Every finding on record at Kenwood View Healthcare and Rehabilitation Center

The facility had a census of 62 residents, The sample included 16 residents. Based on observation, record review, and interview, the facility failed to store and label medications in accordance with professional standards of practice. This placed the residents at risk of medication error. Findings included: - On 12/23/24 at 08:21 AM, during the initial tour of the facility, observation of the medication cart F with Licensed Nurse (LN) H revealed six medication cups with numerous pills in each cup sitting in the top drawer. The cups were labeled with various resident ' s names. LN H stated she placed the resident's medication in the cups for administration and would recheck them when she delivered the medication to the residents. On 12/30/24 at 10:36 AM, Administrative Nurse D verified medications should not be removed from the packing and stored without labeling and dosing instructions. The medications should not be prepared until the time of delivery to the residents. The facility ' s undated Medication Administration policy documented medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The facility failed to ensure the storage and delivery of medications in accordance with professional standards of practice, which placed the residents at risk of medication errors.

The facility had a census of 62 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to ensure ice was maintained in a sanitary manner and failed to implement Enhanced Barrier Precautions (EBP-an infection control practice that uses personal protective equipment (PPE) to reduce the spread of multi-drug resistant organisms (MDRO) for Resident (R) 41 and R6 who had an indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag). These deficient practices placed the residents at risk of contracting or spreading infectious processes. Findings included: - On 12/23/24 at 02:31 PM, observation in the dining room revealed R45 ambulated to the unlocked ice machine, opened the lid, took the scoop off the side of the ice machine, placed his used styrofoam cup over the ice, and scooped ice into his cup. On 12/23/24 at 02:41 PM, observation in the dining room revealed R49 and R42 ambulated into the dining room and went to the drink center. R49 went to the unlocked ice machine, took the ice scoop off the outside to the ice machine, placed her cup over the ice machine bin, and scooped ice into her water container, overfilling it; the ice spilled from the cup back into the ice machine bin. Further observation revealed that R49 retrieved R42's water container, placed it over the ice bin, and filled the water container with ice. On 12/30/24 at 10:27 AM, Administrative Nurse D stated she expected staff to keep the dining room ice machine locked and unlock it during meals when staff were present. The facility's Ice Machines and Portable Ice Carts Policy, revised 01/15/24, documented that the ice machine and ice carts would be accessed by staff only. The facility failed to provide a safe and sanitary environment when R45 and R49 filled their used drinking containers over the ice in the dining room ice machine contaminating the ice. This placed the residents who received ice from the ice machine at risk of acquiring an infectious disease. 37450 - On 12/24/24 at 07:52 AM, observation revealed Certified Nurse Aide (CNA) M and CNA N checked R6's brief, provided perineal care, and catheter care, and then changed R6's incontinent brief. Observation revealed CNA N or M had not gowned before providing the care. Observation on the room door revealed a facility magnet with green arrows. On 12/24/24 at 09:37 AM, observation revealed CNA M providing indwelling urinary catheter care for R41. CNA M only utilized gloves and did not don a gown. On 12/24/24 at 09:40 AM, Licensed Nurse (LN) G stated CNA M should have worn a gown and gloves while providing care for R41. On 12/24/24 at 10:06 AM, Activity Director (AD) Z stated the green magnet on resident room doors informed staff to use EBP. On 12/30/24 at 10:19 AM, Administrative Nurse D stated she expected all staff providing indwelling catheter care to the residents to follow the EBP while providing direct care. Administrative Nurse D verified that staff should have worn gloves and a gown while providing catheter care for R41 and R6. She stated each resident with EBP should have the supplies in their room on the back of the door. Administrative Nurse E verified some resident rooms did not have the supplies in their rooms. The facility's Enhanced Barrier Precaution policy, dated 06/14/23, documented enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). The facility failed to implement EBP for R6 and R41, who had an indwelling urinary catheter. This placed the resident at risk of contracting or spreading infectious processes.

The facility identified a census of 73 residents. The sample included five residents reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to ensure staff provided consistent bathing and/or showers for five sampled residents, Resident (R) 1, R2, R3, R4, and R5. This deficient practice placed the residents at risk for impaired dignity, infection, and alteration in skin integrity. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of left below the knee amputation (surgical removal of a body part), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), morbid obesity, need for ileostomy (surgical formation of an opening through which fecal matter empties), and major depression (major mood disorder which causes persistent feelings pf sadness).The Significant Change Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated R1 had intact cognition. The MDS further documented R1 was dependent on staff for all of his ADLs except eating which he required supervision/clean-up assistance. The Functional Abilities Care Area Assessment (CAA), dated 05/23/24, documented R1 required assistance with all of the self-care or mobility activities R1's Care Plan documented R1 required substantial/maximum assistance with showering/bathing. The care plan lacked documentation ofR1's preferences on showers or baths or when showers or baths would occur. The facility shower schedule documented R1 was to receive showers on every Monday and Thursday. R1's EMR Task tab documented R1 had only received five showers from June 16, 2024 through July 15, 2024. R2's EMR documented R2 had diagnoses of metabolic encephalopathy (broad term for any brain disease that alters brain function or structure), end stage renal disease (ESRD-a terminal disease of the kidneys), right humerus (upper arm bone) fracture (broken bone), and chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Admission MDS, dated [DATE], documented R2 had a BIMS score of 13 which indicated intact cognition. The MDS documented R2 was dependent on staff for toileting, lower body dressing, and donning shoes. The MDS documented R2 required substantial/maximum staff assistance for all other ADLs. The Function Abilities CAA, dated 06/25/24, documented R2 required assistance with all self-care and mobility activities. The Pressure Ulcer/Injury CAA, dated 05/24/24, documented R2 was at risk for pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction)due to her need for assistance for movement in bed. The CAA documented R2 was at further risk for pressure ulcers due to being frequently incontinent of bowel and bladder. R2's Care Plan documented R2 required substantial/maximum assistance with showering/bathing. The care plan lacked documentation R2's preferences on showers or baths or when showers or baths would occur. The facility shower schedule documented R2 was to receive showers on every Wednesday and Saturday. R2's EMR Task tab documented R2 had only received two showers from June 16, 2024 through July 15, 2024. R3's EMR documented R3 had diagnoses of peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel) ESRD, morbid obesity, and DM. The Admission MDS, dated [DATE], documented R3 had a BIMS score of 14 which indicated intact cognition. The MDS documented R3 was dependent on staff for toileting, showering, lower body dressing, donning shoes and transfers. R3 required substantial/maximum assistance with all other ADL's. The Function Abilities CAA, dated 04/25/24, documented R3 required assistance with all self-care and mobility activities. The CAA documented R3 was at risk for further decline in functional abilities, falls, contractures (abnormal fixation of a joint or muscle), isolation, pressure ulcers and incontinence. The Pressure Ulcer/Injury CAA, dated 05/24/24, documented R3 was at risk for pressure ulcer due to her need for assistance for movement in bed. The CAA documented R3 was at further risk for pressure ulcers due to being frequently incontinent of bowel and bladder. R3'sCare Plan documented R3 required substantial/maximum assistance with showering/bathing. The care plan lacked documentation of R3's preferences on showers or baths or when showers or baths would occur. The facility shower schedule documented R3 was to receive showers on every Wednesday and Sunday. R3's EMR Task tab documented R3 had only received three showers from June 16, 2024 through July 15, 2024. R4's EMR documented R4 had diagnoses of hypertension (high blood pressure), ESRD, and DM. The Quarterly MDS, dated [DATE], documented R4 had a BIMS score of 15 which indicated intact cognition. The MDS documented R4 used a wheelchair, a walker, and had a limb prosthesis. The Function Abilities CAA, dated 03/05/24, documented R4 required assistance with all self-care and mobility activities. The CAA documented R4 was at risk for further decline in functional abilities, falls, contractures, isolation, pressure ulcers and incontinence. The CAA documented R4 was blind which further complicated his functional abilities. The Pressure Ulcer/Injury CAA, dated 05/24/24, documented R4 was at risk for pressure ulcer due to his need for assistance for movement in bed. The CAA documented R4 was at further risk for pressure ulcers due to being frequently incontinent of bladder. R4's Care Plan documented R4 required moderate staff assistance with all of his ADL's. The care plan lacked documentation of R4's preferences on showers or baths or when showers or baths would occur. The facility shower schedule documented R4 was to receive showers on every Tuesday and Friday. R4'sEMR Task tab documented R4 had only received one shower from June 16, 2024 through July 15, 2024. R5's EMR documented R5 had diagnoses of lupus (an autoimmune disease that makes the immune system damage organs and tissue throughout the body), major depressive disorder, morbid obesity, and DM. The Quarterly MDS, dated [DATE], documented R5 had a BIMS score of 15 which indicated intact cognition. The MDS documented R5 was dependent on staff for toileting, showering, dressing, bed mobility and transfers. The Function Abilities CAA, dated 04/26/24, documented R5 required assistance with all self-care and mobility activities. The CAA documented R5 was at risk for further decline in functional abilities, falls, contractures, isolation, pressure ulcers and incontinence. The Pressure Ulcer/Injury CAA, dated 05/24/24, documented R5 was at risk for pressure ulcer due to her need for assistance for movement in bed. The CAA documented R5 was at further risk for pressure ulcers due to being frequently incontinent of bowel and bladder. R5'sCare Plan documented R5 was dependent on staff assistance with showering/bathing. The care plan lacked documentation of R5's preferences on showers or baths or when showers or baths would occur. The facility shower schedule documented R5 was to receive showers on every Mondays and Fridays. The EMR Task tab documented R5 had only received two showers from June 16, 2024 through July 15, 2024. On 07/15/24 at 09:45 AM, observation revealed R1 was in bed watching TV. R1 had a distinct odor about him. R1's hair appeared greasy and oily. On 07/15/24 at 10:00 AM, observation revealed R2 sat in her wheelchair. There were food stains and particles on the immobilizer to keep her right humerus fracture still. R2's hair was greasy. R2 had a distinct odor about her. On 07/15/23 at 11:00 AM, observation revealed R3 in bed watching TV. R3's hair was unkempt and appeared greasy. On 07/15/24 at 11:15 AM, observation revealed R4 in bed. R4's hair was greasy and R4 had a distinct odor about him. On 07/15/24 at 12:45 PM, observation revealed R5 sat in a chair watching TV. R5's hair was greasy and oily. On 07/15/24 at 09:45 AM, R1 stated that he did not get showers or baths the way that he was supposed to. R1 stated he thought all of his skin problems were from lnot getting consistent showers. On 07/15/24 at 10:00 AM, R2 stated she did not receive showers the way that she would like. R2 stated when she didn't receive showers she felt unclean and smelly. On 07/15/24 at 11:00 AM, R3 stated she did not receive showers in a timely fashion at the facility. R3 stated she knew she didn't get that dirty laying in bed but with incontinence, brief use, and just sweating she felt dirty and stinky. R3 stated she would like to have more consistent showers. On 07/15/24 at 11:15 AM, R4 stated he did not get showers the way he wanted. R4 stated he could not rely on the facility staff to give him shower. R4 stated he was only able to clean his butt and his head and needed staff assistance with everything else. On 07/15/24 at 12:45 PM, R5 stated she did not get bathed like she wanted. R5 stated she preferred bed baths. R5 stated after going so long without any bathing she felt gross and disgusting. R5 stated she was incontinent of urine and needed to be bathed consistently. R5 stated she had psoriasis (a chronic skin disorder characterized by red patches covered by thick, dry silvery adherent scales) and she said she felt like her psoriasis had progressively gotten worse due to lack of bathing. R5 stated she felt like the facility pulled the bath aide off of baths all of the time to cover for call-ins. On 07/15/24 at 01:00 PM, Certified Nurse's Aide (CNA) M stated the day shift could not get all of the showers done every day and they would tell the evening shift staff to get them done on their shift. On 07/15/24 at 01:15 PM, Administrative Nurse D stated she knew baths were not getting done and that it was a problem facility wide. On 07/15/24 at 01:30 PM, Administrative Staff A, stated she thought the showers were getting done but staff were not charting the showers appropriately. Administrative Staff A stated the facility had come up with a way of monitoring the previous weeks charting to ensure staff were charting in the EMR. The facility's undated Resident Showers Policy documented it is the practice of this facility to assist resident with bathing to maintain proper hygiene, stimulate circulation, and help prevent skin issues as per current standard of practice. Residents will be provided shower as per request or as per facility schedule protocols and based upon resident safety. The facility failed to ensure staff provided consistent bathing and/or showers for five sampled residents, R1, R2, R3, R4, and R5. This deficient practice placed the residents at risk for impaired dignity, infection, and alteration in skin integrity.

