Every finding on record at Kaw River Care and Rehab

Based on interviews, observations, and record review, the facility failed to assist Resident (R) 1 in getting transportation set up to take R1 to her radiology appointment. Findings included:- R1's Electronic Medical Record (EMR) documented diagnoses of atherosclerotic heart disease of native coronary artery without angina (chest pain) pectoris, seizures, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder due to known physiological condition, cardiac pacemaker, rheumatoid arthritis (chronic inflammatory disease that affected joints and other organ systems), reduced mobility, muscle weakness, heart failure, difficulty in walking, unsteadiness on feet, and need for assistance with personal care. R1's Modified Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 had impaired upper and lower bilateral extremities. R1 used a walker and a manual wheelchair (WC). R1 required substantial to maximal assistance with toileting hygiene, showering/bathing, upper body dressing, lower body dressing, putting on and taking off footwear, and personal hygiene. R1's Chronic Pain Care Plan dated 10/05/2022 documented that R1's pain was aggravated by some movements, depending on the day and the area in pain. R1's Activities of Daily Living (ADL) Self Care Plan, dated 05/30/2025, directed that staff R1 required one staff member's assistance with transfers. Review of the facility Transportation Calendar June documented that R1 had an appointment scheduled on 06/04/26 and another appointment on 06/02/26. Review of R1's After Visit Summary dated 06/04/2026 documented that R1's physician set up an appointment for Heart Perf Stress Test for 06/05/2026 at 08:30 AM. The review of R1's EMR lacked progress notes for R1's appointment on 06/04/2026 or for R1's upcoming appointment on 06/05/2026. On 06/23/2026 at 11:25 AM, observation revealed a posted announcement right outside R1's room that read: Appointments before 8 AM, residents to schedule their own transportation per [Administrative Staff A].Unless scheduled with [CNA M] two weeks prior to the appointment dateThank you. On 06/23/2026 at 01:03 PM, R1 stated that the doctors are the ones who make her appointments and that she has to take the appointments when they are made for her. R1 further stated that after each appointment, she makes sure to get two After Visit Summaries, one for the facility and one for herself. R1 stated that all of her upcoming appointments were listed on the first two pages of the summary. R1 stated that she was informed that the staff would not be taking her to her appointment because she had made it at the last minute. R1 stated it was a stress test and felt that her readings would not be true due to the stress of having to set up her own transportation for that appointment. On 06/23/2026 at 12:10 PM, Certified Nurse Aide (CNA) M stated that recently, a sign was posted throughout the building so that the facility would not single out a resident known to make her own appointments. CNA M confirmed that the resident known to do this was R1. CNA M revealed that she was told about R1's appointment on 06/05/2026, and CNA M informed R1 that she would need to find her own transportation to that appointment. CNA M stated the reason she could not give R1 a ride to that appointment was due to the time her day care opened, and that CNA M would not make it in time to take R1 to her appointment. CNA M stated that was why Administrative Staff A made the sign and placed it in the hallways. CNA M stated she was a single parent and could not make accommodations for the residents who had appointments before 08:00 AM. On 06/23/2026 at 01:52 PM, Maintenance U stated the course to become a transportation driver took one to one and a half days to complete and be able to drive the facility vehicle. Maintenance U stated he had only really trained roughly two people in the last year to be a transportation driver. Maintenance U further stated it would not be complicated at all for any of the administrative staff to be trained to do transportation. On 06/23/2026 at 01:45 PM, Administrative Staff A stated that R1 was known to make her own appointments, and that was why R1 needed to set up her own transportation. Administrative Staff A revealed that if the physician set up the appointment, the facility should handle the transportation. Administrative Staff A further revealed that there were only two staff drivers, and one of the drivers was an as needed (PRN) employee and required a few days' notice to drive the facility van. Administrative Staff stated that no administrative staff had been trained to be a backup driver related to the office jobs that had important things to do and would not have time to complete the training. Administrative Staff A stated that some administrative members could be trained to assist with last-minute appointment situations, but no one had been trained for that. The facility's Transportation policy, last approved in October of 2025, documented that the community would help arrange transportation for residents as needed. Social services or a person designated by the community would help the resident, as needed, to obtain transportation. The policy further documented the resident would assume full responsibility for paying for any transportation to or from the facility. The facility's Transportation to Diagnostic Services policy, last approved in October of 2025, documented the community would assist residents in arranging transportation to/from diagnostic appointments when necessary. The policy further stated that should it become necessary for the facility to provide transportation, the social service designee would be responsible for arranging the transportation per community protocol.

The facility had a census of 36 residents. The sample included three residents reviewed for abuse. Based on observation, record review, and interview, the facility failed to ensure that cognitively impaired Resident (R) 1 remained free from injuries of unknown origin. On 06/07/25, R1 sustained a second-degree burn (potentially painful burn which affects the first and second layer of the skin) of unknown origin to his left arm and shoulder. This deficient practice also placed R1 at risk for further injuries, pain, abuse, neglect, and/or mistreatment. Findings included: - The Electronic Medical Record (EMR) for R1 documented diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), cerebrovascular disease (a group of conditions that affect the circulation of blood to the brain, causing limited or no blood flow to affected areas of the brain), generalized muscle weakness, flaccid hemiplegia affecting left non-dominant side (paralysis of one side of the body), unsteadiness on feet, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), and other reduced mobility. The 03/31/25 Quarterly Minimum Data Set (MDS) documented R1 had a Brief Interview for Mental Status (BIMS) score of seven, which indicated severe cognitive impairment. The MDS documented R1 required substantial to maximal assistance for toileting hygiene, bathing, lower body dressing, and personal hygiene. R1 required partial to moderate assistance with moving from a seated to a standing position, chair-to-bed transfers, toilet transfers, tub or shower transfers, and walking 10 feet. The MDS documented that R1 used a wheelchair and was independent in his ability to self-propel. The 07/08/24 Cognitive Loss / Dementia Care Area Assessment (CAA) documented R1 had a cognitive deficit and some difficulty making decisions regarding tasks of daily life. The CAA documented R1 was modified independent (the ability to perform daily tasks independently, but with some level of support or needing extra time or cues) with decision making. The 07/08/24 ADL Functional/Rehabilitation Potential CAA documented R1 had functional limitations related to medical conditions as well as physical deconditioning. R1 required some assistance with most activities of daily living (ADL). R1's Care Plan with an initiated date of 01/02/17, documented R1 had impaired cognitive function or impaired thought processes due to dementia, impaired decision making, neurological symptoms, and past cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). R1's Care Plan with an initiated date of 01/06/17, documented R1 sometimes had behaviors that included yelling, screaming, shouting, anxiety, withdrawal, obsessing over things, insomnia (inability to sleep), paranoia (a thought process believed to be heavily influenced by anxiety or fear to the point of irrational thinking), delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), verbal and physical aggression, refusing medications, history of wandering, and rejecting care. R1's Care Plan with an initiated date of 03/05/25, documented R1 was at high risk for falls related to gait and balance problems, being unaware of safety needs, left-sided neglect, decreased cognition, non-compliance, and hemiparesis/hemiplegia (weakness and paralysis on one side of the body). R1's June 2025 Medication Administration Record/Treatment Administration Record (MAR/TAR) documented a 9 for the dayshift behavior monitoring, on 06/06/25, which indicated to refer to the nurse's notes. R1's EMR recorded a Nursing note dated 06/06/25 at 04:13 PM that documented R1 continued on behavior monitoring. R1 was resistant to care, and cussed at the nurse while they attempted to help R1 get ready for the day. The note documented R1 did not want to get ready for the day. The note further documented R1 was resistant to the Certified Nurse Aide (CNA) giving him care, and R1 complained of pain. The note further documented the nurse assessed R1, and his area of pain kept changing. R1 refused any intervention offered. The note lacked mention of what interventions were offered or the location(s) of R1's pain. R1's June 2025 MAR/TAR documented an order for Ativan (an antianxiety medication) 0.5 mg PRN for anxiety for 14 days. The order lacked a specified frequency. The MAR/TAR lacked evidence the Ativan was offered or administered on 06/06/25. The Pain Level Summary in R1's EMR for 06/06/25 at 04:29 PM documented R1's pain as four out of 10. R1's June 2025 MAR/TAR documented an order for acetaminophen 325 mg two tablets PRN for mild pain every six hours. The MAR/TAR lacked evidence the acetaminophen was offered or administered on 06/06/25. R1's June 2025 MAR/TAR documented an order to place a splint on the resident's left arm each morning at 09:00 AM and an order to remove the splint each evening at 08:00 PM. The MAR/TAR noted a 1 indicating the resident refused the 09:00 AM splint application on 06/06/25, though 08:00 PM splint removal was noted as completed. A Nursing note dated 06/07/25 at 02:07 PM documented R1 continued on behavior monitoring. The note documented R1 was resistant to the CNAs giving him care, and R1 complained of pain. The note further documented the nurse assessed R1, and his area of pain kept changing. R1 accepted Tylenol (acetaminophen) and Ativan (an antianxiety medication) and said it was effective. R1's Pain Level Summary on 6/07/25 at 01:33 PM documented R1's pain was eight out of 10. R1's clinical record lacked documentation related to the area(s) of R1's pain. R1's MAR/TAR on 06/07/25 at 01:33 PM documented R1 received both acetaminophen and Ativan, and both were noted as effective. A Nursing: Medication Note dated 06/07/25 at 02:08 PM documented R1 started on Ativan 06/04/25/ R1 has not had any adverse or allergic reactions. R1's behavior had improved. R1 was stable. R1's June 2025 MAR/TAR documented a 0 for behavior monitoring both shifts on 06/07/25, which indicated the resident had no behaviors. R1's June 2025 MAR/TAR documented a 1 indicating the resident refused the 09:00 AM splint application on 06/07/25, and the 08:00 PM splint removal recorded a 6 which indicated the resident was hospitalized . A Nursing Transfer Note dated 06/07/25 at 05:10 PM documented R1 had been resistant to care since 06/06/25. R1 was combative and cursed at the staff when they tried to give him care. R1 also complained of pain but did not want any interventions at the time. The note recorded on that day documented the resident was still resistant to care and complaining of pain, but the resident did not want the nurse to bother him. In the afternoon, he complained of pain to the aide, who notified the nurse, and Tylenol and Ativan were administered after having to explain for five minutes the benefit of the resident taking the medication. The note recorded that upon reassessment, R1 stated he was not feeling pain. When the CNAs provided care for R1, they found R1 had an alteration on his left arm from his shoulder to his elbow. The skin was sloughed off, and there were multiple blisters. The note documented the skin alteration was not present the previous day (06/06/25) when the nurse tried to apply R1's brace. The nurse notified the on-call provider and received instructions to send R1 to the hospital. Staff notified administrative staff, and R1 was transported to the hospital. A Nursing note dated 06/07/25 at 08:00 PM documented R1 returned to the facility via stretcher transport and was transferred into bed with the assistance of four staff members. R1 was alert and confused, which was his baseline. R1 reported a burning pain in his left upper arm rated six out of 10. R1 had a dressing in place on his left upper arm. R1 stated he did not remember how he sustained the burn to his left upper arm. R1's hospital ED [Emergency Department] Provider Notes dated 06/07/25 documented R1 was brought by Emergency Medical Services (EMS) from the nursing home for a burn on his left upper arm. The note documented nursing home staff reported that R1 had spilled coffee on his arm. They did not notice any blistering or wounds until today. The hospital record further documented, under the final diagnosis section, R1 had a second-degree burn to multiple sites on his shoulder and arm. The facility's investigation, dated 06/10/25, documented on 06/07/25 at approximately 04:54 PM, Administrative Staff A was notified of an injury involving R1. R1 sustained an injury of unknown origin to his left shoulder. The area appeared bright red, with clear evidence of skin sloughing (dead tissue, usually cream or yellow in color) and a partial skin tear. R1 was a known fall risk due to cognitive impairment. In the days leading up to the incident and on the day it occurred, R1 had become increasingly combative toward staff and refused care on multiple occasions. When questioned, R1 was unable to explain how the injury occurred or what may have caused it. R1 was sent to the hospital for evaluation. Medical staff confirmed the injury was consistent with a burn and noted visible evidence of skin sloughing at the affected site. The facility investigation further documented that witness statements were obtained from clinical staff on duty on the day of the incident. The maintenance department conducted a full inspection of the resident's room and found no environmental hazards or equipment that could have caused a burn. A review of the resident's meals and linens showed no evidence of food or beverage spills. The resident was checked on consistently throughout the day and had not received a shower within the 48 hours prior to the incident. The investigation lacked a conclusion of how R1 sustained the burn. An unnotarized Witness Statement from Certified Nurse Aide (CNA) M, dated 06/07/25, documented CNA M was doing a routine check and change for R1 with CNA N, CNA O, and CNA P at 04:30 PM. CNA M documented R1 was combative, uncooperative, and refusing care. CNA M documented they went to change R1's sheets and shirt due to them being wet and noticed the skin peeling off of R1's left arm. CNA M documented they called the nurse into R1's room to assess the situation and then called EMS. CNA M documented the CNAs left the room as EMS arrived. An unnotarized and undated Witness Statement from Licensed Nurse (LN) H documented she saw R1 lying in bed from 06/07/25 to 06/08/25, for the 12-hour shift, on R1's left side. LN H documented there were no complaints from R1, and his eyes were closed. LN H documented they did not notice anything out of the ordinary about R1. An unnotarized and undated Witness Statement from CNA N documented while attempting to complete rounds, at roughly 04:30 PM, CNA N recorded R1's skin was peeling as staff attempted to turn R1 as they cleaned him up for dinner. CNA N documented R1 had been combative and refused care earlier in the day. CNA N documented she went to get the nurse on duty and informed her that R1 had a wound. The nurse came to examine R1, and the nurse felt it best to call EMS as the nurse believed R1's wound may possibly be a burn. An unnotarized Witness Statement from CNA O, dated 06/07/25, documented CNA O and three other aides went to check and change R1 at 04:30 PM due to him being combative and uncooperative. CNA O documented as staff went to change R1's sheets and shirt, because they were wet, they noticed the skin of R1's left arm was peeling off. The nurse was called into R1's room to assess the situation and then called EMS. An unnotarized and undated Witness Statement for Certified Medication Aide (CMA) R documented the last time she saw R1, before R1 went to the hospital on [DATE], was the day before at about 08:30 PM, during evening medication pass. CMA R documented at that time, CMA R gave R1 his night medication and did not notice any changes in his condition at that time. An unnotarized and undated Witness Statement for CNA P documented staff were doing a routine check and change on R1 at about 04:30 PM when they noticed R1 was not acting like himself. CNA P documented she and three other aides were caring for R1; they noticed R1 had what looked like burns on his left upper arm. CNA P documented one of the CNAs got the nurse, and the nurse took it from there. An unnotarized and undated Witness Statement for LN G documented the witness statement was attached. (The attachment was the printed Nursing Transfer Note dated 06/07/25, as listed above). The facility provided investigation did not include a witness statement for CNA Q. On 06/24/25 at 01:55 PM, observation of a photo of R1's burn on Administrative Nurse D's work phone revealed R1 in the photo. The picture was taken from the left side of R1's body. A large red area was observed on the outer portion of R1's left arm. The red area started just below R1's left shoulder and continued to about the level of his elbow. There was a thin layer of skin that had separated from the reddened site and appeared to have sloughed off, exposing the red tissue beneath. On 06/25/25 at 09:17 AM, R1 slept in bed, on his back. With his left side towards the wall. He had the blanket pulled up to his neck. On 06/24/25 through 06/26/25, LN H and CMA R were unavailable for interviews. On 06/24/25 at 06:31 PM, CNA M stated she went in with the other CNAs during breakfast to check and change R1. CNA M stated that R1's brief was wet, and he lay on his left side. CNA M stated R1 was super combative, and he was punching and kicking at the CNAs. CNA M stated staff were able to change R1's brief despite the punching and kicking, but were unable to change his other clothing due to him being combative. She stated they backed off due to him being combative and came back later. CNA M stated they tried to check on R1 throughout the day, but he was still combative. She stated staff went in just after lunch, and R1's shirt was wet, and they decided they could not leave him in his wet shirt. CNA M stated they tried to turn R1, then they saw his arm and notified the nurse. CNA M stated that each time they went into R1's room, the CNAs went in as a group. She stated they went in several times between breakfast and lunch, and his brief was dry until they checked him just after lunch. CNA M stated she believed staff checked on R1 at least four times between breakfast and lunch. She stated R1 was not acting like himself as he was not moving while he was in bed and would not move off his left side. CNA M stated she believed R1 was acting strange, so they checked on him more often. On 06/25/25 at 08:05 AM, CNA O stated she had gone in to check and change R1 with CNA M, CNA N, and CNA P on 06/07/25. CNA O stated R1 was lying on his left side and using his right arm and leg to kick and punch at staff. CNA O stated R1 would not move his left arm and kept saying it hurt. She stated they were going to change R1's clothing and brief. She stated they were going to change R1's sheets as they were soiled. CNA O stated they were only able to change R1's brief due to him being combative, and that he stayed on his left side the whole time. She stated they asked R1 if they could hold his hands so they could change his brief, and he eventually let them. She stated they told the nurse R1 complained of pain, and LN G went in to check R1. CNA O stated the CNAs went in a few times between breakfast and lunch to check on R1. CNA O stated that after lunch, they went in to check him again, and R1 had tears in his eyes and kept saying his left leg hurt. She stated R1 told her to please call somebody, but he would still not come off of his left side. CNA O stated it was unlike R1 to lay in bed all day, as he was normally up and out of bed. CNA O stated R1 does have a history of refusing care, but she had never seen him punch or kick someone prior to this. CNA O stated he would normally refuse and tell staff to get out of his room, but his being combative and the pain he was reporting, she had not witnessed from R1 before. CNA O stated the last time they checked on R1, he had three draw sheets and three chucks under him, and they were all soiled and wet. She stated it looked like someone had placed a clean one over a wet one; however, they were all wet, and his brief was saturated. She stated it looked like the previous CNAs just stuffed more under him. CNA O stated R1 had blisters that had not popped yet on his left arm. She stated she initially thought something hot may have been spilled on him when she saw the burn; however, she did not see anything that looked like a coffee spill on his clothing or in his bed. CNA O stated R1 was not his normal self that day and kept saying he did not want staff to touch him because he hurt. She stated R1 was not acting this way the day before and was out of his room, in his wheelchair, moving around on 06/06/25. CNA O stated she believed the nurse went in to see R1 at least twice on 06/07/25. On 06/25/25 at 08:39 AM, CNA P stated she went in with the other CNAs to help provide care for R1. CNA P stated R1 was on his left side and kept saying his arm hurt. CNA P stated that at breakfast, when they tried to change him, R1 was being combative, so they changed his brief and backed off. She stated they had checked on him a few times between breakfast and lunch on 06/07/25, and it looked like something was not right with him because he was in bed all day. CNA P stated R1 was usually up during the day and gets up to use the bathroom. CNA P stated it was not normal for him to lay in bed on one side all day. CNA P stated she thought R1 was in too much pain to get up, and he would yell for them to stop when they attempted to move him to provide care. CNA P stated that when they went in after lunch to change R1, they noticed his shirt was wet and he had food all over his bed. CNA P stated that when they went to turn him, they noticed the burn, and they went to get the nurse. CNA P stated none of the CNAs grabbed R1's arms or legs to hold him down or to pull on him when they went to provide care. On 06/25/25 at 09:24 AM, CNA N stated she went in with CNA P, CNA O, and CNA M to change R1. CNA N stated she was on orientation at the time, so she did not physically touch R1. CNA N stated that she saw R1 lying on his left side on 06/07/25 when they checked on R1. She stated R1 did not want anyone to touch him because he was in pain. CNA N stated she did not see any of the CNAs grab R1's arms or legs to hold him while they provided care. CNA N stated R1 was being combative, but they were able to get him to calm down enough, and he let them change his brief in the morning and roll him to clean him up around lunch. CNA N stated they saw the burn during the lunch brief change, and everyone gasped when they saw it. On 06/26/25 at 01:06 PM in an interview with CNA Q via phone, CNA Q stated she worked the night of 06/06/25 and stated she had helped R1 off the toilet three times that evening. CNA Q stated R1 often got out of bed to use the bathroom by himself, and could usually get up alone, but that night he was not himself. She stated R1 usually wanders a lot, but was not wandering as much that night. CNA Q stated R1 appeared weaker and was having a hard time standing up from the toilet. She stated she helped him pull his brief up and got him back into bed, but he was struggling. CNA Q stated R1 kept leaning on the sink and sitting back down on the toilet when she was helping him. CNA Q stated she reported what she saw to the other CNAs and nurse and was told the nurse was aware of it. CNA Q stated both LN H and the following morning, LN G stated they knew about R1's pain and situation, and R1 was fine. CNA Q stated R1 was normally very fidgety, even when he was asleep, he would not sleep for long. CNA Q stated that when she went in to help R1 that night, he complained of leg pain, and she noticed he was having a harder time using his leg when she helped him back to bed from the bathroom. CNA Q stated R1 was typically up and down, in and out of the bathroom on his own, but that night R1 was a lot more still, was not moving much, and was quieter. CNA Q stated she thought it may have been related to his pain. CNA Q stated she did not see any burns to R1's left arm at any point during her shift. CNA Q stated R1 has never been combative with her and would check on him by herself at times; however, if she needed to change the resident or reposition him, she would ask other CNAs to assist her. CNA Q stated she did receive an all-employee in-service after the incident, on 06/09/25. On 06/24/25 at 03:53 PM, LN G stated she worked on day shift 06/06/25 and 06/07/25 and stated she did not see a burn on R1's arm 06/06/25. LN G stated the CNAs came to get her and told her it appeared R1 had an area that looked like it had been burned on his arm. LN G stated she got wound cleaner to clean the site, but was careful not to displace tissue. She stated she sent a picture to leadership and the on-call provider and sent R1 to the hospital. LN G stated R1 was very combative while trying to dress his burn. LN G stated R1 had been lying in urine when they found the burn, and he had multiple wet sheets under him. LN G stated the facility had a big in-service related to job duties for nurses and CNAs. LN G stated they increased rounds for R1 after the burn was found, and nurses were supposed to do rounds and make sure CNAs were doing their rounds. LN G stated R1 never should have had that burn. LN G stated R1 was not lying directly on his mattress and was lying on sheets. She stated R1 moves around a lot, is usually restless, has a lot of falls, and moves in bed a lot. On 06/25/25 at 08:44 AM, LN G stated that R1 refused to allow her to place a splint on his left arm on 06/06/25. R1 refused the splint on 06/07/25 and refused to let her touch the resident. LN G said R1 lay on his left side and was resistant to care. LN G stated that R1 could have gotten the injury overnight because R1 refused the splint, and she had not seen his left side until the CNAs got her when the CNAs found the burn. On 06/24/25 at 01:50 PM, Administrative Staff A stated the facility had maintenance inspect R1's room for any leaks, drips from the ceiling, and chemicals, and also inspected his bed. Administrative Staff A stated the facility changed to a hypoallergenic sheet and detergent; the resident was placed on more frequent checks. Administrative Staff A stated housekeeping checked linens and found no evidence of coffee or food spilled on R1's clothing. Administrative Staff A stated they thought it possible could have been a friction burn as staff saw R1 lying on his left side for most of the day. Administrative Staff A stated R1 did not stay still, and it could have been friction from the mattress. Administrative Staff A stated he was told by one of the CNAs that the blanket had slid down the mattress when they found him, and as much as R1 moved around, it was hard to keep blankets on him. Administrative Staff A stated R1's family typically gave R1 a shower, but his family had not been to the facility recently, and there was no evidence R1 had a shower 48 hours leading up to discovering the burn. Administrative Staff A stated he reviewed camera footage for the day and did not see R1 leave his room that day, but went on to say that he did not keep track of who entered R1's room and when. On 06/24/25 at 01:55 PM, Administrative Nurse D stated he was out of town when the burn was discovered but R1 was sent out immediately when the burn was discovered. Administrative Nurse D stated he was not sure what happened, but saw the photos of the burn. Administrative Nurse D stated he had worked with burns in an Intensive Care Unit (ICU) in the past and had never seen a friction burn that resembled the burn R1 had on his arm. Administrative Nurse D stated there was blistering, and his thought was it may have been from hot fluid; however, he stated the facility did not serve fluids that hot to residents. Administrative Nurse D stated R1 was combative with staff, and it usually took multiple staff to assist him. Administrative Nurse D stated that if R1 was in bed, he usually tried to crawl out. On 06/25/25 at 10:19 AM, Administrative Nurse D R1 was usually in his wheelchair, going back and forth in the halls. Administrative Nurse D stated that if a nurse performed an assessment, then ideally, he would want to know what area was assessed. Administrative Nurse D stated the facility had provided education related to documentation. Administrative Nurse D stated if the CNAs saw R1 lying on his left side for a long period of time, and the resident reported he was in pain, it should trigger the CNAs to report to the nurse. Administrative Nurse D stated he expected the CNAs to alert the nurse so the nurse could assess the resident. Administrative Nurse D stated that if it was uncommon for a resident to favor one side, he would want to know what was going on with that side and why the resident did not want to get off of it. He stated a general assessment should be done, and then a more in-depth assessment if the resident complained of pain. Administrative Nurse D stated he expected the nurses to physically move the resident onto their back to take a look at the resident's side if they complained of pain, were favoring it, and did not want to get off of it. Administrative Nurse D stated he believed care in pairs would prevent abuse, neglect, or exploitation, as it would have meant two people had decided to participate in that, and he did not see that happening, but stated the care in pairs was more for staff protection due to behaviors. On 06/25/25 at 11:30 AM, Administrative Staff A stated R1's baseline was for him to be out of bed and moving around a lot. Administrative Staff A stated that one of the reasons R1 was a high fall risk was because he was always moving. He stated that R1 never stays still; he was always moving. Administrative Staff A described R1 as being squirmy. Administrative Staff A stated that if a nurse was notified of R1's pain and did not want to move from his left side, he expected the nurses to document it and attempt to reposition him. Administrative Staff A stated the nurse tried to give R1 pain medication, but he continued to refuse. Administrative Staff A stated that if R1 was doing something outside of his normal behavior, he expected the nurse to document and contact the provider on call of the situation; however, he did not believe R1 was doing anything out of the ordinary on 06/07/25, as it was normal for R1 to favor one side. Administrative Staff A stated he did not know if R1 had moved back and forth between staff checking on him and would have no way of knowing if R1 had just returned to his left side before staff checked on him each time. Administrative Staff A stated he expected the nurses to assess for pain and have done a physical assessment. Administrative Staff A stated that the things the nurse assessed should have been documented if the nurse was able to complete the assessment without R1 refusing or being combative. Administrative Staff A stated that providing care in pairs did not mean there was no possibility that abuse could take place, as anything is possible. Administrative Staff A stated it would be impossible to know what any person was going to do or not do, but with R1's history, they did not want staff going into his room alone. Administrative Staff A stated steps the facility took to protect the residents during the investigation were to switch detergents, contact the maintenance director, and have him inspect the resident rooms to ensure they were safe. Administrative Staff A stated nurses performed wound checks on other residents to ensure there were no other wounds beyond what was already documented. Administrative Staff A stated they had an all-staff in-service related to resident care. Administrative Staff A stated education provided to staff included the need for two-hour checks and changes for CNAs, and having nurses perform random rounding checks to make sure CNAs were completing their rounds. Administrative Staff A stated they were not documenting the rounds by the CNAs or nurses, and were going on what the expectation was from the education provided. Administrative Staff A stated they randomly followed up with residents to make sure staff were completing their rounding. Administrative Staff A stated LN H worked the night shift. The facility's Abuse Prevention Program, Recognizing Signs and Symptoms of Abuse/Neglect (Identification) policy, with an effective date of 10/2024, documented Abuse is defined as willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. Injury of unknown origin is defined as suspicious related to the source of the injury is not observed or the extent or location is unusual, or related to the number of injuries, either at a single point or over time. On 06/09/25, the facility completed corrective actions, which included an all-staff in-service with a topic titled Resident Care Checklist. The Inservice topics included the following: resident rounding every two hours, checking for incontinence, repositioning, monitoring for signs of distress, documentation, accurately documenting all care provided during rounds, noting any changes in resident condition, completing incident reports for any accidents or altercations, nurse oversight, nurse verifies CNA rounds completed and documented, the nurse conducts random resident checks during shift, communication and reporting, report any issues or concerns regarding resident care to the supervisor, notify nurse of any resident altercations and accidents, report any CNA, CMA or nurse not fulfilling their duties, general care standards, maintain residents' dignity and privacy at all times, ensure residents have access to water, call light and personal items, and preventing and identifying abuse, neglect, or unusual behavior. The corrective actions were completed prior to the onsite survey therefore, the deficient practice was cited as past noncompliance at a scope and severity of G (isolated, actual harm).

