spills, clutter, adequate glare free light, a working reachable call light, bed in the safest low position at night and personal items within reach. The medical record lacked revisions to the care plan after 03-04-16. The continence evaluation, dated 3-8-16, assessed the resident with occasional urge incontinence, with awareness of the urge to void was capable of asking for assistance and could remove clothing. This evaluation recommended prompted voiding and incontinence products. The fall risk assessment, dated 3-4-16, revealed a score of 15. The medical record lacked a key for the scoring. Review of the medical record, revealed staff found the resident sitting on the floor beside his/her bed per nurses' note, dated 4-20-16 at 8:02 pm. The staff determined the resident attempted to transfer him/herself from the wheelchair to his/her bed. Staff documented the resident denied hitting his/her head. Staff failed to document vital signs and documented that the neurological check was normal, but did not enter the actual clinical findings in the medical record. Follow up included reminding the resident to use his/her call light, and the resident was to wear nonskid socks while in bed. (This intervention was already in the care plan updated 3-4-16). Review of the unwitnessed fall report, dated 4-20-16, revealed lack of a root cause analysis and interventions to prevent further falls. Review of the medical record, revealed a nurses' note, dated 4-21-16 at 3:00 am, documented the resident was found lying in a fetal position on the floor. This note documented the resident was alert and oriented and told staff he/she hit his/her head. Staff documented the bed was in a low position, the call light was within reach and the bed alarm as in use (but not listed on the care plan). Review of the unwitnessed fall report, dated 4-21-16, revealed lack of root cause analysis and interventions to prevent further falls. Review of the medical record, revealed a nurses' note, dated 4-29-16, at 8:02 pm, documented the resident was found sitting on the floor in his/her bathroom against the foot pedals of his/her wheelchair. The resident had taken his/her shirt off so the personal body alarm (not listed on the care plan) was not sounding. The resident denied hitting his/her head and sustained an abrasion on the right shoulder, measuring 1 by 4 cm and 2 by 2 cm. Review of the unwitnessed fall report, dated 4-29-16, revealed lack of root cause analysis and interventions to prevent further falls. Review of the medical record, revealed a nurses' note, dated 5-11-16 at 3:44 pm, documented the resident was found lying on his/her left side in his/her room, with the bed alarm in place. The resident sustained [REDACTED]. Review of the unwitnessed fall report, dated 5-11-16, revealed lack of root cause analysis and interventions to prevent further falls. Interview, on 9-20-16 at 2:20 pm, with direct care staff FF, revealed the resident required assistance with transfers, had a personal alarm, and staff needed to be sure to keep the foot pedals on his/her wheelchair. Interview, on 9-20-16 at 2:30 pm, with direct care staff EE, revealed the resident had a personal alarm, and tried to get up on his/her own so staff needed to keep an eye on him/her. Staff EE stated he/she thought the resident was on an every 2 hour toileting schedule. Interview, on 9-21-16 at 8:00 am, with administrative nursing staff B, stated the facility revised the policy for fall follow up. Staff B confirmed lack of a key for the numerical rating on the fall assessment. Interview, on 9-21-16 at 8:45 am, with consulting medical staff DD, revealed he/she expected staff to put interventions in place to prevent further falls. The facility policy for accident and incident investigation, revised March 12, 2010, in place at the time of the resident's falls, advised to determine the cause of any conditions identifies and implement preventive measures as appropriate. The facility failed to thoroughly investigate this resident's multiple falls to determine the root cause of the falls to develop and implement appropriate interventions to prevent further falls. The resident sustained [REDACTED].