The facility identified a census of 73 residents with three residents reviewed for abuse and neglect. Based on record review, observation and interview, the facility failed to ensure Resident (R) 1 remained free from verbal abuse and/or mistreatment from staff. This deficient practice placed R1 at risk for fear, intimidation and neglect. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head), major depressive disorder (major mood disorder which causes persistent feelings pf sadness), and seizures (violent involuntary series of contractions of a group of muscles). The Annual Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status score of 15 which indicated intact cognition. The MDS documented R1 was dependent of staff for all her activities of daily living (ADL). R1 had impairment to both sides of her upper extremities, and both sides of her lower extremities. R1 was dependent on a wheelchair for locomotion. The Functional Abilities Care Area Assessment (CAA), dated 01/25/24, documented R1 required staff assistance with all her ADL. The CAA documented R1 was at risk for further decline in functional abilities, falls, contractures (abnormal fixation of a joint or muscle), isolation, pressure injuries and incontinence. The Communication CAA, dated 01/25/24, documented R1 had difficulty expressing her ideas and understanding others. The CAA documented R1 was at risk for missed messages, isolation, and depression. R1's Care Plan documented R1 was completely dependent on staff for all her ADL. The plan directed staff to anticipate and meet R1's needs. Certified Nurse Aide (CNA) N's Witness Statement, dated 04/01/24, documented at around 03:30 AM CNA N and CNA M went into R1's room to do rounds. CNA N and CNA M performed R1's normal routine. When turning R1 to the wall, R1's arm got caught under her and she yelled out, My arm several times. CNA N and CNA M got R1's arm unstuck and then rolled R1 the other direction. CNA N noted when staff finished cleaning R1 up and laid her on her back, R1 stated, You almost broke my neck. CNA M started yelling and pointing his finger in R1's face. CNA M stated, We did not almost break your [expletive] neck. We have been yelled at and cussed at all night and don't [expletive] deserve this [expletive]. We don't get paid enough and we aren't robots. CNA N documented that CNA M then pulled R1's call light out of the wall, plugged it back in and tossed the call light in the chair, and told R1 not to call again and left the room. CNA N told R1 she was sorry, and that she would report the situation to the nurse. CNA N stated she left the room and reported the situation to Licensed Nurse (LN) G. LN G's Witness Statement, dated 04/01/24, documented at 05:00 AM CNA N reported to her that CNA M had treated R1 in an unprofessional manner. CNA N described to LN G CNA M had pushed a chair in R1's room, had spoken to R1 in a harsh manner, and pointed his finger in R1's face. LN G documented CNA N told the two CNA staff were changing R1 and turned R1 and her arm was stuck underneath her. The aides turned R1 to the left side. LN G documented CNA N told her R1 said they were going to break her neck and she would fall. LN G documented CNA N told her CNA M got upset and started yelling at R1 that she would get him in a lot of trouble and that was when the chair was shoved and the finger pointing started. CNA N asked LN G to go talk to R1. LN G asked R1 what had happened. R1 stated she was upset because she thought the aides would break her neck when they turned her, or she would fall. R1's face was red and R1 said, she was afraid and that she thought CNA M was mentally unstable and she had thought that for a long time. LN G left R1's room and went to talk to CNA N. CNA M's Witness Statement, dated 04/01/24, documented CNA N and he were doing rounds and met in R1's room; they turned the lights on and let R1 know everything they were going to do. They started to do cares on R1, then pulled the pad not knowing it was not fully under R1 and it pulled R1's body over and R1 laid on her wrist. CNA M documented they quickly rolled R1 back over to get her arm out and then rolled R1 the other way. R1 said the two staff tried to break her neck. CNA M documented that after they were we finished, he told R1 if she made an accusation like that, the staff could get in trouble when it was not true. CNA M recorded R1 was screaming and yelling, and he told R1 he was done getting yelled at and finished with her. CNA M documented he then tripped on the call light, knocked into R1's chair, grabbed up the mess and left R1's room. CNA M documented he let LN G know what had happened. The Facility Incident Report, dated 04/05/24, documented at approximately 08:00 AM on 03/31/24 LN G notified Administrative Nurse D of a potential incident between R1 and CNA M. LN G told Administrative Nurse D that CNA M's conversation with R1 was reported as unprofessional. LN G stated the incident was reported and witnessed by CNA N. The investigation was started, and CNA M was suspended pending results of the investigation. Administrative Nurse D spoke with R1 on 03/31/24 and R1 stated she could not recall any specific incident or any staff members she had issues with. A skin assessment was completed on R1 and no new variances were noted. Administrative Nurse D spoke with CNA N and obtained her witness statement and obtained a witness statement from LN G. A meeting was held with CNA M and his witness statement was obtained. Law Enforcement was also notified. A follow up with R1 was completed throughout the week and R1 showed no indications of psychosocial affects. On 04/16/24 at 10:30 AM, observation revealed R1 sat in a high-backed wheelchair watching television. On 04/16/24 at 10:30 AM, R1 stated she was upset with CNA M, but she was not afraid because CNA M did not work there anymore. R1 stated she got good care at the facility. On 04/16/24 at 01:00 PM, Administrative Nurse D stated that she expected her staff to report any allegations of abuse to her or Administrative Staff A immediately and if they could not be reached, they should reach out to other facility administrative staff until someone answered and report the situation. Administrative Nurse D stated CNA M should have been sent out of the facility immediately after the incident. Administrative Nurse D stated she re-educated LN G and CNA N on ANE policy and immediate notification. Administrative Nurse D stated CNA M had finished his shift that started on 03/30/24 and ended at approximately 07:00 AM on 03/31/24. On 04/16/24 at 01:30 PM, CNA N stated CMA M was very angry at R1 and was out of control. CNA N stated R1 was scared at the time of the incident. On 04/16/24 at 01:55 PM, Administrative Staff A e-mailed and stated that the all-staff education had not been started after the incident, but education would be started that day. The facility's Abuse, Neglect, and Exploitation Policy, revised 11/06/2017, documented it is the facility's policy to provide for the safety and dignity of all its residents by implementing proper procedures for enforcing residents' rights to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility will not use verbal, mental, sexual, or physical abuse; corporal punishment; or involuntary seclusion. The facility must ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported. The facility must have evidence that all alleged violations are thoroughly investigated. The facility must prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. If the alleged violation is verified, appropriate corrective action must be taken. Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, within five working days of the incident. The facility failed to ensure R1 remained free from staff abuse and/or mistreatment. This deficient practice placed R1 at risk for fear, intimidation and neglect.

The facility identified a census of 63 resident with three residents reviewed for quality care and treatment. Based on record review, observation, and interview, the facility failed to provide quality care and treatment for Resident (R) 1 when staff failed to apply ACE wraps to R1's bilateral legs daily for lymphedema (swelling caused by accumulation of lymph). This deficient practice placed R1 at risk for edema (swelling), skin infections, and skin breakdown. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of lymphedema, hypertension (high blood pressure), and malignant neoplasm (cancerous tumor) of the right breast. The Admission Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R1 was totally dependent for toileting and bathing, required maximum assistance for dressing, and required moderate assistance with bed mobility, transfer, and ambulation. The Pressure Ulcer Injury Care Area Assessment (CAA), dated 09/19/23, documented R1 was at risk for skin breakdown and the goal was to minimize the risk of skin breakdown. The Pain CAA, dated 09/19/23, documented R1 was at risk for uncontrolled pain, social isolation, and decline and the goal was to keep R1's pain managed. R1's Care Plan, dated 09/14/23, failed to address R1's need for ACE wraps to her bilateral lower extremities to be applied every morning and taken off every night. The care plan documented R1 required one staff assistance for all activities of daily living. Staff were directed to monitor and document any signs of edema. The Electronic Treatment Administration Record (ETAR), with the order start date of 09/18/23, directed staff to apply ACE wraps to R1's bilateral lower extremities daily in the morning and take off the ACE wraps at night. On 12/12/23 at 11:10 AM, observation revealed Administrative Staff A answered R1's call light and R1 asked for a nurse to come to her room to apply her ACE wraps. R1 told Administrative Staff A that she had been asking for the ACE wraps to a be applied to her legs all morning. Administrative Staff A told R1 she would notify the nurse. On 12/12/23 at 11:15 AM, observation revealed R1 sat in her recliner watching TV. R1 did not have ACE wraps to her bilateral lower extremities. R1's bilateral legs were very swollen and red. On 12/12/23 at 11:30 AM, observation revealed Licensed Nurse (LN) G entered R1's room to apply her ACE wraps. On 12/12/23 at 11:15 AM, R1 stated there were times when her ACE wraps never got applied and she had to nag nursing staff repeatedly to try and get her ACE wraps applied. R1 stated she should not have to do that as the ACE wraps were part of her plan of care and nursing should follow her plan of care. R1 stated when her ACE wraps did not get applied in the mornings, her legs would swell completely up and caused her pain and she would have less ability to walk to and from the bathroom due to the pain. R1 stated she felt neglected when her ACE wraps did not get applied. On 12/12/23 at 11:30 AM, LN G stated that she expected R1's ACE wraps to be applied to the resident's bilateral lower legs by 07:30 AM in the morning. LN G stated she did not usually work that hall so she was confused as to what the treatments were. On 12/12/23 at 12:30 PM, Administrative Nurse D stated that the facility expected R1's ACE wraps to be applied prior to her getting out of bed to ensure swelling did not get out of control. The undated facility Quality of Care Policy, documented it is the policy of the facility that each resident receives the necessary care to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the resident's comprehensive assessment and plan of care by ensuring that each resident is given the appropriate treatment to maintain or improve his or her ability to bathe, dress, groom, transfer, and ambulate. The facility failed to provide quality care and treatment for R1 when they failed to apply ACE wraps to R1's bilateral legs as required for lymphedema. This deficient practice placed R1 at risk for edema, skin infections, and skin breakdown.

The facility identified a census of 63 residents. Based on record review and interview, the facility failed to provide copies of requested medical records to Resident (R) 1's representative in the required timeframe (within two working days). This placed the resident at risk for impaired rights. Findings included: - The Electronic Medical Record (EMR) documented R1's representative made medical decisions for R1. On 08/15/23 R1's representative stated she requested copies of part of R1's medical record from the facility and was told a lawyer had to look at the requested medical records before she could be given the medical records. R1's representative stated she had signed the release of medical records form at the facility. On 08/23/23 at 10:30AM, Medical Records GG stated that she had just received the signed written release form for medical records to be dispersed on 08/14/23. Medical Records GG stated she had thirty to forty-five days to get medical records to any entity that asked for them. Medical Records GG stated for any medical records request, the request had to be sent to corporate for approval before any entity could be provided with the medical records the entity had requested. On 08/23/23 at 11:30 AM Administrative Nurse D stated the only kind of policy the facility had for medical records was the instructions given to Medical Records GG regarding ensuring the request for medical records was sent to two corporate e-mails for approval for release. Administrative Nurse D was not sure how long the facility had to provide medical records for residents or their representatives requesting their medical records. The facility lacked a medical records release policy. The facility failed to provide medical records to R1's representative in the required two working days. This placed the resident at risk for impaired resident rights.

The facility identified a census of 61 residents with six residents reviewed for comprehensive care plans related to elopement/wandering. Based on record review, observation, and interview, the facility failed to develop and implement a comprehensive person-centered care plan regarding elopement/wandering for Resident (R) 2, R3, R4, and R5. This deficient practice placed the residents at risk for elopement. Findings included: - R2 had diagnoses of alcohol dependence with alcohol induced persisting dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and major depressive disorder (major mood disorder). R2 required extensive assistance of one staff for bathing, dressing, and toilet use. R2 required supervision/set-up assistance with bed mobility, transfer, ambulation, locomotion on and off the unit, eating and personal hygiene. The MDS documented R2 utilized a walker and a wheelchair. R2's Wandering/Elopement Risk Assessment, dated 06/10/23, documented R2 had an elopement risk score of twelve which indicated a high risk for elopement. R2's care plan lacked any interventions regarding elopement/wandering. R3 had diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), hypertension (high blood pressure), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness). R3 required supervision with set-up assistance for all of his activities of daily living. R3's Wandering/Elopement Risk Assessment, dated 06/15/23, documented R3 had an elopement risk score of twelve which indicated a high risk for elopement. R3's care plan lacked any interventions regarding elopement/wandering. R4 had diagnoses of schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), hypertension (high blood pressure), and major depressive disorder (major mood disorder). R4 required supervision to extensive assistance of one staff for all activities of daily living. R4's Wandering/Elopement Risk Assessment, dated 06/01/23, documented R4 had an elopement risk score of ten which indicated R4 was at risk for elopement. R4's care plan lacked any interventions regarding elopement/wandering. R5 had diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), hypotension (low blood pressure), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness). R5 required supervision to extensive assistance of one staff for all activities of daily living. R4's Wandering/Elopement Risk Assessment, dated 05/22/23, documented R5 had an elopement risk score of ten which indicated R5 was at risk for elopement. R5's care plan lacked any interventions regarding elopement/wandering. On 08/08/23 at 10:30 AM, Administrative Nurse D verified that R2, R3, R4, and R5 were at risk for elopement and did not have any focus or interventions in their care plans regarding wandering/elopement. The facility's Comprehensive Care Plans Policy, dated 01/01/20, documented it is the facility's policy to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The facility failed to develop and implement a comprehensive person-centered care plan regarding elopement/wandering for R2, R3, R4, and R5. This deficient practice placed the residents at risk for elopement.