The facility identified a census of 37 residents. The sample included 12 residents, with five residents reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure a safe environment free from accident hazards for Resident (R) 32 when staff transferred R32 with the assistance of one staff instead of two, and failed to use a gait belt (belt used to help transfer or stabilize during activity). This deficient practice resulted in a fall that caused a fracture (broken bone). The facility also failed to implement new fall interventions for R11. This placed R32 and R11 at risk for preventable falls and related injuries. Findings included: - R32's Electronic Medical Record (EMR) documented diagnoses of hemiplegia and hemiparesis (weakness and paralysis on one side of the body) following a cerebral vascular incident (CVA - stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), insomnia (inability to sleep), delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), major depressive disorder (major mood disorder that causes persistent feelings of sadness), displaced closed fracture (traumatic bone break where two ends of the bone separate out of their normal positions without a break in the skin), and a history of falling. R32's Annual Minimum Data Set (MDS) dated [DATE] documented she had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R32 had impairment of both the upper and lower extremities on one side. The MDS recorded R32 required substantial assistance to total dependence on staff for her functional abilities and activities of daily living (ADL). The MDS recorded R32 had no history of falls since the previous assessment. R32 had a recent surgery that required skilled nursing care. R32's Falls Care Area Assessment (CAA) dated 01/03/25 documented R32 had a fall with a major injury (hip fracture) because she attempted to transfer without waiting for adequate staff assistance. R32 had hemiparesis following a CVA. R32's Care Plan revised on 10/23/24 directed staff that she had a fall on 10/19/24 and staff were to use a gait belt with two-person assistance for transfers. The plan of care directed staff to provide care in pairs (two staff present). The plan of care directed staff to check R32's range of motion after a fall. and continue interventions on the at-risk plan. The plan of care directed staff if the resident had a fall with no apparent acute injuries, staff were to determine and address causative factors of the fall. R32's plan of care lacked any new intervention related to the fall on 12/20/24. R32's Progress Notes tab of the EMR documented an Event Note: Fall Related by Licensed Nurse (LN) J, dated 12/20/24. The note stated the Certified Nurse Aide (CNA) came to the nurse stating R32 fell on to the floor. On entering R32's room, LN J observed R32 on the floor; the resident's legs were towards the bed. The note documented R32 hit her head as she fell to the floor while transferring from her bed to her wheelchair. The note documented R32 grabbed the armrest of the wheelchair and stood up; R32 then lost her balance attempting to pivot around into the wheelchair. The note documented that after the fall, R32 complained of a headache. Staff notified the provider, director of nursing (DON), and family representative. An Event Note: Fall Related in R32's EMR dated 12/20/24 at 07:44 PM documented a late entry addendum to the previous note on 12/20/24. The note reported the CNA told the nurse the CNA was transferring R32 from the bed to her wheelchair when R32 lost her balance and fell . The note documented the CNA lowered R32 to the floor. The note documented R32's head was facing the bed, and her legs were under the end side of her bed. R32 told staff her foot hurt, though assessment revealed there was no shortening of either leg or rotation of either foot. The note documented two CNAs transferred R32 back into bed using the Hoyer (total body mechanical lift) lift. An Event Note: Fall Related in R32's EMR dated 12/21/24 at 02:35 AM documented R32 was on fall follow-up with neurological checks. The note recorded R32 said she had not hit her head when she fell but her left leg really hurt. Later that day R32 complained her whole body hurt. The note recorded R32 said she had hit her head, and she wanted a pain pill but not Tylenol (a pain medication). An Alert Note in R32's EMR dated 12/21/24 at 09:16 AM documented R32 complained of leg pain and called Emergency Medical Services (EMS) on her own. Staff notified the provider, DON, and family representative. The note documented R32 stated her pain stemmed from the fall she had the previous day; she said she was in pain all night, and she needed something stronger than Tylenol. The note documented R32 told the emergency services technicians (EMT) that she wanted something stronger than Tylenol. EMS transported R32 to the hospital. An Alert Note in R32's EMR dated 12/21/24 at 12:15 PM documented LN G spoke with the hospital Emergency Department (ED) who reported R32 admitted for a hip fracture. The note documented the ED reported R32's hip fracture surprised the ED staff because R32 yelled about being in pain, but then fell asleep. Staff notified R32's on-call provider, DON, and family representative. A SPN: Admission Note dated 12/24/24 at 03:33 PM in R32's EMR documented R32 arrived at the facility at 02:45 PM via facility transportation. The note documented R32 came back to the facility in a bad mood and refused to go to her room to be assessed; R32 refused three times and stated she wanted to stay up in her wheelchair for dinner. The note recorded R32 stated the hospital staff was mean and rude to her which was why she was in a bad mood. The note documented the staff told R32 if she laid down, facility staff would get her back up for dinner, but the resident refused to lay down for the admission assessment. An After Visit Summary in the Misc. tab of R32's EMR dated 12/24/24 documented a hospital stay from 12/21/24 to 12/24/24 for a hip fracture. The summary noted a left hip percutaneous pinning (a surgical procedure where pins or screws are inserted through small incisions in the skin to hold the broken bone fragments together) surgery was performed on 12/22/24. The discharge instructions included directions for activity as tolerated, instructed by physical therapy. The discharge instructions directed R32 to follow up with the orthopedic surgeon (surgeon specializing in bones) in two weeks. An Event Note: Fall Related dated 12/26/24 at 01:18 PM in R32's EMR documented the Interdisciplinary Team (IDT) met to discuss R32's fall on 12/20/24. The note documented CNA N, who was new, had transferred R32 with just one staff because R32 had insisted. The note documented CNA N lowered R32 to the floor. CNA N stated R32 did not hit her head but R32 stated she had. The note recorded staff determined that R32 needed two-person assistance with transfers using a gait belt as the root cause for the fall. The IDT reviewed R32's Care Plan and noted staff were directed to provide care in pairs. The note documented R32 had been sent to the hospital for a hip fracture. A typed Fall Incident Statement given on 05/07/25 by CNA N documented that on 12/20/24, the shift was very busy. CNA N noticed R32 had her call light on, so she knocked and entered R32's room to ask what she needed. R32 told CNA N she wanted to get up and get dressed. CNA N helped her get dressed, and when it was time to transfer R32 from the bed to the wheelchair, CNA N expressed to R32 that she was not confident transferring R32 alone. R32 urgently and strongly insisted that she be assisted immediately. CNA N stated she felt pressured by R32 because she was not confident in transferring R32 alone but R32 insisted, so CNA N proceeded to try to help R32. During the transfer R32 became unsteady. CNA N attempted to prevent the fall by guiding R32 safely to the floor to minimize the impact and ensure R32 did not hit her head or any nearby objects. CNA N immediately looked for the nurse and called for help. The nurse assessed R32, and all the appropriate protocols were followed. Later, two other CNAs along with CNA N assisted R32 into her wheelchair. CNA N then took R32 to the dining room. CNA N stated it was her fault for not thinking the situation through and failing to assert herself when she should have told R32, not yet or waited and called for another CNA. CNA N said it was a very busy time and she could not find anyone else to help, so CNA N simply followed what R32 instructed her to do because CNA N felt pressured. CNA N stated she had learned her lesson and would make it a priority to follow all transfer protocols in the future to ensure the safety of the residents. On 05/07/25 at 08:48 AM, R32 lay in her bed. She stated on the day of the accident only one staff member assisted her while she was transferred. R32 stated CNA N did not use a gait belt while she assisted R32 with the transfer from the bed to the wheelchair. On 05/07/25 at 08:50 AM, Administrative Staff A stated R32's fall on 12/20/24 was not called into the State Agency as the resident was able to tell staff exactly what happened, and the situation which caused the fall. Administrative Staff A stated when the incident happened there was no concern over any injuries because R32's only reported mild pain. Administrative Staff A stated it was not until the day after the incident that R32 notified staff of her severe pain and was sent to the hospital for evaluation. The facility's Accident and Incidents-Investigating and Reporting policy dated 10/24 documented that all accidents or incidents involving residents, employees, and vendors, occurring on the facility's premises shall be investigated and reported to the Administrator. The Nurse Supervisor shall promptly initiate and document an investigation of the accident or incident. The facility would strive in compliance with current rules and regulations governing accidents and incidents involving a medical device. 49634 - R11's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of Overactive bladder, Psychotic disorder (a severe mental illness characterized by a significant impairment in an individual's ability to distinguish between reality and fantasy), substance dependence, delusional disorders (a mental illness where individuals experience one or more non-bizarre delusions for at least a month, without other signs of psychosis like hallucinations or disorganized thinking), major depressive disorder (major mood disorder that causes persistent feelings of sadness), epilepsy (brain disorder characterized by repeated seizures), mood effective disorder (characterized by significant disturbances in mood, encompassing a range of conditions from depression to mania), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hypertension (high blood pressure), lack of coordination, muscle weakness, repeated falls, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), reduced mobility need for assistance with personal care, flaccid (weak and flabby) hemiplegia (paralysis of one side of the body) effecting left nondominant side, pain, and vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain). The Quarterly Minimum Data Set (MDS) for R11 dated 03/31/25 recorded a Brief Interview for Mental Status (BIMS) score of seven, which indicated severely impaired cognition. The MDS documented R11 required staff to set up and clean up when eating and needed substantial to maximum assistance from staff with dressing and toileting. The MDS documented R11 was frequently incontinent and had one fall with injury. R11's Falls Care Area Assessment (CAA) dated 07/08/24 documented R11 had a fall with a skin tear to his left calf of his leg. R11's Care Plan, revised on 08/05/24, documented staff would offer bathroom assistance to R11 when doing rounds when he was awake. R11's plan of care, revised on 08/12/24, documented that staff were to help with transfers before and after meals and at bedtime. R11's plan of care, dated 09/01/23, documented signs would be added to R11's room and bathroom to remind him to call for assistance.R11's plan of care documented a fall on 03/05/25; the intervention was to place nonskid strips on the threshold of the bathroom entrance. On 05/05/25 at 07:05 AM, R11 laid on his back in bed, with his right leg hanging off the bed. R11's bathroom did not have nonskid strips placed. On 05/06/25 at 08:51 AM, R11 was sitting on the side of his bed. R11's bathroom did not have nonskid strips placed. On 05/07/25 at 10:24 AM, Licensed Nurse (LN) I stated that interventions that were put in place should be followed through. LN I stated she was unsure how the communication was related to staff on what interventions for falls had been put in place. On 05/07/25 at 10:42 AM, Certified Nurse's Aide (CNA)M stated that if a new intervention had been put in place for a fall, she would know this information by asking her nurse. She stated the nurse on duty would inform her of any falls that had happened and the interventions put in place. She stated she does not have access to the care plan. On 05/07/25 at 11:02 AM, Administrative Nurse D stated all staff have access to the communication board, and that was where interventions that had recently been put in place would be found. He stated that staff are asked to read the communications from the last day the staff member had worked to the current day. The facility's Accidents and Incidents policy, dated 10/24, documented all accidents or incidents involving residents, employees, visitors, vendors, occurring in the facility, the nurse supervisor would promptly initiate and document an investigation of the accident or incident. Premises shall be investigated and reported to the Administrator.

The facility had a census of 37 residents. Based on observation, interview, and record review, the facility failed to date three insulin pens when opened, ensure medications were secure when unattended, and failed to remove expired medication from use. This deficient practice placed residents who may have received those medications at risk for ineffective medication. Findings included: - On 05/05/25 at 07:08 AM, the facility's east hall nurse medication and treatment cart held three opened, undated insulin pens for three different residents. Licensed Nurse (LN) H verified the lack of dates. On 05/05/25 at 02:10 PM, the west hall nurse treatment cart was unlocked and unattended by licensed staff. At that time, Administrative Nurse D and Administrative Staff A verified that it should not be unlocked when out of sight of the licensed staff and started looking for the staff responsible for the cart. LN G came out of a closed resident's room near the cart. On 05/06/25 at 07:16 AM, the facility's medication room refrigerator held two vials of Prevnar 23 (pneumococcal vaccine that protects against 23 types of pneumococcal bacteria), single syringes that expired in October 2024, and three vials of Moderna COVID-19 vaccine that expired on 03/10/25. The medication refrigerator temperature logs lacked documentation for May 2025. On 05/07/2025 at 1100 AM, Administrative Nurse D verified that staff were to date insulin pens when opened and dispose of them 28 days after opening. He verified that licensed staff should remove expired medications from potential use. The facility's Storage Recommendations for Injectable Diabetes Medications guidelines, dated 2024, stated that if insulin pens were opened, they were approved for use for 28 days. The facility's Storage of Medications policy, dated 03/2025, stated the facility would store all drugs and biologicals in a safe, secure, and orderly manner. The facility should not use discontinued, outdated, or deteriorated drugs or biologicals. Compartments containing drugs and biologicals should be locked when not in use, and carts used to transport such items should not be left unattended if open or otherwise potentially available to others.

The facility identified a census of 37 residents. The sample included 12 residents, four Certified Nurse Aides (CNAs), and one Certified Medication Aide (CMA) who were sampled for performance reviews. Based on record review and interview, the facility failed to complete the required nurse aide performance review at least once every 12 months. This placed the residents at risk for inadequate care. Findings included: - A review of the facility's staffing list revealed the following CNAs and a CMA were employed with the facility for more than 12 months, lacked evidence that a performance review had been completed: CMA R with a hire date of 01/18/17. The facility lacked evidence that a performance review was completed in the last 12 calendar months upon request. CNA Q with a hire date of 04/01/21. The facility lacked evidence that a performance review was completed in the last 12 calendar months upon request. CNA O with a hire date of 03/07/22. The facility lacked evidence that a performance review was completed in the last 12 calendar months upon request. CNA P with a hired date of 03/22/22. The facility lacked evidence that a performance review was completed in the last 12 calendar months upon request. CNA MM with a hire date of 09/01/22. The facility lacked evidence that a performance review was completed in the last 12 calendar months upon request. On 05/07/25 at 11:08 AM, Administrative Nurse D stated he had not been able to find where prior management staff completed nurse aide performance reviews as required. Administrative Nurse D stated that he would be completing performance reviews on the nurse aide staff and would have them scheduled annually going forward. The facility lacked a policy for nurse aide performance evaluations.

The facility identified a census of 37 residents. The sample includes 12 residents. Based on observation, record review, and interviews, the facility failed to provide consistent weekend activities. This deficient practice placed the affected residents at risk for decreased psychosocial well-being. Findings included: - A review of the facility's Activity Calendar for March, April, and May 2025 was completed. The review revealed in March 2025 the following weekend activities were scheduled: Activities in March revealed on Saturday's hydration cart, daily chronicles, activity cart, and movie matinee. On Saturday, 05/08/25, Karaoke with [NAME], and Bingo with Sannie. On Sundays in March, TV worship hour, an activity cart, and a Tubi movie. On 03/16/25, Victory Hill Church Singers. The review revealed in April 2025, the following weekend activities were scheduled: Activities for April Saturdays: hydration cart, daily chronicles activity cart on 04/05/25, bingo with [NAME], and 04/12/25 rise and shine roaming East, bingo, [NAME] store, jewelry making, and making and eating pinwheels. On 04/19, bingo. On Sundays in April, TV worship, activity cart, and Tubi movie, on 04/13/25, an Easter egg hunt, and on 04/27/25, Victory Hill Church singers. The review revealed in May 2025, the following weekend activities were scheduled: Activities for May on Saturdays: a hydration cart, daily chronicles, an activity cart, and a movie matinee. On 05/10/25, activities with [NAME], on 05/17/25, a garden meet, and on 05/24/25, activities with [NAME]. On Sunday's TV worship, activity cart, and a Tubi movie, on 05/25/25, Victory Hill Church singers. On 05/06/25 at 10:05 AM, Resident Council members reported that activities rarely occurred on weekends, and never a variety of activities on weekdays. The council reported that they watched TV or read. The council reported they would like activities on the weekends, such as interactive groups, and they stated they would like to have staff lead the activities. On 05/07/25 at 10:44 AM, Activities Staff Z stated she lets residents do their own thing on the weekends. Activities Staff Z stated she does leave the activities cart on for the residents on the weekends. She stated that staff could put a movie in for the residents, and residents do very well leading their own activities. On 05/07/25 at 10:53 AM, Certified Nurse's Aide (CNA) M stated she did not do activities on the weekends she had worked. The facility's Activities and Social Events policy, dated 10/24, documented the residents have the right to choose the types of activities and social events in which they wish to participate. The facility would provide activities on lost days, including weekends and holidays, as well as scheduled religious and social activities. Residents are free to decide whether to attend any activity or other scheduled events.