The facility identified a census of 61 residents with three reviewed for accidents and hazards. Based on record review, observation, and interview, the facility failed to ensure Resident (R)2, who was at risk for elopement, received adequate supervision to prevent accident and elopements and provide a safe environment. This deficient practice placed R2 at risk for injury. Findings included: - R2's Electronic Medical Record (EMR) documented R2 had diagnoses of alcohol dependence with alcohol induced persisting dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and major depressive disorder (major mood disorder). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R2 had a Brief Interview for Mental Status score of eleven which indicated moderately impaired cognition. The MDS documented R2 required extensive assistance of one staff for bathing, dressing, and toilet use. R2 required supervision/set-up assistance with bed mobility, transfer, ambulation, locomotion on and off the unit, eating and personal hygiene. The MDS documented R2 utilized a walker and a wheelchair. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 05/24/23, documented R2 had short-term and long-term memory loss. The CAA documented R2 was easily agitated and had verbal outbursts and wandered. The CAA documented R2 wanted to return to the community but the psychiatric provider deemed R2 incompetent and R2 was assigned a guardian. The Behavioral CAA, dated 05/24/23, documented R2 had verbal behavioral symptoms and wandered. The CAA documented R2 had dementia associated with alcoholism and was at risk for having more frequent verbal behavioral symptoms and wandering behaviors. The CAA documented R2's care plan would be updated to minimize risks. The Fall Care Plan, dated 05/23/23, documented R2 was at risk for falls due to being unaware of his safety needs. The care plan directed staff to ensure R2 had appropriate footwear on when ambulating or mobilizing in his wheelchair. The Psychotropic Medications Care Plan, dated 05/29/23, directed staff to monitor/record occurrence for targeted behavioral symptoms: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document per facility protocol. R2's Care Plan lacked any interventions regarding elopement or wandering. The Wandering/Elopement Risk Assessment, dated 05/18/23, documented R2 had a score of three which indicated a low risk for wandering/elopement. The Nurse's Note, dated 05/21/23, documented R2 was following nursing staff during nursing rounds through the hallways. The Behavior Note, dated 05/21/23, documented R2 appeared agitated. R2 asked the Administrative Staff A bout how he could get cigarettes if he was out. Administrative Staff A told him the activities director does resident shopping. R2 used an elevated voice and stated, Everything was good yesterday and now that it is the weekend it's [expletive]. R2 stated he could not wait to get out of the facility. A few moments later R2 asked Administrative Staff A in a more positive tone where to find the door that went outside. The Skilled Note, dated 05/21/23, documented R2 had exceptions noted with his mood and behavior. R2 was noted to be anxious and agitated. R2 had fluctuating moods. R2 was physically aggressive and displayed disruptive behaviors. R2 had wandering behavior. The Skilled Note, dated 05/22/23, documented R2 had exceptions noted with his mood and behavior. R2 was noted to be anxious and agitated. R2 had fluctuating moods. R2 was physically aggressive and displayed disruptive behaviors. R2 had wandering behavior. The Behavior Note, dated 05/22/23, documented R2 complained of three hundred dollars being misplaced. R2's money was supposedly in the inflatable air mattress in his room. R2 was preoccupied with multiple things at one time. The Skilled Note, dated 05/23/23, documented R2 had exceptions noted with his mood and behavior. R2 was anxious and agitated. R2 had fluctuating moods. R2 was physically aggressive and displayed disruptive behaviors. R2 had wandering behavior. The Nurse's Note, dated 05/23/23, documented R2 was confused and forgetful. R2 was able to follow commands but needed reminders. The Skilled Note, dated 05/24/23, documented R2 had exceptions noted with his mood and behavior. R2 was noted to be anxious and agitated. R2 had fluctuating moods. R2 was physically aggressive and displayed disruptive behaviors. R2 had wandering behavior. The Skilled Note, dated 05/25/23, documented R2 had exceptions noted with his mood and behavior. R2 was anxious and agitated. R2 had fluctuating moods. R2 was physically aggressive and displayed disruptive behaviors. R2 had wandering behavior. The Skilled Note, dated 05/29/23, documented R2 had exception noted with mood. R2 had agitation. R2 was alert with very poor short-term memory, reminders needed to be given to R2 frequently throughout the day. R2 needed to be reminded not to ambulate by himself. The Skilled Note, dated 06/01/23, documented R2 was agitated and very forgetful. R2 required reminders for cares and daily routine. R2 was able to make needs known to staff but doesn't remember directions and re-direction. R2's mode of travel was via wheelchair. The Alert Note, written by Licensed Nurse (LN) G and dated 06/10/23, documented R2 was up in his wheelchair that morning and upset about not being able to smoke when he wanted due to needing supervision. R2 stated he wanted to go home, and he does not want to be there. R2 was confused with poor memory. At 09:45 AM, R2 went to the front door and went outside with other residents to the end of the parking lot and was going into the street when staff retrieved him. An assessment was performed without any changes in condition noted. R2 was redirected and provided one on one cares and supervision. The administrator, director of nursing, R2's primary care physician and guardian were notified. The Incident Note, 06/10/23, documented a CNA notified the nurse that R2 went outside possibly when another resident went out the front door. R2 was found out in the front parking lot headed towards the street. R2 stated I just need to go home. R2 was brought back into the building. A head to toe assessment was performed. Fifteen-minute checks were initiated. Predisposing factors that precipitated the elopement were confusion, impaired memory, and active exit seeker and wanderer. This incident note was struck out by Administrative Nurse D. The Wandering/Elopement Risk Assessment, dated 06/10/23, documented R2 had an elopement risk score of twelve which indicated a high risk for elopement. On 08/08/23 at 10:30 AM, Administrative Nurse D stated that she had struck out the nurse's note and the incident note regarding R2's elopement because R2 had never actually left the grounds of the facility and the transportation Certified Nurse's Aide (CNA) O had been sitting out in the transportation van and saw R2 exit the building in his wheelchair out into the parking lot. Administrative Nurse D stated R2 did not ever have a time when someone had eyes on him. On 08/08/23 at 01:30 PM, Regional Nurse E stated the facility did not consider R2 following an alert and oriented resident, who was going outside to smoke, as an elopement because R2 had never gotten off of the facility property and transportation CNA had seen R2 and stopped him from going anywhere. Regional Nurse E stated the facility had given education to the alert and oriented smoker who can smoke independently that smoking needed to occur in the center courtyard and not out in front of the building. On 08/08/23 at 02:00 PM, CNA O stated that he had been about to go on a transport to take a resident to dialysis when he looked up and saw R2 wheeling down the entry way into the parking lot. CNA M stated he got out of the transportation van and stopped R2 and took him back into the facility. CNA M stated that if he had not seen R2, R2 could have eloped. LN G was unavailable for interview. The facility Elopement and Wandering Residents Policy, dated 02/01/20, documented the facility would ensure that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risk, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. The facility failed to ensure R2, who was at risk for elopement, received adequate supervision to prevent accident and elopements and provide a safe environment. This deficient practice placed R1 at risk for injury.

The facility identified a census of 61 residents with three residents reviewed for incontinence. Based on record review, observation, and interview, the facility failed to ensure Resident (R)1, who was incontinent of urine, received appropriate treatment and services to prevent complications from urinary incontinence. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of age-related cognitive decline, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and major depressive disorder (major mood disorder). The Annual Minimum Data Set (MDS), dated [DATE], lacked a Brief Interview for Mental Status assessment and lacked any documentation regarding cognitive patterns. The MDS documented R1 required extensive assistance of one to two staff for all activities of daily living except eating. The MDS documented that a toileting program had not been attempted and R1 was occasionally incontinent of bladder and bowel. The Urinary Incontinence and Indwelling Catheter Care Area Assessment, dated 06/25/23, documented R1 was occasionally incontinent of urine, R1 received daily diuretic (medication to promote the formation and excretion of urine) therapy, required extensive assistance with toileting, and was at risk for skin rashes, skin breakdown, falls, isolation, urinary infection, and R1's care plan would be assessed to minimize risks. The Incontinence Care Plan, dated 09/28/22, directed staff to check and change R1 to maintain dignity and to provide good peri-care after incontinent episodes. The Bowel and Bladder Admission Assessment, dated 08/09/22, documented R1 had a history of being incontinent of urine, decreased mobility and poor vision were potential causes of R1's incontinence, R1 was appropriate for a toileting program, R1 voided correctly without incontinence at least once a day, and R1 was a candidate for toileting schedule time voiding. The Nurse's Note, dated 07/20/23, documented R1's family voices they are upset because R1's personal quilt/blanket was being used as a bed pad and R1 and the items underneath R1 in her recliner are all saturated with incontinent urine. The Hospice Note, dated 07/25/23, documented the hospice worker observed R1 being wet clear through her clothing. The hospice worker pressed the call light and waited for assistance to arrive for thirty minutes. A Certified Nurse Aide (CNA) arrived and stated she would need to get help to get R1 changed. After waiting another ten minutes for help, the hospice worker went to the social services office and was unable to find her. On 08/08/23 at 10:49 AM, observation revealedCNA M used extensive assistance to help R1 to the bathroom. R1 required a gait belt and walker to walk to the bathroom. R1 required extensive assistance of CNA M to pull her pants and attends down. R1 had dark yellow urine in her attends. On 08/08/23 at 10:49 AM, this surveyor asked R1 if she was taken to the bathroom frequently. R1 shook her head no. On 08/08/23 at 11:10 AM, CNA M stated that R1 dribbled urine constantly. CNA M stated R1 did not use the call light when she had to urinate CNA M stated she was not sure what R1's care plan said about a toileting schedule of frequency of toileting, but she knew staff tried to take her every couple of hours. CNA M stated it had been an hour and a half since R1 was last toileted. On 08/08/23 at 11:30 AM, CNA N stated that R1 was not on any kind of a toileting schedule, but she was supposed to be toileted every two hours just like everyone else in the facility. On 08/08/23 at 11:45 AM, R1's representative stated that when her and her family toured the facility they were told that R1 would be toileted every two hours. R1's representative stated there had been numerous times when she visited in the evening that R1 was completely soaked with urine, with urine even being down in her shoes. R1's representative stated R1 was not very verbal and she felt like the staff just forgot about R1 and her cares at times. On 08/08/23 at 01:30 PM, Administrative Nurse D, verified R1 had not had a bowel and bladder assessment or a voiding diary completed since admission. Administrative Nurse D verified that there was no direction in R1's care plan regarding a frequency of toileting or check and change. The facility's Bladder and Bowel Management, dated 02/01/20, documented each resident must be assessed for bladder and bowel functioning within seven days of admission, quarterly, and with any change of condition that affects continence. The interdisciplinary team will: initiate a written plan of care upon completion of the bladder and bowel continence assessment and update as necessary, develop an individualized toileting routine for each individual resident, and ensure that all residents where possible are toileted. The facility failed to ensure R1, who was incontinent of urine, received appropriate treatment and services to prevent complications from urinary incontinence.

The facility had a census of 60 residents. The sample included 17 residents, with three reviewed for accidents. Based on observation, record review, and interview, the facility failed to supervise cognitively impaired Resident, R 36, who exited the North Court Yard door, fell , and obtained a hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) on her forehead. This deficient practice placed R36 at risk for further falls and avoidable injuries. Findings included: - The Electronic Medical Record (EMR) for R36 recorded diagnoses of Alzheimer disease (a progressive mental deterioration characterized by confusion and memory failure), muscle weakness, anxiety (a feeling of worry, nervousness, or unease about something), and abnormality of gait. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R36 had severely impaired cognition, required extensive assistance of two staff for transfers, and extensive assistance of one staff for bed mobility, dressing, toileting, and personal hygiene. The MDS further documented R36 had no function impairment, had unsteady balance, had one non injury fall, and did not ambulate. The Fall Area Assessment (CAA), dated 12/05/22, documented R36 was a fall risk related to balance problems and had no falls during the assessment period. The Wandering/Elopement Assessment, dated 01/16/23 and 04/05/23, revealed R36 was at low risk. The Fall Assessments, dated 02/02/23, 03/02/23, and 04/11/23, was at high risk for falls. The Fall Care Plan, dated 03/16/23, directed staff to anticipate and meet her needs, be sure her call light was within reach and encourage her to use it for assistance when needed, educate the resident about safety reminders, assist R36 with getting comfortable in her chair, and assist the resident into dining room chair for meals. The care plan lacked person-center interventions to prevent further falls. The Nurse's Note, dated 03/02/23 at 06:15 PM, documented a witnessed fall for R36, when she attempted to transfer herself into bed, her wheelchair moved out from under her, and she sat down on the floor with her legs out in front of her and her right arm rested on the bed in a bent position. The care plan lacked documentation of person-centered interventions after the fall on 03/02/23. The Fall Investigation, dated 04/08/23 at 03:01 PM, documented, the nurse got to R36 as she laid face down on the concrete sidewalk in the center of the courtyard. The nurse noted blood under the resident and when she turned her head, noted a large hematoma protruding from the center of her forehead. The investigation further documented, the resident was assisted to a seated position and assisted by two staff into her wheelchair. The witness statement from a visitor in the courtyard documented R36 walked out the courtyard door to the south, lost her balance, fell forward, and slammed her head on the concrete ground very hard. The fall investigation was incomplete and lacked documentation of witness statements from staff regarding the incident. The Nurse's Note, dated 04/08/23 at 06:30 PM, documented R36 returned from the emergency room and the results of the computed tomography (CT, medical imaging used to obtain detailed internal images of the body) scans of her head, neck, and facial bones and X-rays (penetrating form of high-energy that takes images of parts of your body in black and white) of her wrist, chest, and pelvis, were all negative. The note further stated R36 had a forehead hematoma and abrasion, nose hematoma and abrasion, and right wrist abrasion. On 05/03/23 at 10:00 AM, observation revealed R36 propelled herself in her wheelchair down the [NAME] Hall asking where she was supposed to go. Further observation revealed staff lead R36 to her room. On 05/03/23 at 11:36 AM, Certified Nurse Aide (CNA) M stated R36 was cognitively impaired had falls in the past, and did not have a history of exit seeking. CNA M further stated R36 went to the door to the north courtyard, went out the door and fell . CNA M stated staff heard the door alarm, but R36 had already fallen. On 05/03/23 at 02:30 PM, Maintenance U stated he does not check the door alarm for the North Courtyard as it was enclosed and did not lead to anywhere. On 05/04/23 at 10:00 AM, Licensed Nurse H stated R36 had left her wheelchair at the door to the North Courtyard and walked through the door, rounded the corner, and fell on her face. LN H further stated she had seen the resident approximately 20 minutes prior to the fall. On 05/04/23 at 02:03 PM, Administrative Nurse D stated the fall should have been investigated and reported. The facility's Accident and Supervision policy, undated, documented resident environment remained as free of accident hazards as was possible, and each resident received adequate supervision and assistive devices to prevent accidents. This included identifying hazards and risks, evaluating and analyzing hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. The facility failed to provide adequate supervise to cognitively impaired R36, who exited the North Courtyard door, fell and received injury (head and nose hematoma and abrasions) and placed the resident at risk for further falls and injury.

The facility had a census of 60 residents. The sample included 17 residents, with four reviewed for pressure ulcers. Based on observation, record review, and interview, the facility failed to prevent ulcers for two sampled residents: Resident (R) 54, who obtained a facility acquired stage 3 (full thickness tissue loss) and R208, who obtained a facility acquired stage 2 (shallow with a reddish base) pressure ulcer. The facility further failed to ensure weekly monitoring of skin conditions to assess wound status including wound bed, healing, and effectiveness of treatments for R54 and R208. This deficient practice placed those residents at risk for delayed healing or worsened wounds. Findings included: - The Electronic Medical Record (EMR) for R54 had diagnoses of hypertension (high blood pressure), asthma (a respiratory condition in which the bronchial airways in the lungs become narrowed and swollen, making it difficult to breath), and need for assistance with personal care. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R54 had intact cognition, depended upon two staff for transfers and toileting, required extensive assistance of two staff for bed mobility, and extensive assistance of one staff for dressing, eating, and personal hygiene. The MDS further documented R54 had lower functional impairment on one side, at risk for skin breakdown, pressure device for bed and chair, no turning or repositioning program, and had moisture associated skin damage (MASD). The Pressure Ulcer Care Area Assessment (CAA), dated 12/18/22, documented R54 had the potential for pressure ulcers due to the need for extensive assistance with bed mobility, frequently incontinent with urine and always incontinent with bowel. The CAA further documented R54 had MASD and did not have a pressure ulcer but was at risk. The Braden Scale Assessment, (formal assessment for predicting pressure ulcer risk) dated 12/04/22, 12/12/22, 01/04/23, 01/12/23, and 04/10/23, revealed R54 was a moderate risk for breakdown. The Skin Integrity Care Plan, dated 03/23/23, originally dated 12/13/22, directed staff to educate R54 and family to the causes of skin breakdown, encourage to report pain that may prevent repositioning monitor nutrition intake. The update, dated 01/23/23, directed staff to not massage reddened body prominence, ensure adequate protein intake, observe, and assess weekly, refer to dietician with skin concerns, use commercial moisture barrier on skin as indicated, and use pressure redistribution surface to bed and wheelchair, if indicated. The Nutritional Assessment, dated 03/16/23, documented R54 had no supplements, snacks available, and intact skin. The Skin and Wound Evaluation, dated 04/14/23, documented R54 had a stage 3 pressure ulcer on his coccyx (a small triangular bone at the base of the spinal column), which measured 0.8 centimeter squared (cm2) area, 1.5 centimeter (cm) long x 0.9 cm wide, in house acquired, and unknown on how long it was present. The skin evaluation lacked documentation of wound bed, type of odor or drainage, periwound and surrounding tissue, treatment, and modalities. The Physician Order, dated 04/18/23, directed staff to administer amoxicillin-clavulanic acid (an antibiotic to treat infections), 875-125 milligrams (mg), one by mouth every 12 hours, daily for 10 days, for infection. The Physician Order, dated 04/19/23 (five days after finding the pressure ulcer) , directed staff to apply padded foam to sacral/coccyx area and monitor for increased discoloration, decreased blanching, open area, warmth, redness, bleeding, and drainage, every day shift for skin integrity. The Physician Order, dated 04/22/23, directed staff to apply duoderm (a waterproof dressing) or padded foam and monitor for increased discoloration, decreased blanching, open area, warmth, redness, bleeding and drainage, every day shift for skin integrity. The Skin and Wound Evaluation, date 04/21/23, documented R54 had a stage 3 pressure ulcer on his coccyx, which measured 2.5 cm2 area, 2.9 cm length, 1.2 cm wide, in house acquired, unknown how long it was present. The skin evaluation lacked documentation of wound bed, type of odor or drainage, periwound and surrounding tissue, treatment, and modalities. The EMR documented R54 was discharged to the hospital for respiratory infection on 04/22/23. On 05/03/23 at 09:48 AM, Dietary Consultant GG stated she knew R54's skin was reddened but did not know of the pressure ulcer. Dietary Consultant GG further stated she was in the facility on 04/18/23 and the paperwork provided from the facility documented to review his chair for skin issue, but she failed to do so. Dietary Consultant GG stated she would have recommended vitamins for him but since it was already a stage 3, she did not know if it would have helped. On 05/03/23 at 11:14 AM, Administrative Nurse E stated, she was out of the facility when the pressure ulcer was found and unsure why it took several days to obtain treatment for the pressure ulcer. On 05/03/23 at 11:44 AM, Certified Nurse Aide (CNA) M stated R54 did not have any skin breakdown prior to his discharge. CNA M further stated he was not feeling well and required a lot of assistance. On 05/04/23 at 01:39 PM, Administrative Nurse D stated the skin assessments should have been completed at the time of assessment and treatment for the pressure ulcer should not have been delayed. Administrative Nurse D further stated, she had been out of the facility for training and would make sure the whole team meet with the Registered Dietician when reviewing residents. The facility's Pressure Injury Prevention and Management policy, dated 01/01/2020, documented the facility was committed to the prevention of unavoidable pressure injuries and the promotion of healing of existing pressure injuries. The policy further documented the facility would establish and utilize a systemic approach for pressure injury prevention and management, including prompt assessment and treatment, intervening to stabilize, reduce or remove underlying risk factors, monitoring the impact of the interventions, and modifying the interventions as appropriate. The facility failed to implement preventative interventions, and delayed treatment of a facility acquired stage 3 pressure ulcer, this placed the resident at risk for further skin breakdown. 26768 - R208's Electronic Medical Record documented diagnoses of type 2 diabetes (chronic condition that affects the way the body processes blood sugar (glucose), paraplegia (he loss of muscle function in the lower half of the body, including both legs), obesity (overweight), leukemia (cancer of blood-forming tissues, hindering the body's ability to fight infection), and chronic pain. The Admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R208 required supervision for eating, limited staff assistance for hygiene, dressing, and extensive assistance for transfers, bed mobility, and locomotion. The MDS documented rejection of care daily, R208 had one Stage 2 (partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red or pink wound bed, intact or ruptured blister) pressure ulcer (PU), lesion on foot, and Moisture Associated Skin Damage (MASD). The MDS documented interventions were pressure relief to chair and bed, nutrition, pressure ulcer care, dressings, and ointments. The Pressure Ulcer Care Area Assessment (CAA), dated 04/11/23, documented the resident had a Stage 2 PU to the coccyx and multiple wounds. The assessment stated R208 required extensive assistance with bed mobility and was always incontinent of bowel, placing him at risk for further pressure ulcers and worsening of his wounds. The Skin Care Plan, dated 04/06/23, directed staff to educate R208 on the causes of skin breakdown, which included frequent repositioning and staff were to encourage him to report pain that may prevent repositioning. The facility would provide a low air loss mattress (check function) and treatment as ordered. The 04/08/23 update documented the air mattress was changed twice this day. The 04/20/23 update stated all staff were provided education on air mattress function. The Progress Note, dated 04/05/23 at 06:55 PM, documented R208 arrived at the facility per facility transport, in a wheelchair, and able to verbalize needs. Devices to include air mattress and wheelchair, wound care to left heel and left knee. The Admission Nursing Assessment, dated 04/06/23 at 04:02 AM, lacked documentation of any redness or open skin to R208's buttocks or coccyx. The Progress Note, dated 04/06/23 at 04:03 AM, documented staff assessed the resident for a low air loss mattress and put the mattress in place for R208 for optimal pressure reduction, positioning, and safety per assessed needs of this resident. The Progress Note, dated 04/08/23 at 05:01 PM, documented R208 complained off and on today of his bed not working and staff changed the settings multiple times. Staff were unable to keep the mattress inflated fully and placed a new one on his bed. R208 refused initially to switch mattresses, but finally agreed. The Physician Order, dated 04/08/23, directed staff to apply skin prep to the coccyx (tailbone) region, cover with foam for protection, and monitor and change daily as needed. The Progress Note, dated 04/11/23 at 08:53 AM, documented the physician saw R208 with telemedicine on 04/07/23. The physician ordered for staff to continue current care, and Wound Care to evaluate a pressure ulcer of buttock, Stage 2. The note stated the order was faxed to the wound care clinic. The facility's Wound Evaluation, dated 04/12/23, (seven days after admission) documented a right buttock wound measuring 7.44 centimeters (cm) by 1.23 cm. The evaluation lacked any further characteristics or assessment. The Treatment Administration Record (TAR), documented on 04/12/23 staff added Check function of air mattress every shift. The Progress Note, dated 04/13/23 at 04:34 AM, documented R208 did not want to participate in wound care and declined a nursing assessment to coccyx and the reddened skin there. The Progress Note, dated 04/15/23 at 01:36 AM, documented R208 refused wound dressing changes after multiple attempts made by this nurse. The Weekly Skin Check, dated 04/17/23, documented foam to coccyx for redness. The Weekly Skin Check, dated 04/21/23, was incomplete, without measurement or description. The Wound Evaluation, dated 04/21/23 (nine days after the last evaluation), documented a right buttock wound measuring 7.77 cm by 3.73 cm. The evaluation lacked any further characteristics or assessment. The Discharge Assessment, dated 04/27/23, documented R208 required wound care daily to left foot, coccyx, buttocks with bordered foam dressing, April 2023 Grievance Log lacked documentation for R208's concerns. On 05/03/23 at 10:08 AM, Maintenance Staff U stated he had fixed an air mattress last month. He reported the air mattress for R208 had a kink in the air line and he removed the air mattress put new one on. On 05/02/23 at 10:25 AM, R208 stated the air bed failed, deflated, and staff left him on the deflated air mattress all weekend. He stated the pressure caused a new open area on his buttocks. On 05/03/23 at 12:13 PM, CNA N stated she worked the first and second day R208 was admitted to the facility. CNA N stated staff changed his air mattress the first day he was here within a couple of hours of arrival due to three air lines in the mattress did not fill. She stated R208 did not like the larger air mattress and thought it was going flat, but he liked to sit up 90 degrees which caused pressure on his bottom. CNA N stated staff changed the whole mattress five times and maintenance staff changed settings on the motor several times in attempt to please him. On 05/03/23 at 12:20 PM, Licensed Nurse (LN) I stated she did not see any open areas on R208's buttocks, just discoloration. She reported skin care interventions included an air mattress, float heels, and skin prep to buttocks every three days. On 05/04/23 at 10:20 AM, Administrative Nurse D stated the measurements indicated the wound got bigger. Administrative Nurse D stated when staff noted there was a problem with the air mattress staff offered the resident other mattresses. She stated R208 was non-compliant with wound care and refused skin assessments and treatment. The facility's Pressure Ulcer Prevention and Management policy, dated 01/01/20, stated the facility would establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment, reduce or remove underlying risk factors, monitoring the impact of interventions and modifying interventions as appropriate. Assessment of pressure injuries would be performed by a licensed nurse weekly and the staging of pressure injuries would be clearly identified to ensure correct coding on the MDS. The facility failed to prevent the development of a pressure ulcer after placing R208 on a faulty air mattress, placing R208 at risk for a pressure injury.