The facility identified a census of 37 residents. The sample included 12 residents. Based on observation, record review and interview, the facility failed to report to the State Agency (SA) as required when a Resident (R) 32 had a fall that resulted in a major injury. This placed R32 at risk for ongoing neglect and abuse. Findings included: - R32 ' s Electronic Medical Record (EMR) documented diagnoses of hemiplegia and hemiparesis (weakness and paralysis on one side of the body) following a cerebral vascular incident (CVA -stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), insomnia (inability to sleep), delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), major depressive disorder (major mood disorder that causes persistent feelings of sadness), displaced closed fracture (traumatic bone break where two ends of the bone separate out of their normal positions without a break in the skin), and history of falling. R32 ' s Annual Minimum Data Set (MDS) dated [DATE] documented she had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R32 had impairment on one side of her upper and lower extremities. R32 required substantial assistance to being totally dependent on staff for her functional abilities and activities of daily living (ADL). R32 had no history of falls since the previous assessment. R32 had a recent surgery that required skilled nursing care. R32 ' s Falls Care Area Assessment (CAA) dated 01/03/25 documented R32 had an actual fall with a major injury (hip fracture) because she attempted to transfer without waiting for adequate staff assistance. R32 had hemiparesis following a CVA. R32 ' s Care Plan, revised 1/07/25, directed staff that she had an actual fall on 10/19/24, and staff were to use a gait belt with two-person assistance for transfers. R32's plan of care directed staff to provide cares in pairs. R32 ' s care plan lacked a new intervention that was initiated post-fall on 12/20/24. R32 ' s Progress Notes tab of the EMR documented an Event Note: Fall Related by Licensed Nurse (LN) J, dated 12/20/24. The note stated the Certified Nurse Aide (CNA) came to the nurse stating R32 fell on to the floor. On entering R32 ' s room, she was on the floor with her legs facing the bed. R32 hit her head as she fell to the floor. R32 was being transferred from the bed to her wheelchair, R32 grabbed the armrest of a wheelchair, and when R32 stood up, she lost her balance attempting to pivot around into the wheelchair. R32 complained of a headache. The provider, director of nursing (DON), and family representative were called and notified of incident. An Event Note: Fall Related in R32 ' s EMR dated 12/20/24 at 07:44 PM documented a late entry addendum to the Fall note on 12/20/24 at 06:00 PM. The CNA stated to the nurse, as the nurse walked into R32 ' s room, that she was transferring R32 from the bed to her wheelchair. R32 fell when she lost her balance. The CNA lowered R32 to the floor. R32 ' s head was facing the bed, with her legs under the lower side of her bed. R32 stated her foot hurt. Upon assessment, there was no shortening of either leg and no turning in or out of either foot. The two CNAs transferred R32 back into bed using the Hoyer (total body mechanical lift) lift. An Event Note: Fall Related in R32 ' s EMR dated 12/21/24 at 02:35 AM documented R32 on fall follow-up with neurological checks. R32 stated she did not hit her head when she fell , but that her left leg really hurts. Later, R32 complained her whole body was hurting and that she did hit her head and stated she wanted a pain pill and not Tylenol (a nonsteroidal pain medication). An Alert Note in R32 ' s EMR dated 12/21/24 at 09:16 AM documented R32 complained of leg pain and called emergency medical services (EMS) on her own. The provider, DON, and family representative were notified. R32 stated that this pain stemmed from the fall she had yesterday, and it had been hurting her all night, and she needed something stronger than Tylenol. R32 told the emergency services technicians (EMT) that she wanted something stronger than Tylenol and that was all she had been given for her pain management. R32 was transported to the hospital by EMS. An Alert Note in the EMR dated 12/21/24 at 12:15 PM documented Licensed Nurse (LN) G spoke with the hospital emergency department (ER). The ER stated that R32 was going to be admitted for a hip fracture. The ER stated it was a surprise about the hip fracture because R32 yelled about being in pain, then she would fall asleep. R32 ' s on-call provider, DON, and family representative were notified. A SPN: Admission Note dated 12/24/24 at 03:33 PM in R32 ' s EMR documented R32 arrived at the facility at 02:45 PM by facility transportation. R32 came back to the facility in a bad mood and refused to go to her room to be assessed. R32 refused three times and stated she wanted to stay in her wheelchair for dinner. R32 stated that the hospital nurses and CNAs had been mean to her and rude to her, which was why she was in a bad mood. R32 remained in her wheelchair in the dining room, sleeping in her wheelchair. R32 was told that if she lay down, the staff would get her back up for dinner, and R32 refused to lie down for admission assessment. This nurse would pass the information on to the night shift to do the skin assessment on the resident. R32 remained in her wheelchair in the dining room, sleeping in her wheelchair. A After Visit Summary in the Misc. tab of the EMR dated 12/24/24 documented a hospital stay from 12/21/24 to 12/24/24 for a hip fracture. A left hip percutaneous pinning (a surgical procedure where pins or screws are inserted through small incisions in the skin to hold the broken bone fragments together) surgery was performed on 12/22/24. Discharge instructions included activity as tolerated and were instructed by physical therapy. R32 to follow up with the orthopedic surgeon in two weeks. An Event Note: Fall Related dated 12/26/24 at 01:18 PM in R32 ' s EMR documented the Interdisciplinary Team (IDT) met to discuss R32 ' s fall on 12/20/24. R32 had threatened the new CNA N to transfer her by herself. CNA N lowered R32 to the floor. CNA N stated R32 did not hit her head, but R32 stated she had. The root cause was determined that R32 needed a two-person assist with transfers using a gait belt. R32 ' s care plan was reviewed, and it was to provide care in pairs. R32 had been sent to the hospital for a hip fracture. A typed Fall Incident Statement received on 05/07/25 by CNA N documented: On 12/20/24, it was a very busy shift. CNA N noticed that R32 had her call light on, so she knocked and entered R32 ' s room to ask how she could be assisted. R32 told CNA N she wanted to get up and get dressed. CNA N helped her get dressed, and when it was time to transfer R32 from the bed to the wheelchair, CNA N expressed to R32 that she was not confident transferring her alone. R32 expressed the urgency and strongly insisted that she be assisted immediately. CNA N stated she felt pressured by R32 because she was not confident in transferring R32 alone, but R32 insisted CNA N did it anyway, so then CNA N proceeded to try to help her. During the transfer, the R32 became unsteady. CNA N attempted to prevent the fall by guiding R32 safely to the floor, to minimize the impact, and ensuring R32 did not hit her head or any nearby objects. CNA N immediately looked for the nurse and called for help. The nurse assessed the R32, and all the appropriate protocols were followed. Later, two other CNAs, along with CNA N, assisted the R32 into her wheelchair. CNA N continued helping R32 while doing this, R32 and I talked about the situation that had just occurred. CNA N then took R3 to the dining room. CNA N said it was her fault for not thinking the situation through and failing to assert herself when CNA N should have told R32, not yet, or waited and called for another CNA. CNA N said it was a very busy time, and she could not find anyone else to help, so she simply followed what R32 instructed her to do because she felt pressured. CNA N stated she had learned her lesson and would make it a priority to follow all transfer protocols in the future to ensure the safety of the residents. A witness statement was requested by Licensed Nurse (LN) J regarding this incident, but was not received as requested. The facility failed to report R32 ' s fall, which resulted in a major injury to the SA. On 05/07/25 at 08:48 AM, R32, laid in her bed, stated that on the day of the accident, only one staff member assisted her while she was transferred. R32 stated the CNA did not use a gait belt while she assisted with the transfer from her bed to the wheelchair. On 05/07/25 at 08:50 AM, Administrative Staff A stated this fall was not called into the state, as the resident was able to tell us exactly what happened, and the situation that occurred that caused the fall. Administrative Staff A stated that, also, when the incident happened, there was no concern over any injuries, due to R32 ' s reporting of mild pain. Administrative Staff A stated it was not until the day after the incident that R32 notified us of the severe pain and was sent to the hospital for evaluation. The facility's Accident and Incidents-Investigating and Reporting policy, dated 10/24, documented all accidents or incidents involving residents, employees, or vendors occurring on the facility's premises shall be investigated and reported to the Administrator. The Nurse Supervisor shall promptly initiate and document an investigation of the accident or incident. The facility would strive to be in compliance with current rules and regulations governing accidents and incidents involving a medical device.

The facility had a census of 37 residents, with 12 sampled, including two residents reviewed for hospitalization . Based on interview and record review, the facility failed to provide a Bed Hold Notice to Resident (R) 18 or her representative, upon transfer and admission to a hospital. This deficient practice placed R18 at risk for not being permitted to return and resume residence in the nursing facility. The facility further failed to provide a written notification of transfer to R12 or the resident's representative as soon as practicable, which included the required information. Findings included: - R18's Electronic Medical Record documented diagnoses of chronic obstructive pulmonary disease (COPD - progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), acute and chronic respiratory failure with hypoxia (inadequate supply of oxygen), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), anxiety disorder (mental or emotional disorder characterized by apprehension, uncertainty and irrational fear), and congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid). R18's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate impairment of cognition. The MDS documented R18 was dependent on or required staff assistance with most activities of daily living. The MDS documented R18 received numerous medications. R18's Care Plan, dated 04/14/25, directed staff to administer medications as ordered, monitor for side effects, and assess effectiveness. R18's medical record documented R18 was hospitalized on [DATE] and again on 04/30/25. The facility lacked documentation R18 or her representative were provided the bed hold policy or notice at those times. On 05/06/25 at 04:05 PM, R18 was in her room in a wheelchair. R18 stated she had two mice (one white, one gray) that visited her, and she had named them. She talked about other residents and staff, and after talking, she decided to take her concerns to the facility administrator. On 05/06/25 at 09:30 AM, Administrative Staff A reported that the facility should have provided R18 a Bed Hold Notice when she was hospitalized on [DATE] and 04/30/25. The facility's Bed Hold policy, dated 04/2025, stated the facility would inform residents prior to a transfer for hospitalization of the bed hold policy. When emergency transfers were necessary, the facility would provide the resident and their representative with information concerning the bed hold policy per state law. 41713 - R12 ' s Electronic Medical Record (EMR) documented diagnoses of multiple sclerosis (MS - progressive disease of the nerve fibers of the brain and spinal cord), seizures (violent involuntary series of contractions of a group of muscles), respiratory failure (a condition in which your blood does not have enough oxygen), and pneumonia (a lung infection that causes inflammation and fluid buildup in the air sacs, making it difficult to breathe). R12 ' s Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of one, which indicated severely impaired cognition. The MDS documented R12 functional limitation in range of motion with impairment on both sides of the upper and lower extremities. The MDS documented R12 was dependent on staff for all activities of daily living and functional abilities. The MDS documented R12 had an indwelling catheter (tube placed in the bladder to drain urine into a collection bag). The MDS documented R12 had pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). The MDS documented R12 required a gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach) for his nutritional needs. The MDS documented R12 required supplemental oxygen therapy. R12 ' s Discharge MDS dated [DATE] documented an unplanned discharge to an acute hospital with a return anticipated. R12 ' s Entry MDS dated [DATE] documented a re-entry to the facility from an acute hospital. The facility failed to provide the required written notification of transfer to R12 and or his representative for this facility-initiated discharge. R12 ' s Discharge MDS dated [DATE] documented an unplanned discharge to an acute hospital with a return anticipated. R12 ' s Entry MDS dated [DATE] documented a re-entry to the facility from an acute hospital. The facility failed to provide the required written notification of transfer to R12 and or his representative for this facility-initiated discharge. R12 ' s Discharge MDS dated [DATE] documented an unplanned discharge to an acute hospital with a return anticipated. R12 ' s Entry MDS dated [DATE] documented a re-entry to the facility from an acute hospital. The facility failed to provide the required written notification of transfer to R12 and or his representative for this facility-initiated discharge. R12 ' s Discharge MDS dated [DATE] documented an unplanned discharge to an acute hospital with a return anticipated. R12 ' s Entry MDS dated [DATE] documented a re-entry to the facility from an acute hospital. The facility failed to provide the required written notification of transfer to R12 and or his representative for this facility-initiated discharge. R12 ' s Discharge MDS dated [DATE] documented an unplanned discharge to an acute hospital with a return anticipated. R12 ' s Entry MDS dated [DATE] documented a re-entry to the facility from an acute hospital. The facility failed to provide the required written notification of transfer to R12 and or his representative for this facility-initiated discharge. R12 ' s Discharge MDS dated [DATE] documented an unplanned discharge to an acute hospital with a return anticipated. R12 ' s Entry MDS dated [DATE] documented a re-entry to the facility from an acute hospital. The facility failed to provide the required written notification of transfer to R12 and or his representative for this facility-initiated discharge. R12 ' s Discharge MDS dated [DATE] documented an unplanned discharge to an acute hospital with a return anticipated. R12 ' s Entry MDS dated [DATE] documented a re-entry to the facility from an acute hospital. The facility failed to provide the required written notification of transfer to R12 and or his representative for this facility-initiated discharge. R12 ' s Nutrition Care Area Assessment (CAA) dated 10/25/24 documented he required a G-tube for all nutritional and hydration needs. R12 ' s Care Plan, revised on 04/06/25, directed staff to give all medications as directed. The plan of care directed staff to position R32 with the head of the bed elevated to 30 to 40 degrees as needed to facilitate breathing. The plan of care directed staff to provide breathing treatments as ordered and ensure prompt treatment of any respiratory infections. On 05/06/25 at 08:13 AM, R12 laid on his bed, the head of the bed was elevated, with his enteral feeding infusing through his G-tube. R12 had his supplemental oxygen on via nasal cannula (NC - a hollow tube to assist with providing supplemental oxygen). On 05/07/25 at 08:15 AM, Administrative Staff A stated that the prior social services person had not been doing all the bed holds and providing the written notification of transfer as required. Administrative Staff A stated that going forward, he would ensure that both the bed holds and the required written notification were provided upon any discharge. The facility's Transfer and or Discharge, Including Against Medical Advice, Discharge Notification policy, dated 04/25, documented the facility had established transfer and discharge criteria based upon applicable federal requirements. The facility would provide a resident and or the resident's representative with a thirty-day written notice of an impending transfer or discharge when specific criteria had not been reached.

The facility identified a census of 37 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure staff developed and implemented a comprehensive care plan for Resident (R) 29 that included staff direction for activities of daily living (ADL) care. This placed R29 at risk of impaired care due to uncommunicated care needs. Findings included: - R29 ' s Electronic Medical Record (EMR) documented diagnoses of hypertension (HTN - elevated blood pressure), cerebral infarction (stroke), tracheostomy status (opening through the neck into the trachea through which an indwelling tube may be inserted), and gastrostomy status (G-tube: tube surgically placed through an artificial opening into the stomach). R29 ' s Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R29 used a walker or a wheelchair to assist with mobility. The MDS documented R29 required partial to moderated assistance from staff for toileting, bathing, and personal hygiene. The MDS documented R29 had a tracheostomy. R29 ' s Functional Abilities Care Area Assessment (CAA) dated 03/09/25 documented she had decreased functional abilities due to impaired strength and mobility. R29 ' s Care Plan, revised on 05/04/25, directed staff to administer medications as ordered. R29's plan of care directed staff to converse with R29 while providing care. R29 ' s care plan lacked staff direction for her activities of daily living (ADL) care and functional ability assistance. On 05/06/25 at 11:45 AM, R29 wheeled herself out of her room in her wheelchair. On 05/07/25 at 10:24 AM, Licensed Nurse (LN) I stated all nurses were to put interventions in the care plan for each fall. She stated the intervention was communicated to all staff during staff huddles. On 05/07/25 at 10:53 AM, Certified Nurse's Aide (CNA) M stated she did not have access to the care plan. She stated she would ask her nurse, or her nurse would let her know if there were special instructions for each resident she was to care for. On 05/07/25 at 11:02 AM, Administrative Nurse D stated that the administrative staff meet each week, and if there had been a fall, the team discussed interventions. He stated the intervention for the fall was put into the care plan during the meeting. The facility's Comprehensive Care Plan policy, dated 03/25, documented an individualized comprehensive person-centered care plan that included measurable objectives and time frames to meet the resident's medical, nursing, mental, cultural, and psychological needs was developed for each resident. The care plan should describe the resident's nursing, medical physician and mental and psychosocial preferences, they should have specific, measurable objectives and time frames with a goal.

The facility identified a census of 37 residents. The sample included 12 residents, with one resident reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to revise the comprehensive care plan to include interventions for falls for Resident (R) 11. This defiant practice placed R11 at increased risk for future falls. Findings included: - R11 ' s Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of Overactive bladder, Psychotic disorder (a severe mental illness characterized by a significant impairment in an individual's ability to distinguish between reality and fantasy), substance dependence, delusional disorders (a mental illness where individuals experience one or more non-bizarre delusions for at least a month, without other signs of psychosis like hallucinations or disorganized thinking), major depressive disorder (major mood disorder that causes persistent feelings of sadness), epilepsy (brain disorder characterized by repeated seizures), mood effective disorder (characterized by significant disturbances in mood, encompassing a range of conditions from depression to mania), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hypertension (high blood pressure), lack of coordination, muscle weakness, repeated falls, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), reduced mobility need for assistance with personal care, flaccid (weak and flabby) hemiplegia (paralysis of one side of the body) effecting left nondominant side, pain, and vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain). The Quarterly Minimum Data Set (MDS) for R11, dated 03/31/25, recorded a Brief Interview for Mental Status (BIMS) score of seven, which indicated severely impaired cognition. The MDS documented R11 required setup and clean up when eating. The MDS documented R11 needed substantial to maximum assistance from staff for dressing and toileting. The MDS documented R11 was frequently incontinent and had one fall with injury. R11's Falls Care Area assessment dated [DATE] documented R11 had a fall with a skin tear to his left calf of his leg. R11's Care Plan revised on 08/05/24, documented staff would offer bathroom assistance to R11 when doing rounds when he was awake. R11's plan of care, revised on 08/12/24, documented that staff were to help with transfers before and after meals and at bedtime. R11 ' s plan of care dated 09/01/23 documented, signs would be added to R11's room and bathroom to remind him to call for assistance. R11 ' s plan of care documented a fall on 03/05/25, the intervention was to place nonskid strips on the threshold of the bathroom entrance. R11 ' s EMR under Event Note Fall dated 01/29/25 documented the nurse was informed by staff that R11 was on the floor in his room. The nurse arrived at R11's room and observed R11 on the floor sitting upright, with his back against the right side of his bed, and his wheelchair was facing him towards his left side. R11 was alert, and R11 was wearing shoes; no new injuries were noted. R11 was assisted back into his wheelchair. R11 stated he lost his balance and fell . R11 ' s plan of care lacked an intervention for his fall. R11 ' s EMR under Event Note Fall dated 02/02/25 documented the nurse was notified by a CNA that R11 had fallen. Upon entering R11 ' s room, R11 was observed sitting at the end of his bed on his floor with his legs stretched out in front of him. The CNAs applied a gait belt and performed range of motion to all extremities without difficulty. R11 was unable to explain how he ended up on the floor. R11 had his shoes on, his guardian was notified. R11 was helped to a resting position in his bed, with his call light placed at his side. R11 ' s plan of care lacked an intervention for his fall. R11 ' s EMR under Event Note Fall dated 03/02/25 documented nurse was called to R11 ' s room by a Certified Medication Aide (CMA). Upon entering the room, R11 was observed on the floor near the end of his bed with his back to the door. CNAs were getting him fitted with a gait belt to assist him to a standing position. Range of Motion performed. R11 denied hitting his head; his guardian, director of nursing, and physician were notified. The intervention was to place nonskid strips in the entrance threshold of the bathroom. R11 ' s EMR under Event Note Fall dated 05/02/25 documented nurse was notified R11 had fallen and was found on the floor. The director of nursing and the administrator were in R11 ' s room, and a Certified Nurse ' s Aide (CNA). R11 ' s head was resting on the wall, resident admitted to hitting his head on the wall. R11 was helped into his bed without complication. R11 stated he was sitting in his chair. R11 denies passing out. R11 did not remember how he had hit his head. When the nurse asked how he ended up on the floor, he just repeated he was in his chair and then hit his head. This nurse called the resident's guardian and notified her that the resident fell , and the facility was planning to send him to the Emergency Department (ED) for evaluation, due to him admitting to hitting his head. The resident spoke with his guardian, and she agreed to send R11 to the hospital. The resident was then transported to the hospital. R11 ' s care plan lacked an intervention for the fall. On 05/05/25 at 07:05 AM, R11 laid on his back in bed, with his right leg hanging off the bed. On 05/06/25 at 08:51 AM, R11 was sitting on the side of his bed. On 05/07/25 at 10:24 AM, Licensed Nurse (LN) I stated all nurses were to put interventions in the care plan for each fall. She stated the intervention was communicated to all staff during staff huddles. On 05/07/25 at 10:53 AM, Certified Nurse ' s Aide (CNA) M stated she did not have access to the care plan. She stated she would ask her nurse, or her nurse would let her know if there were special instructions for each resident she was to care for. On 05/07/25 at 11:02 AM, Administrative Nurse D stated administrative staff meet each week, and if there has been a fall, the team discusses interventions. He stated the intervention for the fall was put into the care plan during the meeting. The facility ' s Comprehensive Care Plan policy, dated 03/25, documented an individualized, comprehensive person-centered care plan that included measurable objectives and time frames to meet the resident's medical, nursing, mental, cultural, and psychological needs was developed for each resident. The care plan should describe the resident's nursing, medical physician and mental and psychosocial preferences, the care plan should have specific measurable objectives and time frames with a goal.

The facility identified a census of 37 residents. The sample included 12 residents, with two residents reviewed for positioning and mobility. Based on observation, record review, and interviews, the facility failed to assess or provide a restorative range of motion for Resident (R) 16. This deficient practice placed the resident at risk for discomfort, stiffness, and the possibility of forming contracture (abnormal permanent fixation of a joint or muscle). Findings included: - R16's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of seizure (violent involuntary series of contractions of a group of muscles), hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following cerebral infarction (stroke - the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) effecting left nondominant side, attention and concentration deficit, hypertension (high blood pressure), metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), hyperlipidemia (condition of elevated blood lipid levels), and major depressive disorder (major mood disorder that causes persistent feelings of sadness). The Quarterly Minimum Data Set (MDS) dated [DATE] documented R16 had a Brief Interview of Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The MDS documented R16 had impairment on one side of her body, both upper and lower limbs. The MDS documented R16 required set up and clean up for eating, was dependent on staff for toileting, and needed partial to maximum assistance from staff for dressing and bathing. The MDS documented R16 did not receive any therapies during the observation period. R16's The Functional Abilities (Self-Care Mobility) Care Area Assessment (CAA) dated 11/03/24 documented R16 had functional limitations related to medical conditions as well as physical deconditioning. R16 had a stroke, resulting in hemiparesis. R16's Care Plan dated 11/13/24 documented R16 had limited physical mobility related to hemiplegia following a stroke. R16's plan of care documented R16 would maintain or improve her current level of mobility through the review date. R16's plan of care documented she would remain free of complications related to immobility, including contractures, thrombus (blood clot) formation, skin breakdown, and fall-related injuries. The plan of care for R16 stated physical therapy and occupational therapy as ordered, and as needed (PRN). On 05/05/25 at 08:35 AM, R16 laid on her bed, R16's flaccid left hand laid on her lap. On 05/06/25 at 08:30 AM, R16 laid on her bed watching TV. R16's left arm laid on her abdomen. On 05/06/25 at 08:30 AM, R16 stated she had never had range of motion for her hand; she stated she had never had any therapy since coming to the facility. R16 stated she would like to have some kind of therapy. She stated that right now her hand had no contractures, and she would like to have exercises on her hand to ensure she doesn't get contractures. On 05/07/25 at 10:24 AM, Licensed Nurse (LN) I stated the Certified Nurse's Aides (CNAs) were doing exercises with the residents. LN I stated that the orders or education to the CNAs came from the therapy department. She stated that right now, the facility did not have anyone specific for restorative therapy. On 05/07/25 at 10:53 AM, CNA M stated she does not do any range of motion or exercises with the residents. She stated exercises would come from the therapy department. On 05/07/25 at 11:02 AM, Administrative Nurse D stated that at this time the facility did not have a restorative aide and did not have a restorative therapy program. On 05/07/25 at 11:05 AM, Consultant Nurse GG stated that at this time the facility did not have a restorative aide, and the facility was looking into the restorative program. The facility's Range of Motion Exercises policy dated 10/24 documented residents with limited range of motion would receive appropriate treatment and services to increase range of motion and or prevent further decrease in range of motion. Residents with a limited ability of mobility would receive appropriate services, equipment, and assistance to maintain and improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrably unavoidable.