The facility had a census of 60 residents. Based on observation, interview, and record review the facility failed to provide proper infection control when using the same glucometer without disinfecting it between residents, delivering linens throughout the facility in an uncovered cart, during urinary catheter care, while providing oxygen therapy, and filling resident's used water mugs with ice while holding the used mug inside the ice bin. This deficient practice placed the residents of the facility at risk for infections. Findings included: - On 05/01/23 at 12:02 PM, observation revealed Certified Nurse Aide (CNA) Q handled a resident's used water mug and put fresh ice in it from the open ice machine in the dining room. CNA Q held the soiled mug over the ice while filling it and a few pieces of ice flew from the cup to the clean ice in the bin. Continued observation revealed CNA Q served four other residents their beverages, without first changing her gloves. On 05/01/23 at 02:55 PM, observation revealed laundry staff pushed an uncovered cart of clean linen, down the west hall. On 05/02/23 at 09:50 AM, observation revealed CNA N took Resident (R) 25 to her room, removed the nasal canula attached to the tank from the resident, and then started the oxygen concentrator. CNA N picked up the nasal canula attached to concentrator off the floor, instructed R25 to face her and started to place the contaminated cannula on the resident. Surveyor stopped her and asked if she was really going to place that in the resident's nose. CNA N disposed of the oxygen tubing and obtained new tubing and attached to concentrator. Observation revealed no storage bags for the nasal cannula attached to the tank on her wheelchair or on the concentrator. On 05/02/23 at 10:55 AM, observation revealed Licensed Nurse (LN) I used an Assure Platinum glucometer to obtain a blood sugar sample from R37 and then used alcohol wipes to clean the glucometer. Continued observation revealed LN I then obtained R 35's blood sugar. LN I cleaned the glucometer with alcohol wipe and put it in the medication cart. On 05/02/23 at 11:32 AM, observation revealed LN I removed the glucometer from the medication cart and obtained a blood sugar sample from R 158. LN I placed the glucometer in her uniform pocket, pulled it out, wiped it off with alcohol wipe, and placed it back in the same uniform pocket. On 05/02/23 at 02:26 PM, observation revealed Resident (R) 35 brought her soiled water mug to Dietary Staff (DS) BB and he filled it with ice from the ice machine while holding it over the ice bin. He tapped the ice scoop on the top edge of the soiled mug causing a piece of ice to fall back into the bin. On 05/03/23 at 845 AM, observation revealed CNA O took R25 to her room, untangled the oxygen tubing attached to the concentrator, allowing the nasal cannula to drag on the floor momentarily. CNA O started to place the nasal cannula on the resident, was stopped by the surveyor, and when asked if she was going to put that cannula on the resident, she left to get new tubing and cannula. On 05/04/23 at 02:30 PM, Administrative Nurse E verified staff were to bag oxygen cannulas when not in use and to obtain new tubing if the nasal canula becomes contaminated from the floor. On 05/03/23 at 01:50 PM, observation revealed when CNA P and CNA O transferred R35 from a wheelchair to her bed, CNA P hooked the catheter drainage bag on her uniform pocket and then the bed frame. CNA O disinfected the drainage bag port with an alcohol wipe, emptied the bag into a container dated 04/20/23, and touched the port to the inside of the soiled container. On 05/02/23 at 12:05 PM, LN I stated she used the same glucometer for four different residents. She stated the facility had other disinfectant wipes, but she did not like to use them as they were really wet, and she thought that might harm the glucometer. LN I looked but could not find the appropriate wipes. On 05/04/23 at 1030 AM, Administrative Nurse D verified staff were to clean the catheter drainage bag port with alcohol wipes before and after emptying, measure in a cylinder, and change the cylinders if visibly soiled. On 05/03/23 at 09:40 AM, Consultant Dietician GG verified staff were not to hold a soiled container over the ice bin while filling it with ice. The Assure Platinum glucose monitor user instructions stated healthcare professionals should wear gloves when cleaning the glucometer and suggested cleaning the glucometer between patient use. Cleaning and disinfection can be completed by using a commercially available EPA registered disinfectant or germicide wipe. To clean the glucometer, use soapy water or alcohol wipe. To disinfect the meter, use diluted bleach solution of 1/10 or commercially available bleach wipes. The Ice Machine policy, dated 2017, did not include direction for filling resident's individual water mugs. Upon request the facility did not provide a urinary catheter policy. The facility's Oxygen Concentrator policy, dated 2022, directed staff to keep delivery devices covered in plastic bag when not in use and change oxygen tubing and masks or cannulas weekly and as needed if it becomes soiled or contaminated. The facility failed to perform proper infection control measures when using the same glucometer without disinfecting it between residents, delivering linens throughout the facility in an uncovered cart, during urinary catheter care, while providing oxygen therapy, and filling resident's used water mugs with ice while holding the used mug inside the ice bin. This placed the residents at increased risk for infection.

The facility had a census of 70 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility's Quality Assessment and Assurance (QAA) program failed to provide good faith efforts to identify multiple issues of concerns for the 60 residents, who resided in the facility. Findings included: - The facility failed to provide Resident (R)9 dignity related to odorous dressing changes, and R34 for dirty clothes two days in a row. Refer to F550. The facility failed to resolve resident grievance's in a timely manner. Refer to F565. The facility failed to provide R28, R47, and R56 a cost estimate for further services related to skilled services. Refer to F582. The facility failed to protect R35 from misappropriation of property and exploitation. Refer to F602. The facility failed to report a fall with injury for R36. Refer to F609. The facility failed to thoroughly investigate R12's skin tear and R36's fall with injury. Refer to F610. The facility failed to revise care plans for five residents. Refer to F657. The facility failed to provide discharge planning for R45. Refer to F660. The facility failed to assist R34 during meal service as he ate his meal with a knife only and failed to ensure R34 had clean clothes two of four days of the survey. Refer to F677. The facility failed to provide wound care for R9, failed to monitor a skin tear for R12, and failed to provide positioning assistance for R44. Refer to F684. The facility failed to check R44's hearing as requested. Refer to F685. The facility failed to implement preventative interventions for R54 and R208 who had a facility acquired pressure ulcers. Refer to F686. The facility failed to provide adequate supervision to cognitively impaired R36, who went outside and fell , and received injury. Refer to F689. The facility failed to complete dialysis paperwork for R25. Refer to F689. The facility failed to provide behavioral health services for R16 who had a diagnosis of PTSD (post-traumatic stress disorder). Refer to F742. The facility failed to provide medically-related social services to R43, who had behaviors. Refer to F745. The facility failed to obtain a stop date for R16's as needed Ativan medication. Refer to F758. The facility failed to date an insulin pen for R26 and failed to keep temperature logs of the medication room refrigerators. Refer to F761. The facility failed to certify the facility's dietary manager. Refer to F801. The facility failed to follow a recipe while preparing a pureed diet. Refer to F804. The facility failed to provide bedtime snacks for the residents. Refer to F809. The facility failed to store food in accordance with professional standards for food service safety. Refer to F812. The facility failed to provide a safe, sanitary, comfortable environment to help prevent the development and transmission of communicable disease and infection. Refer to F880. The facility failed to maintain two ovens and a plate warmer in working condition. Refer to F908. On 05/04/23 at 02:29 PM, Administrative Staff A stated she collects information from the interdisciplinary team and staff for the quality assessment and assurance program that meets on a monthly basis to formulate plans of improvement. The facility's Quality Assurance Process Improvement Plan policy, dated October 2022, documented the facility strived to provide excellent quality care and services to our residents. The plan systematically monitors, analyzes and improves its performance to improve resident outcomes. The team would identify trends and/or systems needing improvement and will focus on evidence-based best practices, as well as ensuring person-centered care. The facility's QAA committee failed to identify multiple issues of concern for the 60 residents who reside in the facility placing the residents at risk for lack of quality of care.

The facility had a census of 60 residents. The sample included 17 residents. Based on observation, record review, and interview the facility failed to prepare, store, and serve food in accordance with professional standards for food service safety for the 60 residents who resided in the facility and received their food from the facility kitchen, when facility failed to ensure clean and sanitary food prep areas. The facility staff failed to change gloves after touching her glasses, other objects, then picked up bread with the same contaminated gloves. The facility kitchen staff failed to order enough food for the noon meal and the facility staff failed to complete refrigerator logs. This placed the 60 residents at risk for foodborne illness. Findings included: - On [DATE] at 07:17 AM, observation in the kitchen revealed the following: The refrigerator located in the kitchen had a plastic bag with four hamburger patties with an expiration date [DATE]. The silver, three door freezer located in the dry storage room had an open bag of chicken patties, without a label or date. The April refrigerator and freezer logs were incomplete from [DATE] to [DATE]. On [DATE] at 07:17 AM, Dietary Staff (DS) EE verified the above findings and stated she did not know why the logs were incomplete. On [DATE] at 01:53 PM, observation revealed the following in the nourishment refrigerator: A unlabeled, undated bowl of mandarin oranges. A unlabeled, undated plastic container of strawberries, grapes, and watermelon pieces. An uncovered, undated, unlabeled, Styrofoam cup with two hard boiled eggs An uncovered, undated, unlabeled, Styrofoam cup of gravy. An undated, unlabeled ,d+[DATE] full half gallon of curdled whole milk. An unlabeled undated 20 ounce (oz) empty bottle of mustard. An unlabeled, undated slice of cheesecake. An expired 18 oz bottle of diet Dr. pepper and a regular Dr. pepper. An undated, unlabeled container with two molded tacos. An unlabeled container with a empanada dated [DATE]. An unlabeled, undated plastic bag with cut celery pieces. An unlabeled, undated eight oz block of pepper jack cheese. An unlabeled, undated plastic bag with four slices of ham. An undated, unlabeled plastic container with chicken. An unlabeled, undated ice cream sandwich. An unlabeled, undated box of pizza. The bottom drawer of the refrigerator had numerous sizes of dried liquid stain. On [DATE] at 01:53 PM, DM CC verified the above findings and discarded all the items, and took the bottom drawer to the kitchen to clean. On [DATE] at 10:57 AM, observation in the kitchen revealed the following: The oven hood had numerous different size peeling paint on the inside and outside. Skillets stored right side up on five shelf rack on second from bottom shelf. Metal mixing bowls stored right side up on the third shelf on a metal cart. Undated, unlabeled flour and sugar bins. Ceiling light fixtures had numerous different size dust particles. Uncovered big floor mixer. The serving window had chipped, worn, exposed raw wood that was porous and uncleanable. On [DATE] at 12:48 PM, Maintenance Staff (MS) U walked through kitchen without a hairnet during preparation of the noon meal. On [DATE] at 12:48 PM, DM CC verified the above findings and stated staff should label and date items when they place them in the refrigerator and staff should wear a hairnet when entering the kitchen. On [DATE] at 09:13 AM, observation revealed a resident asked for scrambled eggs and DS EE . stated the facility ran out of premade scrambled eggs, the truck usually comes on Tuesday morning but they had not arrived yet. [DATE] at 11:20 AM, DS DD stated it would be at least another hour before she could prepare the pureed diets due to they ran out of chicken breasts and the dietician had to run to the store to get some more. On [DATE] at 11:20 AM, observation revealed a package of uncooked chicken breasts sat on the prep counter. On [DATE] at 02:12 PM, DM CC stated staff do run out of food items at times. DM CC stated the kitchen ran out of chicken breast today due to he placed an order and cooperate had to approve the order before it was sent to the food supplier. If the orders were not approved at a certain time, they did not get ordered, and cooperate staff failed to approve his order in time for the food supplier to deliver it. On [DATE] at 01:00 PM, Consultant Staff (CS) GG stated the dietary manager had to get his food order placed by a certain time, then cooperate staff had to approve it by a certain time, then it had go to the food supplier by a certain time in order to receive the shipment on a certain date. CS GG verified the facility had been short of the chicken breast and stated there was a communication problem between the dietary manager and cooperate staff and they were going to work on a new process for ordering, so food would get to the facility on time. On [DATE] 02:55 PM, Consultant Staff (CS) JJ stated the facility had recognized problems with dietary department and plan to change things. On [DATE] at 11:43 AM, Administrative Nurse D stated the facility had recognized a problem with dietary department and had hired a new dietary manager that would start next week. Upon request the facility did not provide a policy regarding food shortage. The facility's Food Storage Policy, revised on [DATE], documented refrigerated food would be kept clean and foods must be maintained at or below 41 degrees Fahrenheit (F). Thermometers should be checked at least two times each day. All foods should be covered, labeled and dated. All frozen foods should be covered, labeled and dated. The facility failed to prepare, store, and serve food in accordance with professional standards for food service safety. This placed the 60 residents, who resided at the facility and received food from the facility kitchen at risk for receiving foodborne illness.

The facility had a census of 60 residents. The sample included 17 residents. Based on observation and interview the facility failed to employ a full-time Certified Dietary Manager (CDM) for the 60 residents who resided at the facility and received meals from the facility kitchen. This placed the resident at risk for receiving inadequate nutrition. Findings included: - On 05/03/23 at 11:30 AM, observation revealed Dietary Staff (DS) CC in the kitchen overseeing the preparation of the noon meal. On 05/01/23 at 11:00 AM, DS CC verified he was uncertified, had been enrolled in the Nutrition and Food Service Professional training program, completed a couple of the classes but then the facility employed a new administrator and he had not been approved to continue the training program. On 05/04/23 at 11:43 AM, Administrative Nurse D and Administrative Staff A verified DS CC lacked a dietary manager certification and stated the facility hired a new certified dietary manager who would start next week. Upon request the facility failed to provide a certified dietary manager policy. The facility failed to employ a full time Certified Dietary Manager, for the 60 residents who resided in the facility and received meals from the kitchen. This placed the residents at risk for receiving inadequate nutrition.

The facility had a census of 60 residents. Based on observation, interview, and record review the facility failed to ensure essential equipment in the kitchen was maintained in safe operating condition with two ovens and the plate warmer out of service. Findings included: - On 05/03/23 at 10:57 AM, observation in the facility kitchen revealed Dietary Staff (DS) DD pointed to the two ovens below a hood and stated they did not work right. DS DD stated the last administrator was supposed to have a company come and look at them because the pilot light does not stay lit, and a gas odor drifted out. On 05/03/23 at 02:00PM, DS EE stated the plate warmer did not work and had not been working for about three months. On 05/03/23 at 02:05 PM, DS CC verified the findings listed above and stated the former administrator called a company to come fix the ovens, but he did not know if the current administrator was aware of them not working or the plate warmer not working. On 05/04/23 at 11:43 AM, Administrative Staff A stated she was unaware the two ovens and the plate warmer were not working, and stated staff should have reported it to her. On 05/04/23 at 05:10 PM, Maintenance Staff U stated the staff had not reported any issues with the equipment in the kitchen to him. He stated staff were to notify him of any issues verbally or they could write it on the report sheet on his office door. The facility ' s Maintenance Inspection policy, dated 10/25/19, stated the facility would utilize a maintenance inspection checklist to assure a safe, functional environment for residents, staff, and the public. The facility failed to ensure essential equipment in the kitchen was maintained in safe operating condition.

The facility had a census of 60 residents. The sample included 17 residents. Based on observation, record review, and interview the facility failed to act promptly, investigate, and resolve grievances and recommendations of six resident council members (Resident (R)14, R13, R15, R29, R42 and R212). This placed the five resident council members at risk for depression from unsolved concerns. Findings included: - Review of the Resident Council Minutes from 08/30/22 to 03/06/23 revealed the members had concerns regarding snacks not being offered, running out of food, request for different food items to be served, missing resident clothing, not receiving scheduled showers, and rooms not being cleaned. The resident council minutes lacked documentation regarding the above concerns being acted upon and resolved. Review of the Grievance Log from 08/30/23 to 05/01/23 revealed a lack of documentation regarding grievances from resident council members or resolution of them. On 05/02/23 at 10:25 AM, observation revealed R14, R13, R42, R212, R15, and R29 attended the resident council meeting with this surveyor and stated staff did not act upon their same grievances every month and report back to them how they resolved them. On 05/02/23 at 11:30AM, Activity Staff (AS) Z stated he documents the resident council members grievances with resolutions in the facility grievance log. 05/04/23 at 11:48 AM, Administrative Nurse D and Administrative Staff A stated the facility provided AS Z education on 04/26/23 regarding placing resident council grievances on the facility grievance log so staff could investigate them and get back with the residents. Upon request the facility failed to provide a grievance policy. The facility failed to promptly respond to R13, R14, R15, R29, R42, and R212's grievances and follow up with resolutions for them. This placed the residents at risk for depression.

The facility had a census of 60 residents. Based on observation, record review, and interview the facility failed to ensure no more than a 14-hour lapse between a substantial evening meal and breakfast the following day, when staff failed to provide the 60 residents who resided in the facility a nourishing snack at bedtime. This placed the residents at risk for impaired nutrition. Findings included: - On 05/01/23 at 11:00 AM, Dietary Manager (DM) CC stated resident meal times were breakfast at 7:30 AM, lunch at 11:30 AM, and supper at 04:30 PM. On 05/02/23 at 10:25 AM, during resident council meeting, Resident (R) 13, R14, R15, R29, R42, and R212 stated the facility did not pass bedtime snacks and if residents requested a snack sometimes they received one, but most of the time the kitchen was out. On 05/02/23 at 02:17 PM, Certified Dietary Aide (CNA) M stated staff did not deliver snacks, the kitchen staff brought down a snack tray and placed it in the nourishment refrigerator for bedtime snacks. CNA M stated if a resident requested a snack, the staff would give them one. CNA M stated there was not always a variety of snacks on the tray. On 05/03/23 at 02:12 PM, DM CC stated the dietary department placed a tray of snacks in the nourishment refrigerator for the aides to pass at bedtime, but sometimes the tray was still full the next day or they run out of snacks. DM CC verified from supper time (04:30 PM) until breakfast (7:30 AM) the next day, the residents would have 15 hours between meals. On 05/02/23 at 04:00 PM, observation revealed three half peanut butter and jelly sandwiches on a tray in the nourishment refrigerator. 05/03/23 at 07:00 AM, observation revealed three half peanut butter and jelly sandwiches in the snack refrigerator dated 05/02/23. 05/04/23 at 11:43 AM, Administrative Nurse D and Administrative Staff A stated staff should be passing residents snacks at bedtime. The facility's Meal Times and Frequency Policy, revised 2/28/2017, documented there would be no more than 14 hours between a substantial evening meal (supper) and breakfast the following day. All residents would be offered a bed-time snack. The policy documented a substantial evening meal was defined as an offering of three or more menu items at one time, one of which included a high-quality protein such as meat, fish, eggs or cheese. The meal should represent no less than 20 percent of the day's total nutritional requirement. The facility failed to ensure nourishing snacks were provided in order to prevent time between mels from exceeding 14 hours. This placed the 60 residents at risk for impaired nutrition.

The facility had a census of 60 residents. Based on observation, record review, and interview the facility kitchen staff failed to provide food prepared by methods that conserve nutritive value, flavor and appearance, when dietary staff failed to follow a recipe while preparing four residents' pureed diets. This deficient practice placed the four residents at risk for impaired nutrition. Findings included: - On 05/03/23 at 11:12 AM, observation during pureed food preparation revealed Dietary Staff (DS) DD, overlooked and assisted by Dietary Manager (DM) CC, stated the facility had four pureed diets, but she was preparing five because she always made extra in case one resident would like more. DS BB placed an unmeasured amount of cooked peas (used the line towards the top of the steam table pan as guidance for measurement) blended. DM CC retrieved a clean blender container and placed an unmeasured amount of cooked tri color pasta in it, then added an unmeasured amount of chicken base broth and blended. Further observation revealed DS DD and DM CC had not followed a recipe for the pureed food items. On 05/03/23 at 12:00 PM, DM CC verified the above findings and stated staff should follow a recipe. The facility's Puree Food Preparation Policy, revised on 03/20/23, documented facility would provide food that had been prepared in a manner to conserve nutritive value, palatable flavor, and attractive appearance. The facility kitchen staff failed to follow a recipe when preparing four residents' pureed diet, this placed the residents at risk for impaired nutrition.

The facility had a census of 60 residents. Based on observation, interview, and record review the facility failed to date one insulin pen when opened and monitor refrigerator temperatures for two of two medication rooms. This deficient practice placed Resident (R) 26 at risk to receive outdated insulin and residents to receive temperature compromised medications. Findings included: - On 05/01/23 at 08:56 AM, observation revealed the thermometer in the east medication room had a solid red line up to 28 degrees Fahrenheit (F) with more small red lines past that. The temperature log for the refrigerator was dated April and only had a temperature recorded on the first two days. On 05/01/23 at 09:00 AM, observation revealed the east nurse's treatment cart held one undated insulin pen for R26. On 05/01/23 at 09:00 AM, Licensed Nurse (LN) J verified the lack of temperature monitoring in the east medication room and the undated insulin pen in the east treatment cart. 05/03/23 07:51 AM, Administrative Nurse D verified staff were to monitor and document refrigerator temperatures for the medication refrigerators. The facility's Insulin Pen policy, dated 01/01/20, stated Insulin pens must be clearly labeled with the resident name, physician name, date dispensed, type of insulin, amount to be given, frequency, and expiration date. The facility failed to date one insulin pen when opened and monitor refrigerator temperatures for two of two medication rooms, placing Resident (R) 26 at risk to receive outdated insulin and residents to receive temperature compromised medications.