The facility identified a census of 37 residents. The sample included 12 residents. Based on record review and interview, the facility failed to ensure that the daily posted nurse staffing data included the facility census. Findings included: - On 05/06/25 at 01:20 PM, the daily posted staffing sheets were requested for the past 18 months. The daily posted staffing sheets reviewed from 01/01/24 to 03/31/25 lacked the daily facility census number. On 05/07/25 at 11:00 AM, Administrative Nurse D stated the staffing coordinator was responsible for ensuring that the daily posted staffing sheet was posted. Administrative Nurse D stated that he had been made aware recently that the daily posted staffing sheets had not included the census number and has since corrected the issue. The facility's Posting Direct Care Daily Staffing Numbers dated 10/24 documented the facility would post on a daily basis for each shift, the number of personnel responsible for providing direct care to residents.

The facility identified a census of 37 residents. The sample included 12 residents, who were reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to ensure a communication process was implemented, which included how the communication would be documented between the facility and the hospice provider. This deficient practice created a risk for missed or delayed services and impaired care for Resident (R) 30 and R25. Findings Included: - R30's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of cerebrovascular accident (CVA - stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), respiratory failure with hypoxia (occurs when the lungs cannot adequately transfer oxygen into the blood, leading to a low level of oxygen in the blood and tissues), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), pain, unsteadiness on feet, lack of coordination, weakness, diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hypertension (high blood pressure), muscle weakness, and major depressive disorder (major mood disorder that causes persistent feelings of sadness). The Quarterly Minimum Data Set (MDS) for R30 dated 03/21/25 recorded a Brief Interview for Mental Status (BIMS) score of seven, which indicated severely impaired cognition. The MDS documented R30 was independent with eating, required partial to moderate assistance from staff for toileting, and was dependent on staff with bathing. The MDS documented R30 received hospice services during the observation period. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 11/25/24 documented R30 had occasional incontinence and required some assistance with toilet transfers. R30's Care Plan dated 02/05/2025 documented R30 was admitted to hospice and requires palliative care due to end-of-life processes. The plan of care documented the relative amounts and types of curative, restorative, and palliative care appropriate for R30 would be dependent on the individual goals of care and informed choices. R30's plan of care documented activity as tolerated, and staff would administer medications for comfort before activity and or care (Pain medications/respiratory treatments) as ordered. The plan of care for R30 documented staff would assist with supporting activities of daily living (ADL) function of ambulation and mobility to the extent needed. R30's plan of care lacked collaboration of care with the facility and the hospice provider. A review of the hospice-provided communication binder revealed R30 was admitted to hospice services on 02/04/25. On 05/05/25 at 09:42 AM, R30 laid in her bed with her head covered with a blanket. On 05/07/25 at 10:24 AM, Licensed Nurse (LN) I stated she knew each resident who required hospice services had a binder, and she was sure the information was in the binder. LN I stated that the hospice aides communicated with staff, and the staff left the facility knowing what equipment was provided and if bathing was done. LN I stated she was not sure about supplies, as normally the aide would just leave supplies in the resident's rooms. On 05/07/25 at 10:53 AM, Certified Nursing Aide (CNA) M stated she did know where the resident's hospice binders were kept but was unsure what was in the binder. CNA M stated that if she did not know where to find something for a resident, she would go to her nurse. CNA M stated she did not have access to the resident's care plans but could see the care plan if she asked a nurse. On 05/07/25 at 11:02 AM, Administrated Nurse D stated that the care plan for hospice and the care plan for the facility should match. Administrative Nurse D stated hospice and the facility should collaborate on care, and the information should be accessible to staff. The facility's Hospice Program policy, reviewed on 10/24, documented the community may contract for hospice services for residents who wish to participate in such programs, including services that will be provided and the coordination of services. The community may limit the hospice providers in relation to the coordination and communication of care within the community. 41713 - R25 ' s Electronic Medical Record (EMR) documented diagnoses of congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and hypertension (HTN - elevated blood pressure). R25 ' s Significant Change Minimum Data Set (MDS) dated [DATE] documented he had a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderately impaired cognition. R25 had impairment on his lower extremity on one side. R25 was independent to needing partial to moderate staff assistance for his functional abilities. The MDS lacked an indication that R25 was on hospice services. R25 ' s Functional Abilities Care Area Assessment (CAA) dated 05/01/25 documented he required the assistance of one staff for many activities of daily living (ADL). R25 ' s Hospice Care Plan dated 04/21/25 directed staff to adjust the provision of ADLs to compensate for R25 ' s changing abilities. The plan of care directed staff to encourage his participation to the extent the resident wishes to participate, assess his coping strategies, and respect his wishes. The plan of care directed to consult with the physician and Social Services to have hospice care for the resident in the facility. The plan of care directed staff to encourage him to express his feelings and listen with non-judgmental acceptance and compassion. The plan of care directed staff to encourage a support system of family and friends, keep the environment quiet and calm, and keep linens clean, dry, and wrinkle-free. Keep lighting low and familiar objects within reach. The plan of care directed staff to observe R25 closely for signs of pain and administer pain medications as ordered, and notify the physician immediately if there was breakthrough pain. The plan of care directed staff to review R25 ' s living will and ensure it was followed, and involve the family in discussions. The hospice care plan was available for review in the media/copy room closet. The plan of care directed staff to work cooperatively with the hospice team to ensure the R25's spiritual, emotional, intellectual, physical, and social needs are met and work with the nursing staff to provide maximum comfort for the resident. R25 ' s care plan lacked the hospice contact information, how often hospice staff would visit R25, the supplies provided by hospice, the list of medications provided by hospice, and any durable medical equipment (DME) items provided. R25's Orders tab of the EMR documented a physician ' s order dated 04/21/25 for hospice services. R25 ' s Misc. tab of the EMR contained his hospice order and plan of care. On 05/06/25 at 11:15 AM, R25 wheeled himself in his wheelchair about the facility. On 05/07/25 at 10:24 AM, Licensed Nurse (LN) I stated she knew each resident who required hospice services had a binder, and she was sure the information was in the binder. LN I stated that hospice aides communicated with staff, the staff let the facility know what equipment was provided, and if bathing was done. LN I stated she was not sure about supplies, as normally the aide would just leave supplies in the resident ' s rooms. On 05/07/25 at 10:53 AM, Certified Nursing Aide (CNA) M stated she did know where the resident ' s hospice binders were kept but was unsure what was in the binder. CNA M stated that if she did not know where to find something for a resident, she would go to her nurse. CNA M stated she did not have access to the resident ' s care plans but could see the care plan if she asked a nurse. On 05/07/25 at 11:02 AM, Administrated Nurse D stated that the care plan for hospice and the care plan for the facility should match. Administrative Nurse D stated that hospice and the facility should have a collaboration of care, and the information should be accessible to staff. The facility ' s Hospice Program policy, reviewed 10/24, documented the community may contract for hospice services for residents who wish to participate in such programs, including services that would be provided and the coordination of services. The community may limit the hospice providers in relation to the coordination and communication of care within the community.

The facility identified a census of 37 residents. The sample included 12 residents, with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 11, had a time limit of 14-days for his as-needed (PRN) antianxiety (a class of medications that calm and relax people) medication order for Ativan (lorazepam: benzodiazepine medication used to treat anxiety, insomnia (trouble sleeping), severe agitation, and active seizures (violent involuntary series of contractions of a group of muscles)including status eplielticus), and further failed to ensure R32 had a time limit of 14-days for PRN anti-anxiety Ativan with a physician indication of use. This defiant practice placed R11 and R32 for potentially unnecessary psychotropic (alters mood or thought) medication administration. Findings Included: - R11's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of overactive bladder, psychotic disorder (a severe mental illness characterized by a significant impairment in an individual's ability to distinguish between reality and fantasy), substance dependence, delusional disorders (a mental illness where individuals experience one or more non-bizarre delusions for at least a month, without other signs of psychosis like hallucinations or disorganized thinking), major depressive disorder (major mood disorder that causes persistent feelings of sadness), epilepsy (brain disorder characterized by repeated seizures), mood effective disorder (characterized by significant disturbances in mood, encompassing a range of conditions from depression to mania), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hypertension (high blood pressure), lack of coordination, muscle weakness, repeated falls, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), reduced mobility need for assistance with personal care, flaccid (weak and flabby) hemiplegia (paralysis of one side of the body) effecting left nondominant side, pain, and vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of seven, which indicated severely impaired cognition. The MDS documented R11 had impairment on one side of his body. The MDS documented R11 required set up and clean up by staff for eating, and substantial to maximum assistance for dressing and toileting. The MDS documented R11 received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) and an antidepressant (a class of medications used to treat mood disorders) during the observation period. R11 Psychotropic Drug Use Care Area Assessment (CAA) dated 07/08/24 documented R11 used high-risk medications, which could contribute to decreased functionality and less motivation to progress with goals. R11 ' s Care Plan dated 10/27/23 documented R11 was at risk for adverse reactions related to taking medications with Black Box Warning (BBW - the highest safety-related warning that medications can have assigned by the Food and Drug Administration) drugs for patients for whom alternative treatment options were inadequate. Staff were to limit dosages and durations to the minimum required. Staff were to follow patients for signs and symptoms of respiratory depression and sedation. R11 ' s EMR under Orders revealed the following physicians ' orders: Ativan oral tablet 0.5mg (Lorazepam), give one tablet by mouth every eight hours as needed for anxiety, dated 05/01/25. R11 ' s Ativan PRN order lacked a 14-day discontinuation date. On 05/05/25 at 07:05 AM, R11 laid on his back in bed, with his right leg hanging off the bed. On 05/06/25 at 08:51 AM, R11 was sitting on the side of his bed. On 05/07/25 at 10:24 AM, Licensed Nurse (LN) I stated that physicians were not putting in their orders. LN I stated that the nurse taking off the order should be checking the order for accuracy. She stated that, as needed (PRN), psychotropic medications should have a 14-day stop date. On 05/07/25 at 11:02 AM, Administrative Nurse D stated the nurse on duty was responsible for ensuring all orders were entered correctly. He stated R11 ' s PRN Ativan should have had 14 14-day stop date. The facility ' s Free from Chemical Restraints, Unnecessary Psychotropic Medication policy, dated 04/2025, documented chemical restraints shall only be used for the safety and well-being of the residents and only after other alternatives have been tried unsuccessfully. Chemical restraints shall only be used to treat the residents ' medical symptoms and never for discipline or staff convenience. - R32 ' s Electronic Medical Record (EMR) documented diagnoses of hemiplegia and hemiparesis (weakness and paralysis on one side of the body) following a cerebral vascular incident (CVA - stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), insomnia (inability to sleep), delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), major depressive disorder (major mood disorder that causes persistent feelings of sadness), displaced closed fracture (traumatic bone break where two ends of the bone separate out of their normal positions without a break in the skin), and history of falling. R32 ' s Annual Minimum Data Set (MDS) dated [DATE] documented she had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R32 had impairment on one side of her upper and lower extremities. The MDS documented R32 required substantial assistance to being totally dependent on staff for her functional abilities and activities of daily living (ADL). The MDS documented R32 had no history of falls since the previous assessment. The MDS documented R32 had a recent surgery that required skilled nursing care. The MDS documented R32 had received an antidepressant (a class of medications used to treat mood disorders), a hypnotic (medications that depress the central nervous system, leading to relaxation, sedation, and sleep induction), and an opioid (a class of controlled drugs used to treat pain) during the lookback period. R32 ' s Psychotropic Drug Use Care Area Assessment (CAA) dated 01/03/25 documented she used psychotropic medications for depression and to aid in sleep. R32 ' s Behavioral CAA dated 01/03/25 documented she had frequent behavior issues, such as hostile and abusive language towards staff and refusal of care. R32 ' s Care Plan, revised 01/07/25, directed staff to administer medications as ordered. The plan of care documented staff were to monitor and document any side effects and the effectiveness of the medications. R32 ' s Orders tab of the EMR documented a physician ' s order dated 05/01/25 for Ativan (an antianxiety agent) to give 0.5 milligrams (mg) for anxiety at bedtime as needed. This order lacked a 14-day stop date. On 05/07/25 at 08:48 AM, R32 laid in her bed with her curtains drawn and the light off. On 05/07/25 at 10:24 AM, Licensed Nurse (LN) I stated that physicians were not putting in their orders. LN I stated that the nurse taking off the order should have checked the order for accuracy. She stated that, as needed (PRN), psychotropic medications should have a 14-day stop date. On 05/07/25 at 11:02 AM, Administrative Nurse D stated the nurse on duty was responsible for ensuring all orders are entered correctly. He stated R11 ' s PRN Ativan should have had 14 14-day stop date. The facility ' s Free from Chemical Restraints, Unnecessary Psychotropic Medication policy, dated 04/2025, documented chemical restraints shall only be used for the safety and well-being of the residents and only after other alternatives have been tried unsuccessfully. Chemical restraints shall only be used to treat the residents ' medical symptoms and never for discipline or staff convenience.

The facility identified a census of 37 residents. The sample included 12 residents. Based on observation and interview, the facility failed to ensure that residents ' rights and dignity were respected by staff when staff failed to provide a dignity bag for Resident (R) 12's indwelling catheter (tube placed in the bladder to drain urine into a collection bag) bag. This placed R12 at risk for decreased self-esteem and decreased self-worth. Findings: - R12 ' s Electronic Medical Record (EMR) documented diagnoses of multiple sclerosis (MS - progressive disease of the nerve fibers of the brain and spinal cord), seizures (violent involuntary series of contractions of a group of muscles), respiratory failure (a condition in which your blood does not have enough oxygen), and pneumonia (a lung infection that causes inflammation and fluid buildup in the air sacs, making it difficult to breathe). R12 ' s Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of one, which indicated severely impaired cognition. The MDS documented R12 functional limitation in range of motion with impairment on both sides of the upper and lower extremities. The MDS documented R12 was dependent on staff for all activities of daily living and functional abilities. The MDS documented R12 had an indwelling catheter (tube placed in the bladder to drain urine into a collection bag). The MDS documented R12 had pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). The MDS documented R12 required a gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach) for his nutritional needs. The MDS documented R12 required supplemental oxygen therapy. R12 ' s Urinary Continence Care Area Assessment (CAA) dated 10/25/24 documented he had a suprapubic catheter (urinary bladder catheter inserted through the abdomen into the bladder) due to neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system). R12 ' s Care Plan, revised 12/06/24, directed staff to keep the catheter bag below the level of the bladder. The plan of care documented staff were directed to provide routine catheter care. The plan of care documented staff were to observe the catheter tubing for kinks. The plan of care lacked staff direction to provide a dignity bag to cover the catheter collection bag. On 05/05/25 at 08:10 AM, R12 laid in bed with the head of the bed elevated. R12 ' s catheter collection bag was hung on the right side of his bed and was visible from the hallway. The collection bag lacked a dignity bag. On 05/06/25 at 07:09 AM, R12 laid in bed with the head of the bed elevated. R12 ' s catheter collection bag was hung on the right side of his bed and was visible from the hallway. The collection bag lacked a dignity bag. On 05/07/25 at 10:24 AM, Licensed Nurse (LN) I stated she would expect a dignity bag to cover R12 ' s catheter bag, or the bag should be placed on the opposite side of his bed, where it would not be visible from the hallway. On 05/07/25 at 10:53 AM, Certified Nurse Aide (CNA) M stated that the catheter bags should be covered with a dignity bag when the resident was out of their rooms. CNA M stated the bag should be hung on the side of the bed opposite the doorway or be covered with a dignity bag. On 05/07/25 at 11:02 AM, Administrative Nurse D stated that a dignity bag should cover catheter bags when the resident was out of his room. Administrative Nurse D stated the catheter bag should have a dignity bag to cover it while in the room or placed on the opposite side of the bed away from the doorway. The facility's Exercise of Rights/Residents' Rights policy dated 11/24 documented that Residents have the right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility. Residents have the right to be treated with respect and dignity and care that promotes maintenance or enhancement of the resident's quality of life, recognizing each resident ' s individuality. Residents have equal access to quality care, regardless of diagnosis, severity of condition, or payment source.

The facility identified a census of 32 residents. The sample included six residents. Based on record review, observations, and interviews the facility failed to provide care and services that promoted resident dignity for Resident (R) 1. This placed R1 and other residents in the vicinity at risk for impaired dignity and decreased quality of life. Findings included: - The Electronic Medical Record (EMR) documented R1 admitted to the facility on [DATE] with a diagnosis of encephalopathy (diseases of the brain that cause altered mental state and confusion). The EMR recorded R1 had diagnoses of cognitive communication deficit, (problems with communication that have an underlying cause in cognitive deficit rather than a primary language or speech deficit), amnesia, (a partial or total loss of memory), and acute kidney failure (a loss of kidney function caused by illness, infections, or injury). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status score of 11 indicating moderate cognitive impairment. The MDS documented R1 exhibited behaviors of yelling at staff and rejection of care one to three days of the assessment period. The Activities of Daily Living (ADL) Care Area Assessment (CAA) dated 06/20/24 recorded R1 had functional limitations related to medical conditions as well as physical deconditioning. R1 required some assistance with most ADLs including bathing, transfers, and mobility. R1 used a wheelchair for mobility. The Psychosocial CAA dated 06/20/2/4, documented a care plan would be developed due to R1 sometimes yelling at staff members as well as at other residents. R1 sometimes just wanted to be left alone. R1 ' s Care Plan revised 06/28/24 recorded R1 had a history of verbal aggression, refusing care, and physical aggression when agitated. The care plan directed staff to assist R1 in developing appropriate methods of coping and interacting such as: approaching R1 and speaking calmly, diverting R1 ' s attention, and providing opportunities for positive interaction. A Nurse Progress Note, dated 11/14//24 at 01:20 PM documented: that a Certified Nurse Aide (CNA) asked R1 if she wanted a shower, and R1 said no. R1 proceeded to the dining room, where another resident told R1 to put on a smile and R1 stated, I don't like that little black [expletive]. A facility incident report documented on 11/14/24 at 01:10 P.M., CNA O and CNA N asked R1 if she wanted her shower. R1 said, No, get the [expletive] out of here before I call the police. The aides left R1 ' s room. Shortly afterward, R1 wheeled into the dining room where another resident told R1 to put a smile on her face. R1 then looked towards CNA O and said, I don ' t like that little [expletive]. CNA O told R1 You cannot call me that, I wasn ' t named that. R1 then said, Shut up black [expletive]. At that point, CNA O raised her voice and told R1 that it was unacceptable and that she could not speak to her like that. Both were bickering back and forth until one of the medication aides and the social services director stepped in. CNA O was asked to provide a statement along with other staff present and was placed on immediate suspension pending the investigation of verbal abuse towards a resident. Observation on 11/14/24 A 1:10 P.M. revealed CNA O in the facility dining room. CNA O stated to R1 You cannot call me a black [expletive], I will not allow you to disrespect me like that, That is not my name. My name is [CNA O]. If you call me that again I am going to take you to your room. CNA O then continued talking to staff and other residents in a loud voice saying that R1 called her a black [expletive] and repeated this four times. The loud exchange drew the attention of staff and other residents until the Social Services X intervened. On 11/14/24 at 01:47 P.M. R1 sat in a wheelchair in the dining room, dressed appropriately and eating a hamburger, Jello, and lemonade. R1 had a stern, angry, countenance, and was resistant to talk, stating I don ' t like people. R1 became more conversational over time and did not recall or did not want to discuss, the earlier altercation with CNA O. CNA N ' s Witness Statement from 11/14/24 recorded that CNA N took R1 ' s lunch to the room. R1 refused, and when CNA N returned the tray was outside the room and R1 asked another resident, What the hell was she looking at? CNA N documented that R1 then called an aide black [expletive]. CNA M ' s Witness Statement from 11/14/24 documented that at approximately 01:15 P.M., R1 was heard arguing with another resident, but nothing escalated. A few moments later CNA M heard R1 and CNA O arguing. CNA M noted that she then went to Social Services X. CNA O ' s Witness Statement from 11/14/24 documented that R1 looked at CNA O and said she didn ' t like that little [expletive]. CNA O noted she told R1 that she could not call CNA O a [expletive] since CNA O was not named that. CNA O noted that R1 then told CNA O to shut up and called her black [expletive]. CNA O said she told R1 that was unacceptable and told R1 that she could remove herself from the dining room. CNA O noted that Social Services X then entered the area. Social Services X ' s Witness Statement from 11/14/24 documented that after receiving the story of what happened, she asked CNA O to move from the dining room and explained to CNA O that, as professionals, staff should remove themselves from the situation. CNA O refused and said, My mama gave me a name and it isn ' t black [expletive]. Social Services X documented she asked R1 to return to her room and R1 stated she wanted to leave the facility and move somewhere else. CNA O continued saying she was tired of people making excuses and saying people like R1 behavior. Social Services X wrote that she reminded CNA O it is the staff ' s job to act professionally in all situations. Social Services X spoke to Administration A about the incident immediately. Interviewed on 11/14/24 at 02:20 P.M. CNA M stated the R1 often yelled at staff when they came in her room, and just wanted to be left alone, but then other times was cooperative. CNA N said if she had been in that situation she would have just ignored it and told the charge nurse. Interviewed on 11/14/24 at 02:20 PM Licensed Nurse (LN) H said she did not witness the incident but heard the commotion and then saw Social Services X intervene. On 11/14/24 at approximately 2:00 P.M. Administrative Staff A acknowledged receiving a report from Social Services X. Administrative Staff A collected written witness statements and placed CNA O on suspension pending a full investigation. The facility's Exercise of Rights/ Resident Rights policy revised 11/2024, recorded: Our residents have the right to be treated with respect and dignity and care that promotes maintenance or enhancement of his or her quality of life recognizing each resident individuality, Specifically, Staff shall treat cognitively impaired residents with dignity and respect and sensitivity, for example, a) addressing the underlying motives or root causes for behavior and b) not challenging or contradicting the residents' beliefs or statements. The policy further recorded the facility will not hamper, compel by force, treat differently, or retaliate against a resident for exercising his or her rights. The facility failed to provide care and services that promoted resident dignity for R1. This placed R1 and other residents in the vicinity at risk for impaired dignity and decreased quality of life.