The facility identified a census of 69 residents with three residents reviewed for wounds. Based on record review, observation, and interview the facility failed to identify and provide appropriate intervention to prevent pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin) and failed to involve the physician, implement treatment orders, and consistently monitor wound status to promote healing, and prevent infection. Resident (R) 1, who was severely cognitively impaired, required extensive staff assistance for activities of daily living (ADL) and had contractures (abnormal fixed tightening of muscle, tendons, ligaments, or skin) developed a skin alteration on her right knee on 11/01/22. The facility identified the skin alteration on multiple subsequent skin assessments which were not performed routinely and were documented inconsistent with the Skin-Wound Assessments. The wound was noted to have slough (dead tissue usually cream or yellow in color) and redness on 11/21/22 though the record lacked physician notification or involvement and staff did not implement any treatments or interventions aimed to help heal and or prevent further skin injury. On 12/19/22 the wound had black eschar (dead tissue) formation and continued with redness all around the wound, but staff failed to involve the physician and/or implement orders to treat. On 01/03/23 the wound had further deteriorated and on 01/05/23 a wound consult was conducted, and the wound care team identified R1 had a stage 4 pressure injury (deep pressure wound reaching the muscles, ligaments, or bones) to her left knee, which was inflamed, and red. Treatment orders were written on 01/05/23 though the facility did not implement the treatment orders until 01/13/23. On 01/14/23, R1 became lethargic, hyperglycemic (elevated blood sugar levels), and the left knee was swollen and painful. R1 was admitted to the hospital with sepsis (potentially life-threatening condition that occurs in response to an infection), cellulitis (bacterial skin infection), and osteomyelitis (bone infection) of the left knee. This deficient practice placed R1 in Immediate Jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), major depressive disorder (major mood disorder), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 was severely cognitively impaired and had long and short-term memory problems. The MDS further documented R1 was totally dependent on two staff for transfers, locomotion on and off the unit, toileting, personal hygiene, and bathing. R1 required extensive assistance of two staff for bed mobility and eating. The MDS also documented R1 was at risk for developing pressure wounds, did not have any pressure wounds, had an open lesion, had a pressure reducing device for her chair, had a pressure relieving mattress, was not on a turning/repositioning program, and was not receiving any dressing applications. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 06/27/22, documented R1 had short- and long-term memory loss and was unable to complete the Brief Interview for Mental Status (BIMS) testing due to R1 being rarely/never understood and rarely/never demonstrated understanding. The assessment documented R1 as requiring extensive to total assist with all of her activities of daily living. The Pressure Ulcer/Injure CAA, dated 06/27/22, documented R1 as at risk for pressure ulcers due to requiring extensive assistance with bed mobility. The CAA documented R1 was always incontinent of bowel and bladder and had a significant weight loss. The ADL Care Plan, revised 05/23/22, directed staff to transfer R1 with a total body lift with two staff assistance, encourage R1 to allow brief and clothing changes as needed, and to assist R1 with ADL tasks like bathing, grooming, dressing, etc. The Skin Prevention Care Plan, dated 05/13/21, directed staff to assess R1's skin weekly by a licensed nurse, perform a Braden Scale (risk for pressure ulcer scale) on admission, quarterly and with acute changes, document changes such as skin color and turgor; ensure R1 had a pressure reduction mattress and pressure relieving cushion in her tilt/recline chair, and to perform treatments per order. The Braden Scale for Predicting Pressure Sore Risk, dated 10/20/22, documented R1 was at high risk for developing pressure ulcers. The assessment documented R1 had very limited ability to respond to pressure related discomfort, R1's skin was very moist, R1 was chair fast, R1's ability to change and control her body position was very limited, and R1's nutrition was very poor. The Weekly Skin Assessment, dated 10/26/22 documented R1's skin as intact and no new skin concerns were identified. The Nurse's Note, dated 10/29/22, documented R1 had a skin tear to the outside of her left knee measuring five centimeters (cm) by three cm as well as a bruise to her upper lip measuring roughly 1 cm by 0.5 cm. The site to the knee was cleaned and covered due to the nurse being unable to approximate the skin tear. The staff left a message with R1's guardian and a faxed R1's primary care physician. The Weekly Skin Check, dated 11/01/22, documented R1 had new skin concerns that were identified. Staff documented R1 as having redness with a scab to the front of her knee and bruising to the front of her right and left lower extremities. The note recorded staff notified R1's primary care physician of the new skin concern, but lacked evidence staff notified R1's representative. The Physician Order Sheet, dated 11/01/22, documented a new order for staff to monitor R1's reddened area with scab to the left knee and to monitor for increased redness, warmth, swelling, bleeding, or drainage every shift. The order had a start date of 11/01/22. The Weekly Skin Check, dated 11/02/22, documented R1 had a new skin concern identified. Staff documented R1 as having a skin tear to the front of her left thigh and a skin tear to her rear left lower leg. The note recorded staff notified R1's primary care physician of the new skin concern, but lacked evidence the staff notified R1's representative. The Weekly Skin Check, dated 11/09/22, documented R1 had previously identified areas of skin alteration. Staff documented R1 as having a skin tear to her outer left knee/thigh, a skin tear to the back of her left lower extremity, bruising to her bilateral lower extremities, bruising to the top of her right lip, a red/scab to her left knee, a small scab and bruise to her outer right calf, and intermittent redness of her groin. The record lacked evidence of notification to R1's primary care physician or responsible party. The Weekly Skin Check, dated 11/16/22, documented R1 had previously identified areas of skin alteration. Staff documented R1 as having a skin tear to her outer left knee/thigh, a skin tear to the back of her left lower extremity, bruising to her bilateral lower extremities, bruising to the top of her right lip, a red/scab to her left knee, a small scab and bruise to her outer right calf, and intermittent redness of her groin. No notification to R1's primary care physician or responsible party was made. The Weekly Skin Check, dated 11/18/22, documented R1 had a new skin concern identified. R1 had a hematoma (accumulation of blood) to her right forearm, which measured 8cm by 6 cm. R1's primary care physician and responsible party were both notified of the new skin concern. The Nurse's Note, dated 11/19/22, documented R1 continued to have a large hematoma to her right forearm and a scab to her left knee. The nurse noted the skin tear site to the left side of R1's knee was healed. The Skin/Wound Assessment, dated 11/21/22, documented R1 had a new skin alteration to her left knee. R1's left knee skin alteration measured 1.39 cm by 1.11 cm. The area had yellow slough with redness noted all around the peri-wound. There was no treatment in place and no evidence R1's primary care physician was notified of the deteriorating skin alteration to R1's left knee. The Weekly Skin Check, dated 11/24/22, only documented R1 had a previously identified area with a hematoma to her right forearm. The Weekly Skin Check, dated 11/30/22, documented R1's skin was intact and there were no areas of concern noted. The Nurse's Note, dated 11/30/22, documented during rounds R1 was noted to have a left knee scab that was tender, slightly swollen, and R1 cried out when the nurse touched the wound. The area had some warmth to the touch and it was not draining or bleeding. The surrounding skin was swollen and red. The scab appeared soft and cracking and pale in color. The skin tear to R1's left outer knee/thigh was healed and intact. The skin tear to the back of R'1 left lower leg/calf had some scabbed edges with no draining, bleeding or surrounding redness. The record lacked evidence R1's primary care physician was notified of the changes in R1's skin alteration to her left knee. The record indicated there was no treatment being performed to R1's left knee. The Weekly Skin Check, dated 12/07/22, documented R1 had a previously identified areas to her skin. R1 had a skin tear to the back of her left lower extremity, bruising to her bilateral upper and lower extremities (purple/brown/red), a red/scab to her left knee, a small scab and bruise over her right calf, and an intermittent reddened groin. The record lacked evidence of notification to R1's primary care physician or responsible party. The Weekly Skin Check, dated 12/13/22, documented R1 had previously identified areas to her skin. R1 had a skin tear to the back of her left lower extremity, bruising to her bilateral upper and lower extremities (purple/brown/red), a red/scab to her left knee, a small scab and bruise over her right calf, and an intermittent reddened groin. The record lacked evidence of notification to R1's primary care physician or responsible party. The Skin/Wound Assessment, dated 12/19/22, documented R1's left knee wound measured 2.24 cm by 2.16 cm. R1's wound to her left knee had black eschar to the wound bed with peeling skin. There was redness all around the wound. The record lacked evidence of notification to R1's primary care physician or responsible party regarding the worsening wound to the left knee. The Weekly Skin Check, dated 12/22/22, documented R1 had a previously identified areas to her skin. R1 had a skin tear to the back of her left lower extremity, bruising to her bilateral upper and lower extremities (purple/brown/red), a red/scab to her left knee, a small scab and bruise over her right calf, and an intermittent reddened groin. The record lacked evidence of notification to R1's primary care physician or responsible party. The Weekly Skin Check, dated 12/28/22, documented R1 had a previously identified areas to her skin. R1 had a skin tear to the back of her left lower extremity, bruising to her bilateral upper and lower extremities (purple/brown/red), a red/scab to her left knee, a small scab and bruise over her right calf, and an intermittent reddened groin. The record lacked evidence of notification to R1's primary care physician or responsible party. The Weekly Skin Check, dated 01/03/23, documented R1 had a previously identified areas to her skin. R1 had a skin tear to the back of her left lower extremity, bruising to her bilateral upper and lower extremities (purple/brown/red), a red/scab to her left knee, a small scab and bruise over her right calf, and an intermittent reddened groin. The record lacked evidence of notification to R1's primary care physician or responsible party. The Skin/Wound Assessment, dated 01/03/23, documented the wound to R1's left knee measured 3.16 cm by 2.49 cm and was deteriorating. There was white slough covering the wound bed and redness all around the wound. The Wound Care Skin Integrity Evaluation, dated 01/05/23, documented the wound care company that the facility had evaluate pictures of wounds placed in the EMR, came to the facility to personally evaluate R1's left knee wound because they saw deterioration in the wound from the pictures. The evaluation documented R1 had a full thickness wound to her left knee. The left knee wound had moderate amount of exudate (fluid that leaks out of body vessels and tissues), measured 3.2 cm by 2.5 cm, and had serosanguinous (clear/bloody) drainage. The wound bed was 40% red with hypo-granulation tissue, 30% with yellow slough that was mucinous (soft/slimy) and 30 % black, soft eschar. The peri-wound (area around the wound) was inflamed, reddened, firm, excoriated, and fragile. The wound care specialist ordered a dressing change every other day to ensure dressing integrity and moist wound healing environment. The order directed for silver alginate (an anti-microbial dressing) to the wound bed to promote autolytic debridement (using the body's own defense mechanisms and fluids to liquefy eschar, slough, and other forms of necrotic tissue) and address the suspected critical colonization as evidenced by the increase in wound drainage, recalcitrant wound, and redness in the peri-wound. The order was written to cleanse the wound per facility protocol, apply skin protectant to the peri-wound, cut and fit silver calcium alginate to the wound bed, cover with non-bordered heel foam and secure with six-inch tape, and change every other day and as needed. The Treatment Administration Record (TAR), dated January 2023, lacked the wound care specialist orders for wound care from the visit on 01/05/23. The Nurse's Note, dated 01/09/23, documented R1's left knee was swollen, red, with thick scabbed edges. The wound was tender as noted by R1 was grinding her teeth and grabbing at staff's hands and fingers. Underlying connective tissue was visible and the wound was warm to the touch. The Weekly Skin Check, dated 01/10/23, documented R1 had new skin concerns that had been identified. The assessment documented R1 had stage 1 pressure ulcer (pressure injury where skin is red or discolored but not open) to her right hip, a fingernail mark to her right lower extremity, a skin tear to her right lower extremity, a skin tear to her left knee, a stage 4 pressure ulcer to her left knee, a skin tear to her front left lower extremity, a skin tear to the back of her left lower extremity, and stage 1 pressure ulcer to her right heel and a stage 1 pressure ulcer to her left heel. No measurements were provided. The Skin/Wound Assessment, dated 01/13/23, documented R1's left knee wound was deteriorating and measured 3.44 cm by 2.62 cm. The wound bed was 80% yellow slough and 20% eschar with redness noted all around the wound. The Nurse's Note, dated 01/13/23, documented R1 appeared to be lethargic, opened her eyes to her name and responded slowly with movements and responses. The Alert Note, dated 01/14/23, documented the on-line medical service was called regarding R1's increased lethargy, blood sugars ranging from 114 to 547, decreased appetite, multiple wounds to bilateral lower extremities, knee would that was red, swollen, and painful to the touch. The video conference call did not work so the nurse called into the on-line medical service on the phone and it was recommended to send R1 to the emergency room for evaluation of sepsis. R1's responsible party was notified and agreed for R1 to be sent to the emergency room and would meet R1 there. R1 was transported to the local emergency room . The Alert Note, dated 01/14/23, documented R1 was being admitted to the local hospital with the diagnoses of sepsis, cellulitis, and osteomyelitis. The emergency room Department Report, dated 01/14/23, documented R1 presented to the emergency room s with concern for potential sepsis. The emergency room doctor documented he reviewed R1's prior medical record, specifically the last two visits by R1's primary care physician. Review of the chart indicated on the 11/18/22 visit, R1's primary care physician mentioned a skin tear to R1's left knee. Review of the chart indicated on the 12/23/22 visit R1's primary care physician, no wounds were mentioned. The report documented R1 had an exposed patella (knee) bone on the left knee. R1's white blood count (indicates infection) was elevated at 16.3. R1 appeared to be volume depleted on exam. The General Surgery Progress Note, dated 01/15/23, documented R1 had obvious osteomyelitis of the patella and intravenous (IV) antibiotics needed to be continued with local wound care. The Patient Transfer Form, dated 01/19/23, documented R1 was being transferred back to the facility. The transfer form documented R1 was being transferred back to the facility with the diagnosis of Methicillin Resistant Staphylococcus Aureus (MRSA-difficult to treat bacterial infection) osteomyelitis of the left knee. The transfer form directed the facility to administer IV Vancomycin (antibiotic) to R1's peripherally inserted central catheter (PICC) for six weeks and the dosage was to be per trough (the lowest level of the antibiotic in the blood) and kidney function. The facility was directed to clean R1's left knee with wound cleanser and cover with Xeroform (a type of wound dressing that can help keep wounds clean and promote healing), and then cover the Xeroform with a Mepilex (bordered dressing) daily. The transfer form ordered for R1's partial and full thickness wound to her lower extremities (not the knee wound) were to wash with CarraKlenz (a gentle, emulsifying, and safe solution for removing organic material, debris, and dead tissue from wounds) and pat gently dry then apply Mepilex bordered foams over the wounds. Pulsate mattress with turning regiment of at least every two hours at 30-degree intervals with TAPs system (a turn and position material that stays under the patient) in place using wedges. The transfer form continued to instruct the facility to float R1's heels with pillows as best as they could, pad bony prominences with pillows upon turning to make sure knees and feet are not pushing against each other, and if not contraindicated keep head of R1's bed below 30 degrees. On 01/23/23 at 11:00 AM, observation revealed R1 lying in bed on her left side in a fetal position due to contractures to her upper and lower extremities. There was a mattress along the wall of the left side of R1's bed. R1 was up against the mattress with her knees touching the mattress. R1 was dressed in a hospital gown with a sweater on her upper body. R1 did not respond to verbal stimuli. On 01/23/23 at 01:00 PM, observation revealed R1 laying in a fetal position on her left side. R1 was clear up against the mattress along the wall and the left side of her bed. R1 raised her head to her name and looked at this surveyor. On 01/23/23 at 03:30 PM, observation revealed R1 laying in a fetal position on her left side with her forehead and nose, hands, and knees against the mattress along the wall and the left side of her bed. On 01/23/23 at 10:30 AM, Administrative Nurse D stated that she had started taking pictures of R1's knee on 11/21/22 and that was when the area to R1's left knee was new. Administrative Nurse D stated she was unsure why the floor nurses did not monitor R1's knee wound better and notify the physician. Administrative Nurse D stated the wound care specialist company the facility has on staff monitor the EMR for pictures of wounds and when the wound care specialist saw the wound had deteriorated from 11/21/22, 12/19/22, and 01/03/22 when pictures had been taken the wound care specialist came to the facility on [DATE] personally to visualize the wound. The wound specialist ordered a dressing change every other day to R1's left knee. Administrative Nurse D stated that she herself ordered the supplies for the dressing change that day, but the dressing supplies did not arrive to the facility until 01/12/23. Administrative Nurse D stated she thought R1's left knee wound have happened, because R1 was up against the wall in her room and her left knee was rubbing against the wall. Administrative Nurse D stated someone, she did not know who or when, put a mattress against the wall between R1's bed and the wall to protect R1's knees. On 01/23/23 at 02:00 PM, Certified Nurse's Aide (CNA) M stated R1 was not on a turning/repositioning program, but she just did it when she was working because she knew R1 could not reposition herself. CNA M stated she did not know what R1's care plan said about repositioning. On 01/23/23 at 02:30 PM, Licensed Nurse (LN) G stated the nurses were covering the left knee wound to keep R1 from picking at it. LN G stated she did not know why the wound deterioration was not reported to the physician, because she was only there two days a week. The facility's Wound Treatment Management, policy, dated 01/01/20, documented it was the facility's policy to promote wound healing of various types of wounds, to provide evidence-based treatments in accordance with standards of practice and physician orders. In the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders. The effectiveness of treatments will be monitored through on-going assessment of the wound. Considerations for needed modifications include lack of progression toward healing and changes in the characteristics of the wound. The facility's Skin Assessment policy, dated 01/01/20, documented it was the facility's policy to perform full body skin assessments as part of the facility's systematic approach to pressure injury prevention and management. A full body, or head to toe, skin assessment will be conducted by a licensed nurse or registered nurse upon admission/re-admission and weekly thereafter. The assessment may also be performed after a change in condition or after newly identified pressure injury. Facility staff are to note any skin conditions such as redness, bruising, rashes, blisters, skin tears, open areas, ulcers, and lesions. Assessments will be documented in the EMR and include date and time of the assessment, name and title of person completing the assessment, document observations, document type of wound, describe the wound (measurements, color, type of tissue in wound bed, drainage, odor, pain), and document other information as indicated. The facility failed to identify and provide appropriate interventions to prevent pressure ulcers and failed to involve the physician, implement treatment orders, and consistently monitor wound status to promote healing, and prevent infection. This deficient practice placed R1 at risk for hospitalization , infection, and long-term treatment for infection. The facility implemented the following corrections to address the immediacy which was verified on 01/24/23: 1. A facility wide skin sweep was completed on 1/23/23 to ensure that all active wounds in the facility were appropriately assessed and had current treatment. 2. The skin sweeps were reviewed by management nurses on 01/24/23 to ensure current pressure wounds were assessed and up to date with current assessments. 3. On 1/23/23, a Regional Consultant reviewed the Braden assessment for current residents. A preventative care plan was initiated for active residents and interventions placed on the Kardex for direct care staff for focus on prevention of pressure ulcers. 4. On 1/23/23, a Regional Consultant reviewed resident orders for those with pressure wounds to ensure that they had current treatment in place. If the treatment was not effective, a nurse requested a new treatment. 5. The charge nurses, and management nurses notified the physician and families to ensure they were aware of the current pressure ulcers for each resident affected on 1/24/23 by 1000. 6. As of 1/24/23, facility was implementing shower sheets to be completed with resident's shower that nursing assistants document skin integrity concerns on to report to the charge nurse on duty; the charge nurse will complete the wound protocol and sign off and turn into nursing management. 7. The facility held an Ad Hoc QAPI meeting on 1/24/23. The Administrator, ADON, Regional Consultant, Resident Care Coordinator and Medical Director attended. After removal of the immediacy, the citation remained at a scope and severity of a G