The facility identified a census of 33 residents. The sample included 12 residents. Based on observation, record review and interview, the facility failed to ensure that there was a registered nurse (RN) on staff for at least eight consecutive hours, seven days a week. This deficiency had the potential for poor quality of care and negative outcomes for the residents. Findings included: - Review of the facility daily staffing sheets and actual working schedule from 04/01/22 to 12/31/22 and 04/01/23 to 08/24/23 revealed the facility did not provide proof of having eight consecutive hours of RN coverage on 48 days during that period. The facility failed to provide proof of eight consecutive RN hours on the following weekend dates from 04/01/22 to 06/30/22: (04/24/22, 05/01/22, 05/07/23, 05/21/22, 05/22/22, 06/05/22, 06/25, and 06/26/22). The facility failed to provide proof of eight consecutive RN hours on the following weekend dates from 07/01/22 to 09/30/22: (07/09/22, 07/10/22, 07/16/22/22, 07/30/22, 08/13/22, 08/14/22, 08/27/22, 09/05/22, 09/24/22, and 09/25/22). The facility failed to provide proof of eight consecutive RN hours on the following weekend dates from 10/01/22 to 12/31/22: (10/15/22, 11/13/22, 11/24/22, 12/03/22, 12/04/22, 12/24/22, and 12/25/22). The facility failed to provide proof of eight consecutive RN hours on the following dates from 04/01/23 to 08/23/23: (4/9/23, 5/6/23, 5/7/23, 5/20/23, 6/21/23, 6/3/23, 6/4/23, and 6/17/23). On 08/23/23 at 11:30 AM, Administrative Staff A stated that on most days listed above the facility did not have any RN coverage until Administrative Nurse D started about a year ago. Administrative Staff A stated after Administrative Nurse D started, she would cover the RN hours on the weekend or one of the as needed RN staff nurse would work. Administrative Staff A stated she had no proof Administrative Nurse D hours that she had worked due to the fact that she was a salaried employee and had no clock times logged anywhere. Administrative Staff A stated she would have to speak with the corporate office to figure out a way that Administrative Nurse D's hours could be logged. On 08/24/23 at 03:11PM Administrative Nurse D stated when she first started about a year ago there had been some days where there was no RN coverage. Administrative Nurse D stated on some of the weekends she has had to cover but had not clock in/clock out times for those days because she was a salary employee. Administrative Nurse D stated during the week an as needed RN staff member would work to cover RN hours. The facility policy Registered Nurse, Director of Nursing Services last revised 09/22 documented: Except when waived, the community will staff an RN, for at least eight consecutive hours, seven days a week, unless during the establishment and review of the Facility Assessment, it is deemed that the community requires additional hours based upon acuity. The director of nursing may serve as the charge nurse only when the facility had an average daily occupancy of 60 or fewer residents. The facility failed to ensure there was an RN on staff for at least eight consecutive hours, seven days a week. This deficient practice had the potential for poor quality of care and negative outcomes for the residents.

The facility identified a census of 32 residents with one kitchen. Based on observation, record review, and interviews, the facility failed to maintain sanitary dietary standards related to storage of food and kitchenware. This deficient practice placed the residents at risk related to food borne illnesses and food safety concerns. Findings included: - On 08/22/23 at 07:21 AM an observation in the kitchen's dry food storage area revealed one opened bag of wheat bread. The bag was undated. On 08/22/23 at 07:22 AM an observation in the kitchen's dry food storage area revealed one opened bag of hamburger buns. The bag had a large hole torn in it exposing the hamburger buns to air and the bag was undated. On 08/22/23 at 07:23 AM an observation in the kitchen's dry food storage area revealed one opened bag of hotdog buns. The bag had a large hole torn in it exposing the hotdog buns to air and the bag was undated. On 08/22/23 at 07:24 AM an observation in the kitchen's dry food storage area revealed one opened bag of tortilla chips. The bag was undated. On 08/22/23 at 07:33 AM an observation in the kitchen's dry food storage area revealed four plastic storage containers of noodles. The containers were not labeled or dated. On 08/22/23 at 07:36 AM an observation in the kitchen's refrigerator revealed one resealable bag with ham inside. The bag was not labeled or dated. On 08/22/23 at 07:37 AM an observation in the kitchen's refrigerator revealed one opened bag of sausage patties. The bag was not labeled or dated. On 08/22/23 at 07:37 AM an observation in the kitchen's refrigerator revealed one opened bag of country fried steaks. The bag was not labeled or dated. On 08/22/23 at 07:39 AM an observation in the kitchen's freezer revealed one resealable bag of French/Texas toast. The bag was not labeled or dated. On 08/22/23 at 07:40 AM an observation in the kitchen's freezer revealed one cup, with a plastic lid, of what Dietary BB stated was frozen puree strawberries. The cup was not labeled or dated. On 08/22/23 at 07:42 AM an observation in the kitchen's freezer revealed one box of frozen hamburger patties. The box was open to air and the meat was exposed. On 08/22/23 at 07:43 AM an observation in the kitchen's freezer revealed one opened bag of frozen breakfast sandwiches. The bag was not labeled or dated. On 08/22/23 at 07:47 AM an observation in the kitchen's main area revealed two pans stored under a table not covered or inverted. On 08/22/23 at 07:48 AM an observation in the kitchen's main area revealed a stack of metal bowls and a stack of metal pots stored under a table. The pots and bowls were not covered or inverted. On 08/23/23 at 11:26 AM Dietary BB stated all opened food items, including those stored in plastic storage bins, should be labeled, and dated. She stated that she checks each day for items that have not been labeled or dated. She further stated she checks the menu for leftovers that were served and if they are older than three days, she throws them in the trash. Dietary BB stated all pots, pans, and dishes should be stored inverted. The facility's Food Safety Requirements policy revised on 10/2022, documented dry foods that are stored in bins will be removed from original packaging, labeled, and dated. The policy further documented all foods stored in the refrigerator or freezer will be covered, labeled, and dated. The facility failed to maintain sanitary dietary standards related to storage of food and kitchenware. This deficient practice placed the residents at risk related to food borne illnesses and food safety concerns.

The facility identified a census of 33 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to consistently provide facility directed weekend activities to the cognitively impaired residents unable to self direct. This deficient practice had the risk for a decline in psychosocial well-being. Findings included: - The facility had nine residents that had a Brief Interview for Mental Status (BIMS) score of eight or less (indicating severely impaired cognition). Review of the monthly activity calendar for June 2023 revealed weekend activity on Saturday and Sunday of: Resident Choice Movie and Music. On Sunday 06/04/23 and 06/18/23 included the 06:00 PM Church service. Review of the monthly activity calendar for July 2023 revealed weekend activity on Saturday and Sunday of: Resident Choice Movie and Music. On Sunday 07/02/23 and 07/16/23 activities included the 06:30 PM Church service. Review of the monthly activity calendar for August 2023 revealed weekend activity on Saturday and Sunday of: Resident Choice Movie and Music. The weekend activities included self-directed activities but lacked evidence of structured activity offerings for residents with impaired cognition unable to self-direct. On 08/24/23 at 01:57 PM Certified Nurse Aide (CNA) M stated usually on the weekends residents would watch movies or listen to music. CNA M stated the residents usually would start the movie themselves. CNA M stated the facility did have a few activity boards or blankets for the residents with cognitive impairment. On 08/24/23 at 02:18 PM Licensed Nurse (LN) H stated the facility currently did not have an activity director, so weekend activities were basically whatever the residents wanted to do like watch tv, play cards, or games. LN H stated the facility had a blanket or something like that with little activity things on it to let the cognitively impaired residents use. LN H stated there was no staff-initiated activities on the weekend. On 08/24/23 at 03:17 PM Administrative Nurse D stated that weekend activities were resident's choice which was generally movies or games that the residents would initiate themselves. Administrative Nurse D stated the facility's activity director left at the beginning of the month but when she was here, she would come in on some weekends to do activities with the residents. Administrative Nurse D stated she was not certain what activities staff provided on weekends for the residents that were cognitively impaired. The facility policy Activities and Social Events last approved May 2022 documented: Residents had the right to choose the types of activities and social events in which they wish to participate. When developing the resident's activity and social care plan, the resident should be given an opportunity to choose when, where, and how he or she would participate in activities and social events. Activities, social events, and schedules were developed in conjunction with the resident's interests, assessment, and plan of care. Staff would evaluate a resident's physical and mental capacity to participate in various levels of activities. Staff would note any significant physical and cognitive limitations or behavior issues that would influence the level of a resident's participation or type of activity that were relevant to that individual. The facility would provide activities on most days, including weekends and holidays, as well as scheduled religious and social activities. However, residents were free to decide whether to attend any activity or other scheduled event. The facility failed to consistently provide structured weekend activities for cognitively impaired residents. This deficient practice had the risk for a decline in physical, mental, and psychosocial well-being.

The facility had a census of 33 residents. The sample included 12 residents with five residents reviewed for accidents and/or hazards. Based on observation, record review, and interview the facility failed to secure rooms containing hazardous materials to keep out of reach of 12 cognitively impaired /independently mobile residents. This deficient practice placed the 12 residents at risk for preventable injuries and accidents. Findings Included: - On 08/22/23 at 07:04AM an initial walkthrough of the facility was completed. An inspection of the supplemental oxygen storage room revealed no lock or mechanism to secure the room's contents from opening the door. The room contained 20 full cylindrical oxygen cannisters stored in the rack with the room. Licensed Nurse (LN) G stated the door should be locked but she was not sure if it could be. LN G stated she would notify Administrative Nurse D. The lockable doorknob was placed at 09:00AM. An inspection the East Hall revealed an unsecured utility closet with an open and unlocked electrical switch panel. The panel contained the label warning High Voltage, Keep Locked. An inspection the [NAME] Hall revealed an unsecured utility closet with an open and unlocked electrical switch panel. The panel contained the label warning High Voltage, Keep Locked. On 08/24/23 at 01:30PM, Certified Nurse Aide (CNA) M stated rooms that contained potential hazards should be always locked to prevent accidental injuries for the residents. She stated the janitor's closet were usually kept locked but not sure why the oxygen storage room did not have a lock on the door. On 08/24/23 at 01:45PM, Administrative Nurse D stated the oxygen room recently was moved and a lock had been installed to prevent the residents from opening it. She stated all staff were expected to make sure the cleaning closet and shower rooms remained locked after being used. A review of the facility's Environment policy revised 08/2023 indicated the facility will provide a safe, functional, sanitary, and comfortable environment for the residents. A review of the facility's Oxygen policy revised 08/2023 indicated oxygen cylinders will be stored in a locked well-ventilated room separated from electrical appliances. The facility failed to secure rooms containing hazardous materials to keep out of reach of 12 cognitively impaired independently mobile residents. This deficient practice placed 12 residents at risk for preventable injuries and accidents.

The facility identified a census of 40 residents. The sample included 8 residents reviewed for abuse. Based on record review, observations, and interview the facility failed to provide an environment free from abuse when direct care staff P struck, repeatedly on the back, and grabbed resident #1's right arm (leaving a bruise) during a shower on 4/18/19 between 12:00 and 2:00 P.M. This deficient practice placed resident #1 in immediate jeopardy. Findings included: - The (MONTH) 2019 electronic medical record (EMS) documented resident #1 admitted on [DATE] with [DIAGNOSES REDACTED]. Symptoms may also include personality changes and emotional problems). The significant change minimum (MDS) data set [DATE] documented the resident had severely impaired cognition and no behaviors during the 7-day assessment period. He/she required extensive assistance of one to two staff members with most activities of daily living such as transfers, dressing toilet use and personal hygiene. He/she used a wheelchair for locomotion and was incontinent of bowel and bladder. The assessment documented the resident was 5 feet 7 inches tall, weighed 101 pounds, and received antipsychotic medication (a psychiatric medication primarily used to manage [MEDICAL CONDITION], particularly in [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder, and is increasingly being used in the management of non-[MEDICAL CONDITION]). The quarterly 3/7/19 MDS noted no changes in the residents cognitive and/or functional abilities. A skin assessment dated [DATE] at 2:58 P.M. documented a large purple and blue (multiple colors) bruise present on the inner aspect of his/her right arm. and small bruises to his/her right wrist. The resident care plan revised 3/2/19 documented: the resident exhibited behaviors of striking out at times and directed staff to approach calmly, and (if agitated) cease activity and re-approach when calmed. The care plan lacked documentation related any particular precautions during showering. Interviewed on 4/23/19 at 10:30 A.M resident #1 had no memory he/she received a shower on 4/18/19 and stated nobody wanted to mistreat him/her. Review of the facility self-reported (4/23/19) investigation (still in progress) and administrative staff A's notarized witness statement documented: He/she received a telephone call on Saturday 4/20/19 (untimed) when Direct care staff O stated, he/she should have notified administrative staff A of an incident on 4/18/19 (untimed) but did not because he/she was afraid of retaliation. Direct care staff O stated when he/she worked Saturday 4/20/19, he she noticed a bruise on resident #1's arm. Direct care staff O stated he/she remembered an incident that happened on Thursday 4/18/19 (untimed) when direct care staff P hit resident #1 on his/her back and grabbed resident #1's arm during a shower and the bruise was likely a result of that. On 4/23/19 at 10:30 A.M. observation revealed the resident sat in his/her wheelchair in the television viewing area, alert and well groomed Direct care staff O's notarized witness statement dated 4/20/19 A.M. (untimed) documented: On 4/18/19 direct care staff P asked him/her to bring resident#1 to the shower room so she/she could give him/ her a shower. Direct care staff O helped place resident #1 in the shower chair and once in the shower chair, the resident became agitated and combative. Direct care staff P then propelled resident #1 in the chair into the shower stall. Resident #1 was repeatedly hitting direct care staff P and hit him/her on the leg. Direct care staff P then hit resident #1 on his/her upper back multiple times; Staff O told direct care staff P that was enough, and staff P responded that staff O was too sensitive. Resident #1 then tried to hit direct care staff P again which then compelled direct care staff P to grab resident #1's upper arm. At this point direct care staff P told the resident to wash him/her self and handed, resident #1 the wash cloth. Resident #1 threw the washcloth at direct care staff P and staff P threw the wash cloth back at the resident hitting him/her in the face. Direct care Staff P's notarized witness statement dated 4/22/19 (untimed) documented: On (MONTH) 18, 2019 direct care staff P and three other direct care staff were assisting resident #1 with a shower. Staff P wrote that (resident #1) screams, bites, and scratches during his/her shower, so direct care staff P asked direct care staff O if he/she could stop and hold resident #1's arms while he/she washed the resident. Resident #1 still was combative, screaming and trying to hit, so direct care staff P stepped back and washed all the soap off, and resident #1 got louder, and direct care staff O said that was enough because resident #1 wouldn't allow staff to finish washing him/her. Direct care staff P turned the water off and pushed the resident out and direct care staff O finished getting him/her dressed and that was it. Staff P wrote that nobody physically abused resident#1. Review of direct care staff P's employee file revealed a date of suspension of 4/20/18, date investigation completed on 4/22/19, and date terminated on 4/22/19. Interviewed on 4/23/19 at 8:44 A.M. administrative licensed nursing Staff D stated there were 4 people (direct care staff O, P, Q, R) in and out of the shower room during resident #1's shower, but the main one attending to him/her was direct care staff P and there was some sort of incident on 4/18/19. Resident #1 had dementia and was extremely combative during showers. Resident #1's shower occurred on 4/18/19 between 12:00 noon and 2:00 P.M. This event was not reported to administrative staff D until 4/20/19 when direct care staff O reported the occurrence to a nurse. On 4/20/19 the nurse directed staff O to report the occurrence to facility administration. On Sunday 4/21/19 administrative licensed nurse D stated he/she met with direct care staff O at an offsite location and had him/her reenact the event in the shower. After meeting with him/her, staff D felt there was an inappropriate interaction with the resident and direct care staff P was terminated. The facility called the police and reported to the state and the police did an investigation and went to each person's home and interviewed them. All 4 staff involved were immediately suspended (Saturday 4/20/19 A.M.) pending an investigation. Administrative licensed nursing staff D stated his/her expectation of staff was for staff not to be physical with any resident and to report any misconduct immediately. Nurse D stated staff did not follow the facility policy. Interviewed on 4/23/19 at 11:32 A.M administrative staff A stated: The facility recently completed abuse neglect and exploitation education on 4/18/19 with some newly hired employees. Direct care staff O stated he/she did not report earlier out of fear of retaliation. Administrative staff A stated he/she felt staff O's fears might have been valid. Staff A and agency staff nurse Q checked the resident skin and there was a silver dollar size bruise on resident #1's right arm., The facility's policy Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property (ANE) , revised 5/2017 documented: It is the facility's policy to encourage and support all residents , staff , family and visitors and volunteers and resident representatives in reporting any suspected acts of ANE. The policy recorded, abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. While physical abuse includes hitting, slapping, pinching and kicking, it also includes controlling behaviors through corporal punishment. The facility failed to provide an environment free from abuse when direct care staff P physically abused by hitting and grabbing resident #1. This deficient practice placed resident #1 in immediate jeopardy. On 4/23/19 at 4:15 P.M. administrator A, administrative licensed nursing staff D, and administrative licensed nursing staff [NAME] were informed the deficient practice placed the resident in immediate jeopardy. The facility provided an acceptable plan for removal of the immediate jeopardy on 4/23/19 at 5:00 P.M. The onsite review on 4/25/19 at 7:45 A.M. revealed the facility removed the immediate jeopardy when it completed the following: Identified: All residents have the potential to be affected by the alleged deficient practice. Safe survey conducted to other residents showered the day of the incident Acted: Direct care staff P (Alleged Perpetrator) was suspended on 4/20/19 All potential witnesses suspended pending investigation 4/20/19 (direct care staff O, Q, R, S). Notifications were made to Resident #1's physician, family/responsible party Police were notified 4/20/19 Educated CNA witness regarding ANE reporting immediately. Interviewed resident#1 to assess safety. Resident indicated he/she felt safe. He/she said he/she was hit with a rock. Interviewed random residents regarding safety and abuse Alleged Perpetrator (direct care staff P) terminated 4/22/19 Implemented: Staff will be in-serviced on the policy Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property. Staff will take a post test and receive remedial training as indicated. Staff will be in-serviced upon hire, annually, and post allegation. Agency staff will receive this education prior to being placed on the schedule. Education and testing for comprehension initiated 4/23/19. In-service and testing to be accomplished prior to staff accepting care of residents. A payroll sheet is being utilized to track completion and compliance. Monitored: Administrator/designee will interview 4 staff weekly to assess compliance of knowledge of abuse and the reporting of it. Administrator/designee will also interview 4 residents weekly to assess safety and care concerns. These audits will be completed weekly x 4, then biweekly x 2, then monthly x 1. Results of these audits will be submitted to the QAPI Committee for review and recommendation. The deficient practice remained at a scope and severity of a G following the removal of the immediate jeopardy.

The facility presented a census of 41 residents. The sample included 2 residents with tracheostomies (a surgical opening into the windpipe, to help a person breathe). Based on record review and interview, the facility failed to provide adequate [MEDICAL CONDITION] (trach) care (cleaning around and in the [MEDICAL CONDITION] site) to one resident who developed maggots in his/her [MEDICAL CONDITION] site requiring hospitalization (resident #1). Findings included: Resident #1's pertinent [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status BIMS score of 08, which indicated moderately impaired cognition. The resident exhibited no behaviors and required extensive assistance with the majority of Activities of Daily Living (ADLs). The Annual MDS dated [DATE] revealed a BIMS score of 06, which indicated severe cognitive compromise. The resident had no rejection of cares and required extensive assistance for the majority of all ADLs. The Care Area Assessment (CAA) dated [DATE] demonstrated the following care areas triggered for review: The care area for cognitive loss indicated a progressive decline is BIMS score, and cognition. The ADL CAA demonstrated the resident required extensive assistance of 2 or more staff for the majority of ADL's. The communication CAA documented the resident wore a speaking valve (a plastic cover applied to [MEDICAL CONDITION] allows the resident to breathe and speak) to the [MEDICAL CONDITION] during the day The [MEDICAL CONDITION] care plan revised on [DATE] directed staff to ensure [MEDICAL CONDITION] to be secure at all times; and to monitor Oxygen saturation (amount of oxygen in the blood) when speaking valve was in place while awake every hour. It directed staff to have the resident wear the speaking valve during waking hours and to suction the resident as necessary and once each shift. The nurse's notes revealed a Situation Background Assessment Recommendation (SBAR) note dated [DATE] by Administrative Nursing Staff D documented Licensed Staff G found maggots (a soft bodied legless larva from a fly) in and around the [MEDICAL CONDITION] and stoma (opening) when he/she performed the [MEDICAL CONDITION] care at the beginning of his/her shift. Additionally, the documentation [MEDICAL CONDITION] revealed numerous gaps in the night shift documentation. There was no documentation of [MEDICAL CONDITION] care on the night shift for the following dates: [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE] and [DATE]. On [DATE] at 2:15 PM While walking in the east hall, this surveyor observed a fly circling me. On [DATE] at 2:30 PM while talking with the administrator and the regional manager, this surveyor noted a fly in the office. On [DATE] during a tape-recorded interview with investigators from the attorney general's office, licensed nursing staff G stated he/she found maggots in and around the [MEDICAL CONDITION] site when he/she removed the gauze from the trach. He/she immediately obtained a pulse oximeter reading of 96% and phoned the resident's physician, received orders to send the resident to the hospital and called for Emergency Medical Services (EMS). On [DATE] during a tape-recorded interview with investigators from the attorney general's office licensed nursing staff H stated he/she assisted staff G to suction the resident. He/she stated he/she saw many worm-like insects crawling on the resident's shirt and under [MEDICAL CONDITION] (a plastic fitting around [MEDICAL CONDITION] covers the edges of the stoma. He/she stated he/she removed [MEDICAL CONDITION] on one side of the resident's neck, suctioned a large number of the insects after the resident coughed. The resident then pulled the [MEDICAL CONDITION] out of the stoma. He/she stated when the resident coughed, a large amount of mucus was expelled from the stoma, with numerous worm-like insects in the mucus. On [DATE] during a tape-recorded interview with investigators from the attorney general's office, licensed nursing staff I stated he/she was charting from the previous overnight shift, when he/she was called in to help the nurses with the resident. He/she acknowledged the presence of worm-like insects present in and around the trachea (the wind pipe). On [DATE]at 4:30 PM staff nurse J stated in the recent past several weeks, when he/she changed out the inner cannula (round plastic tube within the outer plastic tube of the [MEDICAL CONDITION]) from this resident's [MEDICAL CONDITION], he/she noted a strong odor. He/she stated the secretions were discolored, but he/she normally had discolored secretions. On [DATE] at 4:45 PM Administrative nurse D stated he/she expected the nurses to [MEDICAL CONDITION] as ordered. Staff D further stated he/she expected the nurses to follow the facility's policy which was to change the dressing each shift, change the inner cannula once a day, and change the outer cannula once a month. According to CDC.gov, Healthy Housing Reference Manual - Chapter 4: Disease Vectors and Pests, maggots can be hatched in 24 hours or less after being laid by a fly. The facility's policy titled [MEDICAL CONDITION] care dated (YEAR) outlined the procedure for cleaning the inner cannula and changing the dressings on the [MEDICAL CONDITION] site. The facility failed to provide adequate [MEDICAL CONDITION] care to this cognitively impaired resident who developed maggots in his/her [MEDICAL CONDITION]. This was deemed past non-compliance when the DON conducted a review of [MEDICAL CONDITION] practices for all of the nursing staff in the facility (including the CNA's who may assist the nurses with the procedure) and did direct observation of all nurses who would perform the task, completed by [DATE]

The facility's census totaled 45 residents with 3 residents sampled. Based on observation, record review, and interviews, the facility failed to provide timely and effective interventions to prevent falls for 2 of 3 sampled residents (#1 and #2) reviewed for falls that resulted in injuries. Resident #1 had a fractured (broken bone) left upper arm and resident #2 had a laceration (wound to the skin) on the back of his/her head. Findings included: - Resident #1's annual Minimum Data Set ((MDS) dated [DATE] documented the Brief Interview for Mental Status (BIMS) score of 4 which revealed the resident's cognitive status was severely impaired. The MDS documented the resident required extensive assistance of 2 staff members with transfers, dressing, and toilet use, and extensive assistance of 1 staff member with bed mobility and personal hygiene. The MDS documented the resident's balance was not steady and was only able to stabilize with staff assistance. The resident's range of motion was impaired with both upper and lower extremity of 1 side of his/her body. The MDS further documented the resident had 2 or more falls since the last assessment. The quarterly MDS dated [DATE] documented the resident required extensive assistance of 1 staff member with bed mobility, transfers, dressing, and toilet use and limited assistance of 1 staff member with personal hygiene. The MDS documented the resident ' s balance was not steady and only able to stabilize with staff assistance. The resident had no impairment of his/her range of motion. The MDS further documented the resident had 1 fall with no injury since the last assessment. The fall Care Area Assessment (CAA) dated 5/11/15 documented the resident was unable to maintain balance without staff assist. He/she required extensive assist of at least one staff for all transfers. He/she had a history of [REDACTED]. These were non-injury falls and related to self-transfer attempts. He/she received psychotropic medication daily which had potential adverse effects that may influence balance disturbance. The fall care plan revised on 7/29/15 documented the resident fell in the past 30 days, had a history of [REDACTED]. size; assess the need for footrests; assess for the need to have the wheelchair locked/unlocked for safety; anti-tippers, and assess for pain every shift . The new interventions added on 7/29/15 included an X-ray (a radiographic image projected into a photographic plate) of his/her left shoulder. The resident was transferred to the emergency room for evaluation and treatment. The resident had a fracture (broken bone) of the left humerus (the bone between the elbow and the shoulder) related to a fall. The resident had a sling (immobilizer) to the left shoulder and to be worn at all times. The nursing staff to monitor placement of the sling. The nursing staff to monitor the resident ' s circulation and comfort on every shift. The quarterly review dated 7/28/15 related to fall risk scored 19 (total score of 10 or above deemed the resident was at risk for falls). Review of the nurse's notes documented the resident had 19 falls in 1 year: 8/26/14 at 9:00 A.M. on the floor by his/her bed with no injury 9/30/14 at 6:55 A.M. in the bathroom with an abrasion to his/her back 10/1/14 at 11:30 A.M. by his/her bed with no injury 11/5/14 at 4:00 A.M. by his/her bed with no injury 11/15/14 at 7:11 A.M. by his/her bed with no injury 11/24/14 at 3:45 P.M. by his/her bed with no injury 12/6/14 at 6:38 A.M. by his/her bed with no injury 12/8/14 at 3:00 A.M. by his/her bed with no injury 12/10/14 at 6:55 A.M. on the floor in his/her room with no injury 12/17/14 at 4:00 P.M. by his/her bed with no injury 12/21/14 at 7:54 P.M. by his/her bed with no injury 12/28/14 at 9:55 P.M. on the floor in his/her room with no injury 12/31/14 at 9:45 P.M. by his/her bed with no injury 2/16/15 at 7:33 A.M. by his/her bed with no injury 2/18/15 at 1:38 P.M. on the floor in his/her room with no injury 3/11/15 at 9:00 A.M. by his/her bed with no injury 4/18/15 at 1:45 A.M. by his/her bed with no injury 5/23/15 at 3:10 P.M. on the floor in his/her room with no injury 7/28/15 at 7:05 P.M. by his/her bed with complaint of left shoulder pain resulted in a fractured left upper arm. The facility failed to complete a thorough investigation to determine casual factors of the falls. The hospital x-ray report dated 7/29/15 documented a displaced fracture of the left humerus (upper arm bone). The kardex (a report used by the nursing staff that documented the resident's cognitive status and the resident's care needs) printed on 8/26/15 documented the resident with no injury from falls and no assistive devices marked. On 8/26/15 at 10:00 A.M. observed the resident in a high back wheelchair with his/her left leg up on a wheelchair pedal and his/her left arm contained in a sling. The resident was able to move the wheelchair by the use of his/her right leg. The resident had tennis shoes on both feet. The resident tends to lean to his/her left side. On 8/26/15 at 4:00 P.M. observed the resident in bed sleeping with the call light on the bed next to the resident and the wheelchair placed next to the bed. The bed was at the regular height, not lowered. The resident had personal belongings within reach in his/her room, no reacher noted. Interview on 8/26/15 at 11:00 A.M. administrative nursing staff D stated the resident had a lot of falls and the facility had interventions in place like involving him/her in activities, stand him/her up when he/she was restless, and getting him/her snacks like candy. The care plan lacked these interventions. Administrative nursing staff D stated the interventions placed on the care plan after each fall had been resolved (removed) and not sure why the nursing staff had removed them. Administrative nursing staff D stated the kardex documented the cares and assistance the resident needed. Interview on 8/26/15 at 11:10 A.M. direct care staff O stated they just watch this resident closely since he/she is at risk for falls and if we see him/her headed for his/her room then we make sure and go after him/her. He/she does not remember to wait for help. We use to have an alarm on his/her wheelchair but the alarm just aggravated his/her behaviors, so the alarms were removed. They tried a transfer pole and he/she would get up by self, so the pole was removed. The mat at bedside was also removed. Interview on 8/26/15 at 3:43 P.M. licensed nursing staff H stated we keep a close eye on him/her, try to do restorative exercises with him/her, and sometimes preoccupy him/her with jokes. He/she forgets his/her left side does not function and then he/she will try and stand and fall. His/her falls have been mostly in his/her room when he/she tried to get in or out of bed. He/she would tell us when he/she wants something and we would watch for signs of restlessness. There were fall mats next to the bed but the facility thought they caused him/her to have more falls and the mats were removed. Interview on 8/26/15 at 3:54 P.M. direct care staff P stated the staff check on him/her every hour. He/she was mobile throughout the building. Interview on 8/27/15 at 10:37 A.M. physician AA stated this resident had poor cognition and poor insight; he/she was unsure what the facility had in place to prevent the resident from falling. The resident had a history of [REDACTED]. The undated facility policy Falls Management Guideline instructed the nursing staff after a resident has a fall the licensed nurse assessed the resident for injuries and provided the necessary treatment, notify the physician and family, implement appropriate interventions, and update the care plan. The facility failed to complete a thorough investigation to determine causal factors of the falls. The facility failed to develop, identify and implement appropriate interventions to prevent falls for this high risk, cognitively impaired resident to prevent multiple falls which ultimately resulted in an arm fracture. - Resident #2's annual Minimum Data Set assessment ((MDS) dated [DATE] documented the Brief Interview for Mental Status (BIMS) score of 2 which documented the resident with severely impaired cognitive status. The MDS documented the resident required extensive assistance of 1 staff member with bed mobility, transfers, dressing, eating, personal hygiene, and toilet use. The MDS further documented the resident with unsteady balance and only able to stabilize with staff assistance. The MDS documented the resident had limited impairment of both lower extremities. The fall Care Area Assessment (CAA) dated 8/7/15 documented the resident was at risk for falls related to requiring assistance with transfers. The 8/17/15 fall care plan included the following interventions: assess for any pain, assess that wheelchair was of the appropriate size, assess the need for footrests, assess for need to have the wheelchair locked/unlocked for safety, anti- tippers on the wheelchair, bed in lowest position, call light and personal items available and in easy reach, footwear to prevent slipping, gait belt with all transfers, keep environment well lit and free of clutter, keep the resident clean dry and odor free, observe for side effects of medications, and therapy referral as needed. Added to the care plan on 8/26/15 assessed per change, assessed for pain, first aide, anti-trippers placed on the wheelchair, to the emergency room for evaluation, computed tomography (CT scan) - test that used x-ray technology to make multiple cross-sectional views of organs, bone, soft tissue and blood vessels- scan of head and no abnormalities seen, assess back of the resident's head every shift for complication until healed, neuro checks initiated, medication reviewed due to behaviors, and referred to therapy for positioning. The kardex (a report used by the nursing staff that documented the resident's cognitive status and the resident's care needs) printed on 8/26/15 did not documented the resident had any falls and no assistive devices marked. The nurse's notes documented the resident fell on [DATE] around 8:30 P.M. in the common area while watching television. The resident had a laceration (wound to the skin) in a y shape to the back of his/her head that measured 3 centimeters by 3 centimeters by 3 centimeters. The nursing staff applied pressure to the area to stop the bleeding and was sent to the hospital per ambulance. The emergency room report was not in the resident's clinical record. Administrative nursing staff D provided the emergency room report which documented the resident noted with 1.5 centimeter laceration to the occiput (back of the head). A computerized tomography of the head and cervical spine was unremarkable for anything acute. The next nurse's note dated 8/25/15 at 5:07 P.M. documented the resident's injury site was clean with no induration or sign or symptoms of infection with staples intact. On 8/26/15 at 7:30 A.M. the resident sat in the dining room. A fall mat was observed next to the resident's bed in his/her room. On 8/26/15 at 1:00 P.M. the resident stated he/she fell out of his/her wheelchair and hit his/her head. The resident ruffled his/her hair to show his/her injured head. Observation revealed dried blood from the top of his/her head to the nape of his/her neck and 3 staples in place on the back of his/her head. Interview on 8/26/15 at 11:05 A.M. direct care staff O stated the nursing staff has to get to him/her before he/she does anything by him/herself because he/she did not remember to wait. Interview on 8/26/15 at 3:40 P.M. licensed nursing staff H stated he/she would tell us when he/she needs something and we need to respond right away. The nursing staff has to keep an eye on him/her. The resident had a fall mat next to his/her bed and his/her wheelchair should be positioned away from his/her bed, so he/she cannot reach the wheelchair by him/herself. Interview on 8/26/15 at 4:00 P.M. direct care staff P stated the nursing staff should watch him/her real close. He/she would use the call light. Interview on 8/26/15 at 5:45 P.M. administrative nursing staff D stated the care plan lacked interventions related to the fall on 8/24/15 and he/she was updating the care plan on 8/26/15. The care plan had nothing related to the laceration and staples the resident received from the fall. The clinical record lacked documentation when the resident returned from the hospital and no nurse's note for 20 hours after the resident fell . The undated facility policy Falls Management Guideline instructed the nursing staff after a resident has a fall the licensed nurse was to assess the resident for injuries and provided the necessary treatment, notify the physician and family, implement appropriate interventions, and update the care plan. The facility failed to develop, identify, and implement appropriate interventions to prevent falls for this high risk, cognitively impaired resident which ultimately resulted in a scalp laceration with staples.

The facility identified a census of 46 residents. The sample included 25 residents. Based on observation, record review, and interview the facility failed to provide effective pressure ulcer prevention measures for 2 (#24, #46) of 3 residents developed avoidable pressure ulcers. Findings included: - Review of resident #46's computerized medical [DIAGNOSES REDACTED]. The resident's admission Minimum Data Set (MDS) 3.0 dated 5/18/13 identified the resident had a score of 3 (severely impaired cognition) on the Brief Interview for Mental Status, required extensive assistance with bed mobility, and transfers, did not walk in the room/corridor, totally dependent upon staff for locomotion on/off the unit, eating, toilet use, and hygiene. The MDS coded the resident had an indwelling catheter, was always incontinent of bowel, and sustained a fracture related to a fall in the 6 months prior to admission/entry/reentry. The MDS recorded the resident weighed 207 pounds, had not experienced a weight loss, had a Percutaneous endoscopic gastrostomy (PEG-a tube inserted to provide a mean of nutritional intake), the resident received 51 percent (%) or more of his/her nutrition through the PEG and at least 501 cubic centimeters (cc) of fluid each day through the PEG. The MDS coded the resident was at risk for the development of pressure ulcers, did not have unhealed pressure ulcers, had moisture associated skin damage, and had a pressure relieving device for his/her bed and chair. The MDS did not identify the resident was on a turning/repositioning program. The resident's pressure ulcer Care Area Assessment (CAA) dated 6/7/13 documented after the observation period on 5/31/13 the resident developed the following pressure ulcers: unstageable pressure ulcer due to slough on his/her right ankle that measured 2.9 centimeters (cm) by 1.8 cm, a Stage 2 on his/her right rear hip that measured 1.3 cm by 2.1 cm and a Stage 2 pressure ulcer versus excoriation on his/her right buttock that measured 1.0 cm by 0.8 cm and staff observed the excoriation prior to 5/31/13. The CAA included the resident had a scabbed area prior to 5/31/13 on his/her right great toe that measured 1.1 cm by 1.5 cm and a scabbed area on his/her right second toe that measured 1.4 cm by 0.7 cm. The CAA included the resident was at high risk for skin breakdown due to impaired mobility, bowel incontinence, serum [MEDICATION NAME] (laboratory value used to determine nutritional status) of 3.0 grams/deciliter (g/dl) (normal reference range 3.4-5.4 g/dl) , wore a boot on his/her right lower extremity for a healing distal fibula, the head of the resident's bed was elevated due to PEG, the resident's indwelling catheter was discontinued on 6/7/13 and the resident was incontinent of urine. The resident's Clinical Health Status assessment dated [DATE] included on 5/11/13 staff observed the resident had a Stage 1 pressure ulcer on his/her bottom that measured 13 by 5 and 13 by 6 (no unit of measurement included). The resident's care plan dated 5/17/13 included the resident was at risk for altered skin integrity due to a fracture and brace on the resident's right lower extremity, staff monitored the resident for signs and symptoms of infection, staff performed the treatment to the excoriation on the resident's buttock each shift, and the resident's bed and chair had a pressure relieving device. An entry dated 5/15/13 included staff received a physician's orders [REDACTED]. condition twice a day (BID). An entry dated 5/31/13 included staff placed Santyl (a [MEDICATION NAME] ointment) as physician ordered to the open area on the resident's right ankle on a daily basis. An entry dated 6/7/13 included on 5/31/13 the resident had actual skin breakdown; an unstageable pressure ulcer on his/her right ankle, and a Stage 2 pressure ulcer on his/her right hip. The entry included on 6/6/13 the physician discontinued the resident's indwelling catheter, and the resident was incontinent of urine. The entry included staff turned and repositioned the resident every 2 hours when in bed, and kept the pressure off the resident's right side, and staff repositioned the resident every hour when he/she was in his/her wheelchair. The resident's Physician order [REDACTED]. condition in the nurse's note twice a day everyday. A physician's wound care note dated 7/2/13 documented according to therapy and nursing staff the resident wore a brace which caused the wound on the resident's right lateral ankle and the wound was covered with eschar (dead tissue). The resident's right lateral ankle Wound Evaluation Flow Sheet included the following: 5/31/13: 3.2 cm by 2.3 cm unstageable pressure ulcer 6/7/13: 3.2 cm by 2.6 cm unstageable pressure ulcer 6/13/13: 3.2 cm by 2.6 cm unstageable pressure ulcer 6/20/13: 3.4 cm by 2.6 cm unstageable pressure ulcer 6/27/13: 3.7 cm by 2.6 cm by 0.4 cm Stage 3 pressure ulcer 7/2/13: 3.5 cm by 2.5 cm by 0.2 Stage 3 pressure ulcer A nurse's note dated 5/15/13 and timed 1:55 P.M. documented the resident had bruising on the lateral side of his/her right leg and 2 scabs on the top of his/her toes (under the brace). A nurse's note dated 5/18/13 and timed 6:05 A.M. documented the right cheek of the resident's buttock had scant bleeding, and an area on the resident's right buttock was very excoriated and red. A nurse's note dated 5/19/13 and timed 12:51 P.M. documented the resident had bruising on lateral side (outer aspect) of his/her right lower extremity, and 2 scabs, one on the great toe and one on the second toe. A nurse's note dated 5/25/13 and timed 4:23 A.M. documented the resident's skin under the brace was warm, dry to touch, and with bruising on the lateral area. A nurse's note dated 5/28/13 and timed 7:09 P.M. documented the resident's skin under the brace was intact with bruising on the lateral side and 2 scabs, one on the great toe and one on the second toe. A nurse's note dated 5/31/13 and timed 5:44 A.M. documented per shift report the resident had an open area on his/her right ankle, and scabs on his/her right toes. Staff ensured the immobilizer was not pressing on the resident's toes, and staff supported the resident's right leg with pillows. A nurse's note dated 5/31/13 and timed 2:53 P.M. documented the resident had a small blister on his/her right ankle. A nurse's note dated 6/3/13 and timed 10:17 A.M. documented on 5/31/13 the facility received a physician's orders [REDACTED]. The note included the stabilizer boot rubbed the resident's great and second toe and caused the scabbed areas. Review of the resident's nurse's notes from 5/15/13 to 5/31/13 did not reveal the facility consistently documented on the skin under the resident's brace twice a day as the physician ordered. Review of the resident's clinical record lacked evidence to support the facility attempted to minimize the pressure from the brace prior to the development of the unstageable pressure ulcer. The clinical record lacked evidence to support the facility documented the description of the bruising on the lateral aspect of the resident's ankle nor did it support the facility assessed the resident for suspected deep tissue injury prior to 5/31/13. On 7/8/13 at 7:38 A.M. the resident sat in his/her wheelchair in his/her room. During interview with the resident at that time the resident stated upon admission to the facility he/she wore a boot on his/her right foot, the boot kept rubbing the side of his/her foot and now he/she had a bad sore on his/her foot. Observation revealed the resident had a pressure relieving device in his/her wheelchair and a low air loss mattress on his/her bed. On 7/8/13 the resident continued to sit in his/her wheelchair at 7:50 A.M., 8:00 A.M., 8:15 A.M., 8:30 A.M., 8:45 A.M., 8:59 A.M., 9:15 A.M., 9:30 A.M., 9:45 A.M., 10:00 A.M., 10:15 A.M. and 10:28 A.M. (duration of 2 hours and 50 minutes). On 7/8/13 the resident sat in his/her wheelchair at 11:30 A.M., 11:45 A.M., 12:00 P.M., 12:15 P.M., 12:30 P.M., 12:45 P.M., 1:00 P.M., 1:15 P.M. and 1:30 P.M. (duration of 2 hours). On 7/8/13 at 3:00 P.M. direct care staff O and T transferred the resident from the wheelchair to the bed. Observation revealed the resident incontinent of urine and resident's buttock red. During interview with direct care staff T at that time, he/she stated staff repositioned/turned the resident every 2 hours when in bed and in the chair. On 7/8/13 at approximately 3:10 P.M. licensed nurse J performed the treatment on the resident's right ankle. Observation revealed the resident had a Stage 3 pressure ulcer that measured approximately 3 cm by 3 cm and the wound bed had approximately 75% of yellow slough (dead tissue). Observation also revealed the resident's great and second toe on his/her right foot had an unopened purple colored area. On 7/8/13 at approximately 3:20 P.M., licensed nurse J stated upon admission the resident wore an immobilizer on his/her right leg, the immobilizer rubbed the resident's skin and caused the pressure ulcer on the resident's ankle and the areas on the resident's toes. On 7/9/13 the resident sat in his/her wheelchair at 1:05 P.M., 1:15 P.M., 1:30 P.M., 1:45 P.M., 2:00 P.M., 2:15 P.M., 2:30 P.M., 2:45 P.M., 3:00 P.M., 3:15 P.M., and at 3:30 P.M. (duration of 2 hours and 25 minutes). On 7/11/13 at approximately 10:15 A.M., direct care staff Q stated staff repositioned and turned the resident every 2 hours in bed and in the chair. On 7/11/13 at approximately 1:15 P.M. administrative nursing staff E confirmed the areas on the resident's right foot were facility acquired and were caused by the brace. Nursing administrative staff E stated staff should document in the nurse's notes per physician orders. Nursing administrative staff E stated staff should reposition residents according to the resident's care plan. The facility failed to minimize the friction caused by the brace on the resident's right foot, failed to thoroughly assess the bruising, failed to document on the resident's skin as physician ordered and failed to reposition the resident every hour when he resident sat in the wheelchair as planned. The facility failed to prevent the development of multiple avoidable pressure ulcers for this dependent resident. - The quarterly Minimum Data Set 3.0 ((MDS) dated [DATE] for resident #24 revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. The resident required extensive assist of 2 people for bed mobility, transfers, toilet use, and personal hygiene. He/she was admitted with 1 stage IV pressure ulcer measuring 0.6 centimeters (cm) by (x) 0.2 cm x 0.9 cm, and developed 1 stage IV pressure ulcer or the pressure ulcer increased in size since prior assessment/admission. The 10/19/12 Care Area Assessment (CAA) for pressure ulcers revealed the resident had a stage IV pressure ulcer. The care plan regarding impaired skin integrity with a revision date of 2/27/13 revealed the resident had a stage IV pressure ulcer on his/her coccyx. The care plan showed staff repositioned the resident every 2 hours while in bed and every hour while up in the chair, conducted weekly skin assessments, provided the resident with a low air loss mattress, provided the resident with a pressure reducing cushion while in the wheelchair, provided the resident with good skin care after each incontinent episode, and performed Braden Pressure Ulcer Screening quarterly and as needed. The care plan regarding impaired skin integrity with a revision date of 7/3/13 revealed the resident developed a stage IV pressure ulcer on his/her left perianal area. The wound evaluation flow sheet dated 7/2/13 revealed staff identified an unstageable pressure ulcer on the resident's left perianal area on 7/2/13 measuring 1.1 cm x 0.4 cm x 0.1 cm with slough (dead tissue, usually cream or yellow in color) present in the wound bed. Observation on 7/10/13 at 1:15 P.M. revealed the resident sat in a wheelchair in the independent dining room/television room watching television. At 1:30 P.M. the residents position was unchanged. At 1:45 P.M. the resident sat at a table in the main dining room waiting for the Bingo activity to start. The resident's position was unchanged. At 2:00 P.M. the resident was actively playing Bingo but his/her position was unchanged. At 2:15 P.M. the resident's position was unchanged. At 2:30 P.M. the resident's position was unchanged. At 2:45 P.M. the resident's position was unchanged. At 3:00 P.M. the resident's position was unchanged. At 3:00 P.M. the resident's position was unchanged. At 3:15 P.M. the resident's position was unchanged. At 3:30 P.M. staff propelled the resident in his/her wheelchair from the dining room to the resident's room to lay down (duration of 2 hours and 15 minutes). Interview on 7/11/13 at 9:01 A.M. with direct care staff Q revealed staff repositioned the resident every 2 hours while in bed and/or chair. Interview on 7/11/13 at 10:55 A.M. with licensed nursing staff H revealed staff repositioned the resident every 2 hours no matter his/her location. Interview on 7/11/13 at 11:35 A.M. with administrative nursing staff F revealed he/she was the nurse that followed the resident's wounds. Staff F reported that he/she did wounds rounds on 6/27/13 and the perianal wound was not present. Staff F then went on vacation and returned 7/9/13 and found out the resident had developed the perianal wound which was described as unstageable. He/she reported he/she did not consider the wound was actually unstageable, more likely stage 2 but the person who identified the wound on 7/2/13 must have due to the presence of slough. Staff repositioned the resident every 2 hours while in bed and every hour while in the chair. Staff F expected the staff to follow the care plan. Interview on 7/11/13 at 11:49 A.M. with administrative nursing staff E revealed he/she expected staff to follow the care plan. The policy regarding skin integrity guidelines provided by the facility which was revised in 2013, revealed the care plan reflected current interventions and staff initiated a positioning schedule to meet individual resident's needs to minimize concentrated pressure to skin. The facility failed to prevent the development of an avoidable pressure ulcer. The facility failed to reposition the resident as planned.

The facility had a census of 45 residents. The sample included 4 residents. Based upon observation, record review and interviews the facility failed to provide timely and effective interventions for fall prevention for 1 (#1) of 3 residents sampled for falls. Findings included: - Resident #1's computerized medical [DIAGNOSES REDACTED]. The resident's quarterly Minimum Data Set (MDS) 3.0 dated 10/11/12 identified the resident scored 5 (severely impaired cognition) on the Brief Interview for Mental Status, was totally dependent upon staff for bed mobility, transfers, toilet use, personal hygiene and bathing, did not walk in the room/corridor, required staff supervision with locomotion on/off the unit, and limited staff assistance with dressing, and eating. The MDS recorded the resident was not steady, only able to stabilize with human assistance when moved from seated to standing position, moving on/off the toilet, and surface to surface transfers and the activity of walking did not occur. The MDS recorded the resident fell on ce since admission/reentry or prior assessment. The resident's activities of daily living Care Area Assessment (CAA) dated 7/16/12 included the resident required total assistance of 2 staff with bed mobility, repositioning, toileting, and transferring. The CAA documented the resident self propelled his/her wheelchair and accepted staff assistance with locomotion if he/she was lost. The resident's falls CAA dated 7/16/12 documented the resident had a [DIAGNOSES REDACTED]. The resident's care plan dated 10/19/12 addressed the resident was at risk for falls related to medication use, new environment and a history of falls. The care plan included the facility maintained the resident's bed in the lowest position and placed a fall mat at the resident's bedside when the resident was in bed. An entry dated 10/27/12 included the facility placed a mattress at the resident's bedside when the resident was in bed. An entry dated 10/30/12 included the facility applied an alarm pad on the resident's bed. An entry dated 1/9/13 included staff ensured the resident was properly positioned in his/her "new" Broda (specialized wheelchair with the ability to tilt and recline) chair as the resident had a tendency to slide out of the wheelchair. An entry dated 1/13/13 included staff repositioned the resident often in his/her reclining tilt back wheelchair as the resident attempted to sit up frequently. An entry dated 1/21/13 included staff ensured the resident's tilt back wheelchair was in the reclined position which prevented the resident from sliding out. A nurse's note dated 6/10/12 and timed 4:00 P.M. documented the resident fell from his/her wheelchair in the west hallway, the resident's nose was bleeding, the resident's face abraded, the facility transferred the resident to a local hospital and the resident had a nasal bone fracture. Review of the facility's investigation regarding the resident's fall on 6/10/12 included the resident wheeled himself/herself down the hallway, set off the door alarm, staff brought the resident back to the television room, the resident placed his/her feet on the floor, pushed himself/herself out of the wheelchair, fell and hit his/her nose on the floor. The investigation included the following interventions in place prior to the fall: night light, toileting schedule, assistive device within reach, transfer pole, wheelchair positioning, bed in low position, safety cues, and call light within reach. The investigation included the resident would have a psychiatric evaluation. The clinical record lacked evidence the facility implemented any other interventions. A nurse's note dated 7/11/12 and timed 3:10 P.M. documented as staff propelled (wheelchair) the resident to his/her room, the resident planted his/her feet on the floor, and fell to the floor. The resident had a nose laceration, a hematoma (a collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) above his/her left eye and the facility transferred the resident to a local hospital. Per the facility's investigation regarding the resident's fall on 7/11/12 new intervention included: pain assessment. A nurse's note dated 7/11/12 and timed 9:48 P.M. documented the resident returned to the facility with a [DIAGNOSES REDACTED]. A nurse's note dated 9/22/12 and timed 2:00 A.M. documented staff found the resident on the floor mat, the resident laid on his/her stomach, the resident's right cheekbone reddened and the resident's bed was in the lowest position. The facility investigation report dated 9/22/12 for the resident's 9/22/12 fall included recommendations: soft touch pad call light, and the resident's roommate (the resident's spouse) would call for assistance when needed. A nurse's note dated 10/23/12 and timed 6:20 A.M. documented the resident laid on the floor by his/her bed. According to the facility's investigation dated 10/23/12 documented new fall interventions for the resident's 10/23/12 fall included: staff checked the resident every 1-2 hour when the resident was in bed. A nurse's note dated 10/27/12 and timed 3:00 A.M. documented the resident laid on his/her stomach on the floor mat, the left side of the resident's face and left arm reddened, and a bruise on the resident's left wrist. According to the facility's fall investigation dated 10/27/12 the intervention included staff performed hourly checks when the resident was in bed. A nurse's note dated 10/29/12 and timed 2:10 A.M. documented staff found the resident on the floor mat. According to the facility's fall investigation dated 10/29/12 new interventions included: the facility ordered a bed alarm on 10/26/12, would place the alarm upon arrival and staff placed a mattress next to the resident's bed for an extra landing surface. A nurse's note dated 11/25/12 and timed 12:45 A.M. documented staff found the resident on the mat on the floor. According to the facility's investigation for the resident's 11/25/12 fall revealed prior interventions included a bed/chair alarm, the resident's bed in low position, safety cues/reinforcement, the resident's call light within reach, a fall mat and the facility would continue with the resident's plan of care and no new interventions attempted. A nurse's note dated 12/28/12 and timed 10:07 P.M. documented the resident propelled himself/herself in the wheelchair, the resident fell on the floor, the resident's left hand received a skin tear and the resident's left cheek was bruised. According to the facility's investigation dated 12/28/12, the facility would obtain a therapy consultation for wheelchair positioning and strengthening. A nurse's note dated 12/29/12 and timed 3:58 P.M. documented staff found the resident on the floor of C-D hallway at 12:00 P.M. on his/her left side and the resident's wheelchair at the bottom of the resident's feet. The note included the resident had a small bruise above his/her right eye, the resident was confused and unable to state what happened. The note included the resident had an additionally fall at 12:30 P.M.; staff found the resident on the floor of the main dining room in front of the beverage cart on his/her left side and the resident's wheelchair at the bottom of his/her feet. The note included the resident's right eye was swollen and bruised, the resident was confused and unable to state what happened. The note included the facility transferred the resident to a local hospital. A nurse's note dated 12/30/12 and timed 2:38 A.M. documented the resident returned to the facility, the resident's left shoulder was in a sling due to a closed left humerus (bone of the upper arm) fracture, a laceration on the right side of his/her head, and multiple bruises on his/her head, face, arms and hands. The facility's investigation for the resident's two falls on 12/29/12 revealed the new interventions included a Broda chair (tilt reclining chair) for positioning. A nurse's note dated 1/9/13 and timed 7:00 P.M. documented staff found the resident on his/her left side on the floor in the living room, the resident complained of side and left arm pain. According to the facility investigation dated 1/9/13 new intervention included: the staff were in-serviced not to use the wheelchair. A nurse's note dated 1/13/13 and timed 9:37 P.M. documented the resident sat on the floor in the dining room at the foot of his/her geriatric chair. A nurse's note dated 1/13/13 and timed 9:52 P.M. documented the resident's spouse stated the resident slid down the chair and landed on the floor. According to the facility's investigation for the resident's 1/13/13 interventions included: staff laid the resident down between meals and repositioned the resident every 2 hours. A nurse's note dated 1/21/13 and timed 1:36 P.M. documented staff found the resident on the floor on his/her back in the Garden Cafe. Per the facility's fall investigation dated 1/21/13 new interventions included: staff continued to keep the resident with in vision, staff reclined the resident's chair as needed, and staff performed 1:1 activities with the resident. On 1/31/13 at 12:40 P.M. observation revealed the resident sat at the dining room table in a tilt recliner chair, the chair in the upright position and the resident's left arm was in a sling. On 1/31/13 at 12:50 P.M. direct care staff H wheeled the resident down the hall toward the resident's room. Direct care H entered the resident's room, the resident sat in the tilt recliner chair and direct care staff H stated he/she was waiting for staff so they could transfer the resident to bed. Observation revealed the tilt recliner chair was not fully reclined and the resident raised his/her back from the chair. Direct care staff H stepped out into the hallway to seek assistance and the resident rose forward. Direct care staff H stepped back into the resident's room, and wheeled the resident down the hall and asked another staff to assist him/her. Interview at that time with direct care staff H stated the resident's chair was not fully reclined. Approximately 2 to 3 minutes later direct care staff H and I entered the resident's room. At approximately 1:00 P.M. direct care staff H and I transferred the resident from the tilt recliner chair to the bed via a mechanical lift. Observation revealed the resident's bed was in the lowest position which was approximately 5 inches from the floor. On 1/31/13 at 1:10 P.M., 1:45 P.M., 2:00 P.M., 2:30 P.M., 3:00 P.M. and 3:30 P.M. the resident laid in bed, the bed approximately 5 inches from the floor, call light in place (the call light was not a soft touch call light), fall mat by bedside, and no mattress or bed alarm pad observed as planned. On 2/1/13 at 7:20 A.M. staff wheeled the resident toward the dining room, the tilt chair in the upright position, and the feet of the chair elevated. On 2/1/13 at 8:15 A.M. the resident sat at the dining room table in the tilt chair, the chair in the upright position and the feet of the chair down. On 2/1/13 at 9:20 A.M. the resident sat in the tilt chair and attended an activity in the Garden Cafe. Observation revealed the chair in an upright position, the foot board of the chair down, staff interacted with the resident, and the resident raised forward in the chair. On 2/1/13 at 1:30 P.M., 1:45 P.M. 2:00 P.M. and 2:15 P.M. the resident laid in bed. Observation revealed the resident's bed in the lowest position (approximately 5 inches from the ground), a non soft call light in place, a fall mat beside the resident's bed, no mattress or bed alarm pad observed. On 2/1/13 at 2:15 P.M. nursing administrative staff B stated the resident was at risk for falls, utilized a pad alarm, soft call light and mattress on top of the fall mat when in bed. Nursing administrative staff B confirmed the mattress, pad alarm and soft call light were not in place at this time. On 1/31/13 at 3:30 P.M. licensed nurse D stated the resident was at risk for falls, had utilized the tilt recliner chair for approximately 3 weeks, staff placed a fall mat but no mattress beside the resident's bedside when the resident was in bed and the resident did not utilize a pad alarm when in bed. Licensed nurse D stated the resident's left arm was fractured as a result of a fall while in the facility. On 1/31/13 at approximately 4:00 P.M. direct care staff J stated the resident's bed was in the lowest position, approximately 5 inches from the floor, confirmed the resident did not have a soft touch call light, mattress by his/her bedside and the pad alarm was not in place. On 2/1/13 at approximately 12:45 P.M. direct care staff K stated the resident had utilized a pad alarm, the alarm broke and the facility did not replace the alarm. On 2/1/13 at approximately 1:30 P.M. licensed nurse D stated the resident did not currently utilize a pad alarm or mattress beside his/her bed. The facility's fall management clinical guidelines with a revised date of January 2011 included the interdisciplinary team evaluated the fall prevention plan of care for a resident at risk for falls and appropriate interventions were implemented. The facility failed to place the soft touch call light, failed to place the mattress on top of the fall mat, and failed to place the pad alarm for this resident with a history of falls. The facility also failed to place effective interventions in a timely manner for this cognitively impaired resident with a history of multiple falls and multiple fractures.

The facility identified a census of 38 residents. The sample included 24 residents. Based on observation, interview and record review, the facility failed to timely assess, notify, and provide treatment for 1 of 1 resident's sampled (#11) for skin issues. Findings included: - Resident 11's physician's orders [REDACTED]. The significant change in status Minimum Data Set (MDS) 3.0 with an Assessment Reference Date (ARD) of 1/19/12 identified the resident with a Brief Interview for Mental Status score of 4 indicative of severely impaired cognition. The MDS further noted the resident required extensive to total staff assistance with bed mobility, toilet use, transfers with a mechanical lift, locomotion on/off the unit, personal hygiene and bathing. The assessment identified the resident with bowel/bladder incontinence and a stage II pressure ulcer (present since admission) with dressing changes. The MDS noted the use of a pressure reducing device for chair and bed, and a nutrition/hydration program to manage the skin problems. The cognitive loss CAA dated 1/26/12 noted the resident switched from subject to subject with nonsensical conversation at times. The nutrition CAA dated 1/26/12 identified the resident's increased nutritional needs for wound healing. The pressure ulcer CAA dated 1/26/12 identified the resident at risk for infection due to open ulcer and at risk for pain to site of injury. The 12/20/12 Braden scale (a tool used to identify residents that are at risk for skin breakdown) score of 14 identified the resident as a moderate risk. The reviewed 2/27/12 care plan that addressed pressure ulcers documented: Focus: Pressure ulcer actual or at risk due to pressure ulcer present, assistance required in bed mobility, Braden score of 18 or less, and bowel incontinence. Interventions: Complete Braden Scale per Living Center Policy. Conduct weekly skin inspection. Do not massage over bony prominence. Float heels. Nutritional and hydration support: Med Pass, Vitamin D, Vitamin C, Iron, Folic Acid. Provide pressure reducing wheelchair cushion. Provide pressure reduction/relieving mattress. Provide thorough skin care after incontinent episodes and apply barrier cream. Skin assessment to be completed per Living Center policy. Toileting plan. Treatments as ordered: Santyl and Zinc Oxide to left heel. Weekly wound assessment. 1/25/12 Cleanse wound to left heel with normal saline or wound cleanser. Apply Zinc Oxide to outer edges of wound. Apply Santyl nickel thick to wound bed, cover with skin integrity gauze, cover with pad, secure with Kerlix and tape. 1/26/12 Pressure reduction boots bilaterally. Review of the weekly "Wound Evaluation Flow Sheet" completed by licensed nursing staff C from admission on 12/20/11 through 3/12/12 included documentation of an open area. The assessments failed to identify the location or stage of the wound. Review of the weekly skilled nursing skin assessments for February 2012 entitled " Non-Pressure Ulcer Skin Conditions" identified an open area to left heel with no measurements or stage of the open area. Review of the weekly skilled nursing skin assessments for March 2012 documented assessments completed on 3/3/12, 3/10/12, 3/17/12, and 3/24/12. Staff documented the letter "P" with each assessment. On 3/23/12 at approximately 1:30 P.M., administrative nursing staff C revealed the "P" indicated the staff detected a problem and addressed the problem in the nurses' notes. Review of the nurses' notes lacked documentation on 3/3/12. However, on 3/6/12 at 12:21 P.M. staff documented they performed a skin assessment on 3/3/12 and identified a bruise to the left forehead with skin intact except for the old wounds at the left heel and the side sole of the right foot. The 3/7/12 at 1:19 P.M. nurses' note identified the interior of the left heel area bright pink with a moist look to surface, and no drainage noted at removal of dressing. The note further described an area on the right foot, lateral aspect near fifth toe interior as a dry, waxy, dark brown surface. The clinical record lacked documentation the facility notified the physician or obtained a treatment order for the area at this time. The 3/17/12 at 2:17 P.M. nurses note identified redness at the scrotum and the side of the right dorsal foot. The physician's orders [REDACTED]. Observation on 3/22/12 at 10:20 A.M. revealed the second toe on the left foot with a dressing that protruded from a hole in the top of the toe. No dressing covered the packing. Observation during wound care provided by licensed nursing staff C and L on 3/26/12 at 10:33 A.M. revealed an open area wound to the lateral aspect of the right foot, an open area to the left heel and an open area to the top of the second toe on the right foot. At this time, licensed nursing staff C revealed staff discovered the open area on the lateral aspect of the right foot on 3/20/12, at which time he/she described as "black eschar". (The staff documented the presence of the open area initially on 3/3/12 and again on 3/7/12 in the nurses notes). Licensed nursing staff C further identified the open area as unassuageable due to the black eschar. The area measured 1.9 centimeters (cm.) in length, 2.1 cm in width. and 0.5 cm in depth. Licensed nursing staff C used the cotton tipped end of an applicator to measure the depth of the wound. Licensed nursing staff C dressed the area to the lateral aspect of the right foot with Santyl (a [MEDICATION NAME] agent) to the wound bed, zinc to the surrounding area, covered with Skin integrity hydrogel gauze and secured with kerlix dressing. Licensed nurse C stated the staff identified a new area on the resident's third left toe on 3/25/12 as they gave him/her a bath. This observation revealed the area to the right foot became worse from 3/7/12 to 3/20/12 when the staff finally obtained an order for [REDACTED]. On 3/27/12 at 5:22 P.M., administrative nursing staff S confirmed he/she performed the skin assessment documented in the nurses notes on 3/7/12 where he/she described the area to the lateral aspect of the right foot. He/she stated that he/she notified both administrative nursing staff B and licensed nursing staff C of the findings either on 3/7/12 or 3/8/12. Further observation during the dressing change on 3/26/12 at 10:33 A.M. revealed Licensed nursing staff C proceeded to measure the open area to the left heel. The area measured 0.8 cm in length, 1.5 cm in width, and 0.3 cm in depth. Licensed nursing staff L proceeded to dress the open area with calcium alginate covered with [MEDICATION NAME] dressing. Licensed nursing staff L failed to stage the open area on the left heel. Licensed nursing staff C proceeded to remove the dressing from the top of the second toe on the left foot. At that time, licensed nursing staff C revealed the top layer of skin was gone on the day prior. Observation revealed the area black with the middle of the wound bed yellowish in color and the surrounding skin on the toe red. Licensed nursing staff C measured the area as 0.7 cm. in length, 0.8 cm. in width, and no depth. Licensed nursing staff C put calcium alginate in the center of the wound bed and covered the area with an [MEDICATION NAME] dressing. Observation during the dressing changes on 3/26/12 at 10:33 A.M. revealed the resident with bilateral foam boots in place and the right foot crossed and laid on the left foot. On 3/22/12 at 1:21 P.M., administrative nursing staff B revealed the facility had not staged ulcers for approximately a year and a half. On 3/27/12 at 1:32 P.M., direct care staff M revealed the resident wore foam boots continuously, had an air mattress, and noted the staff repositioned the resident every two hours. On 3/27/12 at 1:45 P.M., licensed nursing staff Q noted the presence of an ulcer to the left heel and a recently acquired open wound to the lateral aspect of the right foot. He/she further revealed the resident frequently laid foam boots on top of each other in the bed and in the chair and noted the resident crossed his/her feet a lot. On 3/27/12 at 4:35 P.M., administrative nursing staff B revealed he/she expected the staff to stage pressure ulcers. He/she further noted if the staff suspected a wound may be vascular related, they should notify the physician for assessment and obtain a doppler study, if needed. He/she stated if these steps were not done, staff should go ahead and treat it as a pressure ulcer. The facility provided a Radiology Diagnostic Report dated 3/29/12 (after the on-site survey) that a doppler was completed that day and revealed the resident had bilateral [MEDICAL CONDITION]. On 3/27/12 at 5:43 P.M., licensed nursing staff C revealed he/she had not personally staged any wounds since his/her employment at this facility. He/she further denied any knowledge of the open area to the lateral aspect of the right foot prior to 3/20/12 and revealed he/she expected the staff that first identified the open area on 3/3/12 to notify the physician and get a treatment in place. The revised January 2011 facility policy entitled "Skin Integrity Guideline" identified the purpose was to provide a systemic approach and monitoring process for skin and to decrease pressure ulcer formation by identifying those residents who were at risk and developing interventions. The objective was to decrease the prevalence and incidence of residents that develop pressure ulcers. The policy further identified the director of nursing services or designee was responsible to implement and monitor the skin integrity program and noted the wound status was monitored on a weekly basis. The facility failed to provide treatment, for this resident with multiple open areas who developed a further open areas, until 13 days after staff identified the area and that area worsened with necrotic tissue present. The clinical record lacked evidence the facility completed comprehensive assessments of the skin breakdown.

The facility identified a census of 39 residents. Sample size was 22 residents of which 3 were reviewed for nutritional status. Based on observation, record review, and staff interview, the facility failed to provide timely interventions for the presence of weight loss for 2 (#6, #40) residents of the sample. Findings included: - Resident # 6's physician's orders [REDACTED]. The POS ordered a regular diet, puree consistency, thickened liquids honey thick, high protein snack every day and a house supplement three times daily. The resident's medical record documented the resident was admitted to hospice on 12/19/09 for the [DIAGNOSES REDACTED]. The annual Minimum Data Set 2.0 dated 8/27/10 recorded the resident with swallowing problem and the resident weighed 201 pounds. The quarterly Minimum Data Set 3.0 dated 2/14/11 recorded the resident's weight was 203 pounds and with no significant weight loss and no swallowing problems. Review of the care plan for nutrition last revised on 5/06/11 directed the staff to weigh the resident monthly and as needed, provide food for comfort, provide a fortified snack as ordered, provide adaptive equipment as ordered, house supplement as ordered. The weight log in the resident's medical record documented on 11/01/10 the resident's weight was 203 pounds and on 1/15/11 the residents weight was 175 pounds. This log also recorded the resident's weight was 176 pounds on 2/16/11, indicating a significant weight loss. The dietary progress note dated 2/03/11 recorded the resident's weight was 175 pounds which was an increase of 0.5 pounds. The Dietary Progress Notes dated 11/23/10 recorded the resident weighed 202.6 pounds and was taking fortified cereal every day and fortified pudding every day along with a house protein supplement every day. The Dietary Progress Note dated 12/06/10 recorded the resident weighed 175.4 pounds and had significant weight loss of 13.4% in 30 days and 14.5% in 90 days and was taking fortified cereal every day and fortified pudding every day along with a house protein supplement every day. Dietary staff failed to add any new interventions for this resident's significant weight loss. Staff failed to document the physician was notified of the weight loss until 12/30/11. The Dietary Progress Note dated 1/19/11 recorded the resident weighed 177 pounds which was significant weight loss of 12.5% in 90 days and 11.9% in 180 days. Dietary staff recommended the house protein supplement be increased to twice daily. The medical record recorded the following laboratory results: 7/13/10 [MEDICATION NAME] = 3.9, total protein =. 6.9; normal ranges for [MEDICATION NAME] were 3.5 - 5.7 and normal protein was 6.4 - 8.9 indicating the resident's laboratory findings were within normal ranges. Review of the Medication Administration Records (MAR) for 11/01/10 - 05/30/11 revealed the 11/01/10 MAR failed to document the staff gave the resident any supplements. The 12/01/10 MAR failed to document the staff gave the resident any supplements. The 01/01/11 MAR indicated [REDACTED]. Nursing staff failed to document that they gave the resident any supplements until 01/20/11. Review of the Physician's Progress Note dated 12/22/10 revealed the physician failed to address the resident's significant weight loss. Review of the Physician's Progress Note dated 12/30/10 revealed the resident had weight loss and that dietary recommended increased supplement. The medical record lacked documentation that the physician ordered the supplement to be increased. During observation on 05/31/11 at 12:48 P.M. staff served the resident puree taco salad , milk and thick water, corn bread puree and pudding. The resident was fed by staff and consumed approx 25% of the taco salad and drank 10% of fluids. The resident was not offered the house supplement as ordered. During interview on 5/31/11 at 12:48 P.M. direct care staff H reported the resident didn't eat very well due to a cough. Direct care staff H reported no knowledge of this resident receiving a house supplement. Staff H pointed to the carton of Vanilla Shake this resident's table mate received and reported that was the only resident at the table that should have gotten a supplement. During interview on 5/31/11 at 8:40 A.M. licensed nursing staff B reported staff should have given the resident a house shake with the meal which came in a carton marked Vanilla Shake. He/She acknowledged that staff failed to provide this resident with the ordered supplement. He/She went to the kitchen and obtained the carton of Vanilla Shake and took it to direct care staff H to give to the resident. He/She reported staff monitored if residents got their supplements by asking the nurse's aides who record the meal percentages, then the nurse records what the direct care staff told them. During interview on 5/31/11 at 9:14 A.M. licensed nursing staff A reported thickened supplements were mixed in the kitchen and served during the meal. Direct care staff and licensed nursing staff would not know if a resident was served a house supplement, but the dietary slip should say house supplement along with the ordered diet. During interview on 5/31/11 at 1:03 P.M. consultant B reported the resident was documented to have unavoidable weight loss by physician on 4/11/11. She/He also reported the resident was on hospice services. The resident currently had fortified cereal at breakfast and fortified pudding at lunch and a house supplement three times a day. During interview on 06/01/11 at 12:34 P.M. dietary staff A reported fortified foods meant to give pudding, ice cream or yogurt or cereal. The facility did not fortify foods. The facility provided a policy entitled Weight Monitoring dated 2002 which directed the licensed nurse should monitor the resident for a significant or severe weight change and notify the resident's physician and family member. The licensed nurse would carry out treatment orders. The facility provided a policy entitled Food First dated 2002 directed individual supplements would be documented on the Nourishment and Supplement Feeding List. After each house supplement pass, the ordered supplements would have been recorded in the medical record by the nursing department with the percent intake consumed. Individual supplements must be labeled with the resident's name, room number, date and the specific time to be given. Supplements must not be served with meals unless ordered by physician. The facility failed to assess this resident for weight loss. The facility failed to report timely to the physician the identified weight loss. The physician failed to address the resident's weight loss in a timely manner. The facility failed to provide new interventions in a timely manner for this resident with significant weight loss. The facility failed to document that ordered supplements were given to the resident. The facility failed to follow their policy for serving supplements. - Resident #40's signed physician's orders [REDACTED]. The quarterly Minimum Data Set (MDS) 3.0 with an assessment reference date of 3/4/11 revealed a Brief Interview Mental Status of 6 which indicated severe impairment. This MDS revealed the resident required limited assistance with bed mobility, transfers, personal hygiene, and independent with eating except for set-up. The 9/22/10 Resident Assessment Protocol (RAP)for cognition documented the resident had impaired decision making. The resident had a history of [REDACTED]. The care plan listed the interventions dated 12/30/10: food for comfort snack as care planned provide supplement as ordered honor food preferences provide diet as ordered The physician's orders [REDACTED]. The Weight Record revealed the following weights in pounds: 11/10 - 138.3 12/10 - 138.6 1/15/11 - 137 2/17/11 - 135.8 3/16/11 - 133.6 3/22/11 - 131 4/2/11 - 130.8 4/27/11 - 127 Consisting of an 8.1 percent or 11.3 pounds in 5 months. The weight committee noted dated 4/1/11 and timed 4:44 P.M. stated the resident continued to ask for ice cream several times ad day but stated he/she could not remember if they had eaten or not. The weight committee notes dated 4/15/11 and timed 10:24 A.M. documented that the resident's weight was down 5.2 pounds from last week. The team recommended 2.0 supplement 30 cubic centimeters (cc) every day. The 4/11 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The clinical record lacked evidence the facility initiated further interventions for the weight loss during this time period. The Food Preference Form, with no date, listed the drinks the resident wanted at each meal but staff did not list any other preferences. Observation on 5/31/11 at 8:06 A.M. revealed the resident sat at the dining room table eating jelly out of the packet with a fork. Observation on 5/31/11 at 9:40 A.M. revealed the resident drank his/her juice, 10 percent of the muffin, 100 percent of the scrambled eggs, and 75 percent of the cereal, without staff assistance. Observation on 5/31/11 at 12:20 P.M. revealed the staff served the resident 8 ounces of milk and 8 ounces of ice water, taco salad, and corn bread. Observation on 5/31/11 at 12:50 P.M. revealed the resident ate 50 percent of the taco salad and the corn bread without staff assistance. Staff did not offer the resident a substitution. Interview with licensed nurse A on 6/1/11 at 4:20 P.M. revealed the facility could not find any additional interventions for the weight loss from 9/10 to 4/27/11. The facility's policy for Weight Monitoring documented that if a significant loss or a trend is identified, an assessment of nutritional status is completed to identify the cause of change and nutritional intervention staff should implement. The facility failed to provide timely assessment and interventions for the prevention of weight loss for this resident with a 11.3 pound weight loss.

The facility identified a census of 39 residents. The sample included 22 residents. Based on observation, interview and record review the facility failed to provide care and treatment to prevent the worsening of pressure ulcers for resident # 26 and failed to provide care and treatment to prevent pressure ulcers for resident's #40, #54 and #45 who were at risk for the development of pressure ulcers. Findings included: - Resident # 26's physician's orders [REDACTED]. This POS ordered staff to clean the coccyx wound with normal saline or wound cleanser, pack with calcium alginate rope and cover with [MEDICATION NAME] and secure with [MEDICATION NAME] tape daily on the day shift. The POS ordered staff to clean the gluteal wound with wound cleanser, pack with calcium alginate rope, cover with [MEDICATION NAME] and secure with [MEDICATION NAME] tape every day. The significant change Minimum Data Set (MDS) 3.0 dated 2/11/11 recorded the resident with moderately impaired cognitive status. The resident did not have behaviors and did not reject care. The resident required total assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. The resident had an indwelling catheter and was always incontinent of bowel. There was no bowel toileting program. The resident was at risk of developing pressure ulcers and had unhealed pressure ulcers, two stage 3 pressure ulcers. The dimensions of the largest ulcer were 0.5 centimeters (cm) in length and 0.2 cm wide and 0.4 cm deep. The care area assessment dated [DATE] for pressure ulcers recorded the resident with two pressure areas which he/she was admitted with. There was tunneling on both wounds. Both wounds had gotten smaller in size, but remained open. The quarterly MDS dated [DATE] recorded the resident was extensive assistance with bed mobility, total assistance with transfers, total assistance with toileting and extensive assistance with personal hygiene. The resident was at risk for the developing pressure ulcers and had unhealed pressure ulcers. The resident had 2 stage 4 pressure ulcers that were present on admission. The resident did not have any unstageable pressure ulcers. The length of longest pressure ulcer was 1.6 centimeters long and 1.7 centimeters wide and was 3.8 centimeters deep. This assessment indicated the wound had increased in size. The two pressure ulcers progressed from a stage 3 to a stage 4 as indicated on the minimum data sets. The care plan for pressure ulcers last updated 04/29/11 directed staff to complete the Braden scale as indicated by the facility policy, diabetic foot monitoring, not to massage over bony prominences, float heels, pressure reduction cushion to wheelchair and pressure reduction mattress, provide barrier cream after incontinent episodes, skin assessment, up in wheel chair for meals and the resident was to lay down after meals in order to provide pressure relief to wound areas. The Wound Evaluation Flow Sheets documented the resident's gluteal pressure ulcer on 04/05/11 measured 0.2 cm long x 0.2 cm wide and 0.3 cm deep. The next documentation on 04/11/11 recorded the pressure ulcer measured 0.3 cm long x 1.0 cm wide and 2.8 cm deep which indicated the pressure ulcer was deeper. Documentation on 5/25/11 recorded the gluteal wound measured 0.3 cm long x 0.3 cm wide and 2.9 cm deep, indicating the pressure ulcer continued to get deeper. The Wound Evaluation Flow Sheets documented the resident's coccyx pressure ulcer on 1/06/11 measured 0.5 cm x 0.3 cm x 4.0 cm deep. On 5/25/11 the pressure ulcer measured 1.1 cm long x 1.2 cm wide x 3.3 cm deep, indicating the pressure ulcer had gotten worse. Review of the physician progress notes [REDACTED]. The resident was started on [MEDICATION NAME] HCL 300milligrams twice daily. During frequent observation on 05/31/11 from 8:05 A.M. until 10:43 A.M. revealed staff did not reposition the resident in the wheelchair and the resident did not reposition himself/herself. Staff did not offer to lay the resident down to relieve pressure off the coccyx and left gluteal pressure ulcer areas. This was a total frequent observation of 2 hours and 38 min. During observation on 5/31/11 at 8:20 A.M. staff wheel the resident to his/her room and left the resident in the wheelchair. Staff did not reposition the resident. During observation on 5/31/11 at 8:32 A.M. the resident sat in the wheelchair in her/her room watching television. Staff did not reposition the resident. During observation on 5/31/11 at 10:09 A.M. staff wheeled the resident to the beauty shop and did not reposition the resident. During observation on 5/31/11 at 10:20 A.M. staff wheeled the resident from the beauty shop to the hall and the resident sat under the hair dryer. The staff did not reposition the resident. During observation on 5/31/11 at 10:24 A.M. staff wheeled the resident into the living room and did not reposition the resident During observation on 5/31/11 at 10:32 A.M. the resident remained in the same position in the living room area. During observation on 05/31/11 at 12:00 P.M. direct care staff B and direct care staff D provided perineal care for the resident who had been incontinent of bowel. Observation of the resident's buttocks revealed two open, uncovered pressure ulcers with no visible dressings on the resident's buttocks or in the incontinent brief. Staff cleaned the resident with the wet wipes and while cleaning the bowel movement off of the rectum did wipe the stool toward the back and over both pressure ulcers causing the stool to contaminate the two uncovered pressure ulcers. Staff finished the incontinence care and assisted the resident back to the dining room failing to notify the nurse of the undressed pressure ulcers. During interview on 05/31/11 at 12:05 P.M. direct care staff B acknowledged nursing staff failed to cover the pressure ulcers with a wound dressing. During observation on 05/31/11 at 2:04 P.M. the resident laid in bed on his/her back with his/her buttocks and feet resting on the mattress. Licensed nursing staff B and D were observed as they removed the resident's pants and exposed the buttocks. The resident was incontinent of bowel movement. The two pressure ulcers were not covered with wound dressings. Staff provided pressure ulcer wound care. The wounds were cleaned with wound cleanser and dressed with the appropriate dressings according to the physician's orders [REDACTED]. During interview on 5/31/11 at 2:04 P.M. licensed nursing staff D reported licensed nursing staff should have placed the prescribed wound dressings on the pressure ulcers. He/She reported the direct care nursing staff failed to inform him/her that the resident's pressure ulcers did not have wound dressing on them at 12:00 P.M. when observed during incontinence care. During interview 05/31/11 at 4:36 P.M. licensed nursing staff F reported this resident was at risk for the development of pressure ulcers. Staff had to reposition the resident every 2 hours because the resident couldn't reposition herself/himself. He/She would have expected direct care staff to inform him/her if a wound dressing came off or if a pressure ulcer didn't have a dressing so he/she could dress the wound. During observation on 06/01/11 at 6:40 A.M. the resident sat up in the wheel chair in the dining room at the dining room table. During observation on 06/01/11 at 7:00A.M. the resident remains at the table feeding himself/herself. During observation on 06/01/11 at 7:15 A.M. the resident continued to eat and his/her position was unchanged. During observation on 06/01/11 at 7:30A.M. the resident ate 75-90% of the pancakes, sausage and cereal without difficulty.She/He consumed 50% of the fluids and drank 100% of the ordered supplement. Staff had not repositioned the resident. During observation on 06/01/11 at 7:45 A.M. the resident remains at the dining room table visiting with other residents in the same position. During observation on 06/01/11 at 8:00 A.M. the resident remains in the same position. During observation on 06/01/11 at 8:15 A.M. staff have not repositioned the resident. During observation on 06/01/11 at 8:30 A.M. the resident remains in the same position, staff have not repositioned the resident. During observation on 06/01/11 at 8:45 A.M. direct care staff B pushed the resident from the dining room to his/her room. The resident requested a sweater so staff gave her a choice of what to wear and put the sweater on the resident. Licensed nursing staff A entered the room and direct care staff B requested assistance to pull the resident up in the wheelchair as he/she slid down and his/her feet where hanging off of the pillow which was placed under the resident's feet on the wheelchair foot rest. Licensed staff A and direct care staff B held the resident under the arms and slid the resident back up against the chair back. Direct care staff B then wheeled the resident out of the resident's room to a group activity. Staff failed to reposition the resident to relieve pressure off of the pressure ulcers. During frequent observation on 06/01/11 at 6:40 A.M. - 8:45 A.M. revealed the resident remained in the same position and staff failed to attempt to reposition the resident to relieve pressure off of the pressure ulcers During observation on 06/01/11 at 9:00 A.M. the resident is sitting in the main room with a group of residents for an exercise activity. During observation on 06/01/11 at 9:10 A.M. the resident is doing arm exercises in the main living room. Staff had not repositioned him/her. During observation on 06/01/11 at 9:23 A.M. the resident remained in the wheelchair in the main room with some residents. The group exercise activity had finished and staff did not reposition the resident. During observation on 06/01/11 at 9:27 A.M. direct care staff H pushed the resident from the living room to the resident ' s room and put the left hand brace on the resident. Staff then left the resident sitting up in the wheelchair in his/her room. Staff did not reposition the resident to relieve pressure off of the pressure ulcers. Frequent observation on 06/01/11 from 6:40 A.M. - 9:27 A.M. revealed the resident remained seated in the wheelchair in the same position. During observation on 06/01/11 at 9:46 A.M. direct care staff B and F entered the resident's room where the resident sat in the wheelchair. Staff lifted the resident with the sling lift and laid the resident in bed. During frequent observation on 06/01/11 from 6:40 A.M. - 9:46 A.M. a total of 3 hours and 6 minutes the resident was observed sitting in the wheelchair. Staff failed to reposition this resident to prevent pressure on the existing two stage 4 pressure ulcers. During interview on 06/01/11 at 9:47 A.M. direct care staff F reported that was the first time staff had repositioned the resident since they got the resident up that morning. During interview on 06/01/11 at 2:16 P.M. licensed nursing staff A reported nursing staff should reposition the resident every 2 hours. Licensed nursing staff A reported the resident was repositioned at 8:45 A.M. when he/she and direct care staff B slid the resident back in the wheelchair. She/He reported the resident preferred to stay up for activities rather than lay down. The facility failed to provide a policy for repositioning residents. The facility failed to prevent worsening of pressure ulcers for this dependent resident. The facility failed to perform dressing changes as ordered to two stage 4 pressure ulcers. The facility failed to assist this dependent resident with 2 stage 4 pressure ulcers to repostion every 2 hours. - The signed Physician orders [REDACTED]. Interview with licensed nurse B on 6/1/11 at approximately 10:00 A.M. revealed the facility admitted the resident on 5/24/11. The 5/26/11 Physician orders [REDACTED]. The Clinical Health Status dated 5/24/11 at 2:00 P.M. documented the resident had a stage one pressure ulcer to the coccyx. The Braden Scale dated 5/24/11 recorded a score of 12 with a score of 10-12 indicating a high risk for skin breakdown. Interview with licensed nurse B on 6/2/11 at 8:55 A.M. revealed the facility admitted the resident with a non-stageable pressure ulcer to the left heel. The initial care plan dated 5/25/11 listed the interventions: wheel chair to the dining room, incontinent 2 plus times a week, briefs at all times, assess for signs and symptoms of urinary tract infection, keep the resident clean and dry, and check and change every 2 hours. The initial care plan did not include interventions for the pressure ulcers on the coccyx and the left heel. The Certified Nurse Assistant Resident Care Sheet dated 5/31/11 listed the interventions: incontinent, reposition in bed and in wheel chair. This care sheet did not include the frequency of the repositioning and off loading the heels. Observation on 5/31/11 at 7:19 A.M. while direct care staff A and E provided AM cares revealed the incontinence brief saturated with urine. This observation revealed an open area to the coccyx and red unblanchable skin. The resident's heels were in direct contact with the bed and a dressing was present to the left heel. Staff transferred the resident to his/her wheel chair and assisted to the dining room. Observation on 5/31/11 at 8:03 A.M., 8:35 A.M., and 8:45 A.M. revealed the resident remained in the dining room with no change in position. Observation on 5/31/11 at 8:55 A.M. revealed the staff wheeled the resident to his/her room but did not provide a change in position. Observation on 5/31/11 at 9:10 A.M., and 10:00 A.M. revealed the resident remained in his/her room without a change in position. Observation on 5/31/11 at 10:01 A.M. revealed the staff wheeled the resident to the front living room but did not provide a change in position. Observation on 5/31/11 at 10:20 A.M., 10:34 A.M., 10:52 A.M., and 11:02 A.M., revealed the resident remained in the living room and staff did not provide a change in position. Observation on 5/31/11 at 11:04 A.M. until 11:25 A.M. revealed therapy staff wheeled the resident into therapy but did not provide a change in position. Therapy staff completed passive range of motion to the lower extremities and range of motion to the upper extremities. Observation on 5/31/11 at 12 noon revealed the resident sat in his/her wheelchair in the dining room but staff did not provide a change in position. Observation on 5/31/11 at 12:08 P.M., 12:14 P.M., 12:35 P.M., and 12:50 P.M. revealed the resident sat in the dining room without a change in position. Observation on 5/31/11 at 1:06 P.M. revealed direct care staff A and D transferred the resident to his/her bed. Staff at that time confirmed the resident's brief as wet. This staff left the residents house slippers on and did not off load the heels. The staff did not reposition this resident for over 5 hours. Observation on 6/2/11 at 8:55 A.M. while licensed nurse B completed pressure ulcer treatment to the left heel revealed a 1.2 centimeter (cm) by 1.6 cm non-stageable pressure ulcer Direct care staff F on 5/31/11 at 5:00 P.M. stated the staff should reposition this resident every 2 hours. He/she also stated they did not have to do anything with the feet except for reminding the nurse to change the dressing. Licensed nurse B on 6/1/11 at 9:58 A.M. stated the staff should reposition the resident at a minimum of every 2 hours and off load the heels when in bed. The facility's policy for Skin Care Guidelines included the intervention to initiate positioning schedule to meet individual resident needs and minimize concentrated pressure to skin. The facility failed to reposition this resident with pressure ulcers every 2 hours and failed to off-load the heels as planned. - Resident #40's signed physician's orders [REDACTED]. The quarterly Minimum Data Set (MDS) 3.0 with an assessment reference date of 3/4/11 revealed a Brief Interview Mental Status of 6 which indicated severe impairment. This MDS revealed the resident required limited assistance with bed mobility, transfers, personal hygiene, and toileting, and the presence of a catheter. The 9/22/10 Resident Assessment Protocol (RAP)for pressure ulcers stated the resident had a brace to the right arm which increased his/her risk for skin issues. The resident had a pressure relieving mattress to the bed and a cushion to the wheel chair. The RAP dated 9/22/10 for activities of daily living documented that the resident required limited staff assistance with transfers and had impaired cognition and poor safety awareness. The up-dated care plan dated 3/10/11 listed the interventions: bed mobility with assistance of one, inspect skin with cares, and assist me with any personal cares I can not complete myself. The nurse's note dated 5/29/11 and timed 7:25 P.M. revealed the resident had a slightly reddened bottom and the staff notified the physician. physician's orders [REDACTED]. Observation on 5/31/11 at 7:58 A.M. while direct care staff A provided A.M. cares revealed the resident's brief wet with urine. After providing incontinence care this staff transferred the resident to his/her wheel chair. Observation on 5/31/11 at 8:35 A.M. revealed the resident sat in the dining room eating breakfast. Observation on 5/31/11 at 8:59 A.M., 9:20 A.M. and 9:40 A.M. the resident remained in the dining room without a change in position. Observation on 5/31/11 at 9:41 A.M. revealed the resident wheeled him/herself to the front living room. Observation on 5/31/11 at 10:02 A.M., 10:20 A.M., 10:40 A.M., 10:51 A.M., and 11:01 A.M. the resident remained in the living room with no change in position. Observation on 5/31/11 at 11:17 A.M. revealed the resident in his/her wheel chair in the doorway of his/her room with no change in position to relieve pressure off the buttocks. Observation on 5/31/11 at 11:30 A.M. revealed staff changed the resident's shirt but did not provide a change in position. Observation on 5/31/11 at 12:14 P.M., 12:20 P.M., 12:35 P.M., and 12:50 P.M. the resident sat in the dining room with no change in position offered. Observation on 5/31/11 at 1:00 P.M. direct care staff B and C transferred the resident from the wheel chair to his/her bed. The staff did not check for incontinence. The surveyor asked for a skin check and the resident had reddened inner buttocks that blanched. The facility did not reposition this resident for approximately five hours. Observation on 5/31/11 at 2:15 P.M. revealed staff wheeled the resident from his/her room to the dining room. Observation on 5/31/11 at 2:20 P.M., 3:07 P.M., 3:21 P.M., 3:38 P.M., 3:55 P.M., 4:10 P.M., 4:35 P.M., and 5:50 P.M. revealed the staff did not reposition the resident, a duration of 3 and 1/2 hours. Direct care staff A on 5/31/11 at 11:32 A.M. stated they reposition the resident when he/she requested. Direct care staff A on 5/31/11 at 1:00 P.M. stated they reposition the resident every 2 hours. Licensed nurse B on 6/1/11 at 10:16 A.M. stated the staff should turn and reposition the residents at a minimum of every 2 hours. The facility's policy for Skin Care Guidelines included the intervention to initiate positioning schedule to meet individual resident needs and minimize concentrated pressure to skin. The facility failed to reposition this resident that requested assistance every 2 hours. - The 4/11 physician's orders [REDACTED]. The quarterly Minimum Data Set (MDS) 3.0 with the reference date of 4/10/11 revealed the resident had short and long term memory problems, required extensive assistance of two people with bed mobility, transfers, dressing, toileting, and personal hygiene. This MDS identified the resident at risk for developing a pressure ulcer. The Care Area Assessment for pressure ulcers based on the reference date of 1/21/11 assessed the resident at risk for pressure ulcers due to limited mobility and incontinence status. The resident was unable to alert staff when he/she needed to toilet or had an incontinent episode. The resident was unable to reposition him/herself in bed or the wheel chair without assistance from staff. The up-dated care plan dated 3/28/11 listed the interventions: Braden scale per Living center policy conduct wkly skin inspections nutritional and hydration support pressure reducing wheel chair cushion pressure reduction/relieving mattress provide thorough skin care after incontinent episodes and apply barrier cream turn and reposition schedule per assessment The Braden Scale dated 3/24/11 revealed a score of 12 with 10 to 12 indicating the resident at a high risk for developing pressure ulcers. Observation on 5/31/11 at 8:46 A.M. revealed the resident sat in a wheel chair and staff were combing his/her hair. Observation on 5/31/11 at 8:58 A.M., 9:00 A.M., 9:15 A.M., 9:26 A.M., 9:36 A.M., 9:41 A.M., 9:51 A.M., 10:03 A.M., 10:25 A.M., 10:36 A.M., 10:52 A.M., 11:02 A.M., 11:19 A.M., 11:35 A.M., 12:05 P.M., 12:15 P.M., 12:32 P.M., 1:00 P.M., 1:20 P.M. revealed the resident sat in the wheel chair, rolling self around the facility and eating breakfast and lunch but staff did not attempt to provide a change in position. Observation on 5/31/11 at 1:45 P.M. a visitor came and took the resident outside for a visit. Observation on 5/31/11 at 2:55 P.M. the friend brought the resident back in and staff took the resident to his/her room and changed his her wet brief. Skin check on 6/1/11 at 8:31 A.M. revealed no skin breakdown. Licensed nurse B on 6/1/11 at 9:49 A.M. stated the staff should reposition this resident at a minimum of every 2 hours. The facility's policy for Skin Care Guidelines included the intervention to initiate positioning schedule to meet individual resident needs and minimize concentrated pressure to skin. The facility failed to reposition this resident that requested assistance every 2 hours.