The facility had a census of 67 residents. The sample included two residents reviewed for accidents. Based on record review and interview, the facility failed to ensure that a Hoyer lift (a mechanical device used to assist in transferring a resident) full body sling strap (a fabric device used to help suspend and attach to the Hoyer lift when transferring a resident) was fully attached to the hook on the lift arm of the Hoyer lift. As a result, Resident (R) 1 slipped from the sling and was lowered to the floor, which resulted in a fractured seventh rib and complications related to internal injuries. Findings included: - R1's Physician's Order, dated 03/07/22, documented diagnoses of disease of the spinal cord, unsteadiness on feet, [CONDITION(S)] (condition of musculoskeletal pain, spasms, stiffness, fatigue and severe sleep disturbance), fracture of neck of left femur (hip fracture) and [CONDITION(S)] (chronic [CONDITION(S)] disease that affected joints and other organ systems). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of six, which indicated severely impaired cognition. She required extensive assistance of two staff with bed mobility, dressing and personal hygiene. R1 was dependent on two staff for transfers, toilet use, and bathing. She required the use of a wheelchair for mobility and had no history of falls since the prior assessment. The Activities of Daily Living (ADLs) Care Area Assessment (CAA), dated 11/02/21, documented R1 required extensive assistance for bed mobility and did not walk. R1 recently returned from the hospital after repair of a left hip fracture. The Falls CAA, dated 11/02/21, documented R1 had fall risk factors, which resulted from balance problems. Nursing staff assisted R1 with ADLs as needed according to the facility policy and R1 was at risk for fall related injury. R1 worked with therapy and the care plan would include a goal to have no serious fall related injuries. The ADL Care Plan, dated 02/16/22, directed two staff to assist R1 with all of her cares including transfers, positioning, and ADLs to ensure she remained free of falls. Transfers should be completed using a total lift. A Witnessed Fall incident report dated 04/02/22 at 11:30 AM documented Certified Nurse Aide (CNA) N called Licensed Nurse (LN) G to R1's room as R1 was on the floor. When LN G got to R1's room, CNA N explained the resident fell out of the lift sling assisted by CNA N and CNA M. LN G gathered all vital sign equipment and saw R1 on the floor moaning in pain. R1 pointed to her right ribcage area and stated it was painful. R1 also had a right elbow skin tear. Staff cleansed the skin tear and applied a bandage for protection. Staff notified the on-call physician, who ordered a mobile x-ray for the right ribcage area and right elbow. Staff called for the mobile x-ray. A Nursing Note by LN G on 04/02/22 at 12:04 PM documented R1 fell from the lift sheet during a transfer. Staff assisted R1 to the ground and she did not hit her head. Staff notified the physician, Director of Nursing (DON), and the family. Due to continued acute pain in the right ribcage and right elbow the physician ordered a mobile x-ray. A Nursing Note by LN G on 04/02/22 at 02:24 PM documented the mobile x-ray completed three views of the right ribcage and two views of the humerus (large upper arm bone) area. A Radiology Report, dated 04/02/22, documented a nondisplaced fracture involving the lateral aspect of the right seventh rib. A Nursing Note by LN H on 04/03/22 at 12:55 AM documented the certified medication aide (CMA) reported R1 threw up black vomit and it was on the front of her gown. LN H went to R1's room and saw the gown covered in black vomit. R1 complained of right shoulder pain and arm pain. LN H felt R1's left upper abdominal area with tightness noted and the resident voiced pain. A Nursing Note by LN H on 04/03/22 at 12:57 AM documented she called the on call physician and reported the black vomit with complaints of nausea. Staff informed on call physician that the resident fell earlier and the physician directed staff to send the resident to the hospital. A Radiology Report, dated 04/03/22 at 02:12 AM, documented a traumatic grade 3 liver injury with parenchymal laceration (cut affecting the functioning tissue of the organ) and subcapsular hematoma (accumulation of blood). A Radiology Report, dated 04/03/22 at 02:12 AM, documented mildly displaced fractures of the right ribs seven and nine with small right pneumothorax (puncture of lung) and right lower lobe contusion and small pulmonary laceration (lung bruise and cut). The Investigation Report documented around 11:30 AM on 04/02/22, CNA M and CNA N transferred R1 from her bed to the wheelchair. The CNAs had R1 in the Hoyer lift when she began to move around and shifted her weight to one side. At that time, the lift sling came unhooked on one corner of the lift, causing R1 to begin to fall. Both aides assisted the resident to the floor. CNA M braced R1 under her head and shoulders and assured the resident did not hit her head as she was lowered to the ground. CNA N held onto R1's right hip and assisted the resident down by her legs. R1 hit her bottom on the ground as they went to the floor. Upon getting R1 to the floor, CNA N noticed the resident was bleeding from a skin tear to her right elbow. The CNAs notified LN G immediately of the incident. LN G entered R1's room and saw CNA M with the resident's head braced. The CNAs described the incident, what happened, and how they lowered the resident. R1 also stated staff lowered her to the ground after beginning to fall from the lift. R1 stated she had generalized pain at the time and did complain of pain in her right rib area. Staff assisted the resident back into bed and LN G called R1's physician and family. Due to R1's right elbow and rib pain, the physician ordered x-rays, but did not direct the facility to send the resident to the emergency department. On 04/11/22 at 10:47 AM, CNA N stated on 04/02/22 she and CNA M went into R1's room to check on her and assist her up for lunch. The Hoyer lift was brought into R1's room and both aides placed a sling under the resident and attached the sling loops to the Hoyer lift. CNA N started raising R1 up with Hoyer lift and CNA M was behind R1 guiding her off of the bed. Staff raised R1 about five inches off the bed, started to move the resident off of the bed, and R1 shifted her bottom which she had a habit of doing. The top sling loop came undone, CNA M grabbed the resident from behind, and CNA N grabbed R1's right side. R1's bottom went to the floor and CNA M held the back of her head, so it didn't touch the floor. Once R1 reached the floor, CNA M sat behind the resident with R1's head in her lap. R1's right arm hit the leg of the Hoyer lift and CNA N felt a skin tear as she touched the resident's arm. CNA N went to the resident's door and called for help. LN G came right into the room and assessed the resident. On 04/11/22 at 01:48 PM, CNA M stated on 04/02/22 CNA N asked her to come and assist R1 from her bed to her wheelchair. CNA N brought the Hoyer lift to R1's room. CNA M placed a sling under the resident, both aides attached the sling loops to the Hoyer lift and called out the colors of the loops to be attached. CNA M stated she prompted R1 to cross her arms on her chest and CNA N started to raise the resident up off of the bed with the Hoyer lift about three inches. As she raised R1 CNA M was behind the resident and held onto the back of the lift sling. The resident was barely off the bed and R1 shifted her weight at her hips and the sling loop closest to R1's head came off of the hook. CNA N grabbed R1 at the waist and CNA M held the resident at her back by the sling. The lift went to the floor and CNA M held onto the resident in the sling and went down to the floor with R1's back and head ending up in CNA M's lap. R1's butt and hips went to the floor, but her head did not hit the floor. R1's right elbow hit the legs of the lift and she received a skin tear. CNA N ran out and got LN G. CNA M asked R1 if she knew what happened and she said yes she fell and her left side hurt. On 04/11/22 at 09:03 AM, Administrative Nurse D verified completion of an in-service with approximately 25 of the 36 aides on 04/07/22 and determined during observation that some of the CNAs attached the sling loops straight up and down and were not leaving the excess sling loops to the side. Administrative Nurse D felt this could be what happened during the fall incident with R1. Education has been provided and will continue to be provided to all of the aides on the proper sling loop placement prior to the aides next day of work. On 04/11/22 at 09:03 AM, Administrative Staff A stated after the investigation and the in-servicing the facility determined the sling loops may not have been attached properly to the Hoyer lift. The facility's undated Accidents and Supervision policy documented the resident environment remains free of accident hazards as is possible and each resident received adequate supervision and assistive devices to prevent accidents. The definition of accident refers to any unexpected or unintentional incident, which results in injury or illness to a resident. The undated Mechanical Lift policy documented a mechanical lift is used appropriately to facilitate transfers of residents. Procedure number six documented to lower the lift and place hooks in the appropriate holes of the lift sling with hooks facing way from resident. The facility failed to ensure the safe transfer of R1 with the use of a Hoyer lift and sling when staff members failed to securely attach the sling strap to the lift arm hook. This deficient practice resulted in an avoidable accident when R1 slipped out of the sling which resulted in a fracture to R1's right rib cage and lacerated liver. On 04/07/22 the facility completed the following corrective actions: Staff were re-educated on Hoyer lift usage, proper placement of slings when doing a transfer, how to properly apply the sling to the lift hooks, and return demonstration of the correct way to transfer a resident from the bed to their wheelchair and back. Education was also given about the importance of always watching the sling while the resident is on the lift and making sure the resident is the only focus at the time. The deficient practice was cited at past non-compliance.

The facility had a census of 59 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to provide the necessary care and services to ensure the resident wore her leg immobilizer (a leg brace is a device used to immobilize a joint or body segment, restrict movement in a given direction, reduce weight bearing forces, or correct the shape of the body) during transfers as physician ordered for Resident (R) 33. Findings included: - R33's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had severely impaired cognition, required extensive assistance of two staff for bed mobility, and dependent upon two staff for transfers. The MDS documented the resident did not ambulate. The Activities of Daily Living (ADLs) Care Plan, dated 11/03/21, directed staff to place the knee immobilizer to the residents left lower extremity during transfers and check skin integrity at least daily. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/10/21 at 10:40 AM, observation revealed Certified Nurse Aide (CNA) M and CNA O attached the sling (a flexible strap or belt used in the form of a loop to support or raise a weight) to the full mechanical lift (used to move those who are unable to stand on their own or whose weight makes it unsafe to move or lift them manually), lifted the resident and transferred her to her bed. Further observation revealed the leg immobilizer was not placed on the resident's leg. On 11/15/21 at 12:50 PM, observation revealed CNA N and CNA P attached the sling to the full mechanical lift, lifted the resident and transferred her to her bed. Further observation revealed the leg immobilizer was not placed on the resident's leg and the immobilizer was on top of the resident's dresser. On 11/15/21 at 12:50 PM, CNA N stated she had not used the immobilizer for over a month because she thought the resident did not use it anymore. On 11/15/21 at 02:20 PM, Licensed Nurse (LN) G stated the resident wore the immobilizer during transfers and documented in the medical record skin checks three times a day to make sure the immobilizer was not rubbing the resident's skin. On 11/15/21 at 02:00 PM, Administrative Nurse E stated if the immobilizer was ordered by the physician, staff were to follow the order. Upon request, a policy for following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The facility failed to follow a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

The facility had a census of 66 residents. The sample included 4 residents. Based on observation, record review, and interview the facility failed to provide competent cares and services to implement the use of a feeding tube (tube for introducing high calorie fluids into the stomach) for 1 of 4 sampled residents. Staff cut off the port end (allows fluid access into the feeding tube) of Resident #2's feeding tube, which displaced the feeding tube, and caused feeding tube fluids to enter his/her abdominal cavities instead of the stomach. Resident #2 was transported to the hospital with severe abdominal pain, and required emergency surgery for [REDACTED].#2 in immediate jeopardy for pain and worsening infection. Findings included: - Resident #2's medical record documented the following Diagnoses: [REDACTED]. The resident admitted to the facility on [DATE] and sent to the emergency roiagnom on [DATE], an (MDS) Minimum Data Set assessment was not completed. The 7/09/19 admission care plan recorded the resident was alert and oriented, and able to make his/her needs known. The care plan directed staff to assist the resident as needed with (ADLs) Activities of Daily Living, but lacked information regarding the resident's PEG tube (percutaneous endoscopic gastrostomy - an endoscopic medical procedure in which a tube (PEG tube) is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate). The 7/09/19 at 5:39 PM, nurse's note recorded the resident arrived to the facility by (EMS) Emergency Medical Service vehicle. The note recorded the resident was alert and oriented, walked independently with a cane, and had a [MEDICAL CONDITION] (opening though the neck into the trachea through which an indwelling tube may be inserted), with speaking valve in place. The 7/9/19 at 8:08 PM, admission summary note recorded the resident had a PEG placed, with orders to administer 5 cans of formula daily with 1/2 can at bedtime, 3 full cans so far today. Arrived to facility at 5:50 PM, rated pain at 8 (scale 0-10). The 7/9/19 at 11:36 AM, surgical hospital discharge instructions instructed staff to give the resident bolus (a single dose of a drug or other medication preparation given all at once) or syringe feedings over 20 minutes. Feedings given too fast can cause cramping and loose stools. The nursing facility's 7/9/19 at 10:31 PM, admission evaluation recorded to administer 1.5 calorie feedings by gravity (a way to deliver formula through your feeding tube, formula flows out of a bag and into your tube by gravity). The 7/10/19 at 9:20 AM, nurse's note recorded the DON (Director of Nursing) was called to the resident's room by his/her primary nurse and unit manager to assess PEG tube port as port was not compatible with the facility's equipment and syringes. The note recorded the port was changed out with a compatible one that the facility had on hand so resident could receive his/her feeding. The note recorded the process was explained to the resident who voiced understanding, patency (being open or unobstructed) verified by primary nurse. The 7/10/19 at 10:35 AM, nurse's note recorded after receiving his/her feeding and medication at 9:30 AM, resident complained of stomach pain and feeling hot, and had a period of diaphoresis (sweating) while the nurse was at break. Staff placed a fan near the resident who stated the fan helped, and being hot was easing along with the ache. The 7/10/19 at 1:38 PM, nurse's note recorded a nurse was called to the resident's room and found the resident complaining of pain again in his/her abdomen. Abdomen soft to touch, bowel sounds normoactive (normal level of activity) in four quadrants, stated he/she felt like he/she might have emesis (vomiting), emesis basin provided, vital signs obtained and within normal limits. The 7/10/19 at 5:51 PM, nurse's note (late charting) recorded the resident was sent to the emergency room due to no residual (remaining after the greater part or quantity has gone) and no active bowel sounds to verify tube feeding placement. During an assessment, the unidentified RN (Registered Nurse) noted dried blood underneath gauze covering tube insertion site. The resident complained of severe abdominal pain and staff notified the physician. The note recorded the physician ordered to transfer the resident to the emergency room . The 7/10/19 at 6:24 PM, nurse's note recorded staff transferred the resident to the emergency room per the resident and the resident's family member's request, to verify PEG tube placement. Staff notified the emergency room , and transferred the resident via the nursing facility bus. The 7/10/19 at 6:57 PM, hospital emergency room note recorded the resident was brought to the emergency room with complaints of left upper quadrant abdominal pain and a problem with his/her PEG tube. The note recorded the resident had a planned PEG tube placed a little over a week ago, arrived at the nursing facility the previous day and today had difficulty with a syringe port for PEG tube, so facility staff cut the tip off and put a new tip on. The note recorded since this happened, with any feeding or infusion the resident had severe pain in his/her left upper quadrant. Upon arrival to the emergency room , the resident did have a fever of 101.4 degrees F (Fahrenheit), pain rated at 8 (scale 0-10), had a slight cough, but no chest pain or shortness of breath. The 7/10/19 hospital history and physical recorded the resident had a PEG tube placed on 7/1/19 and was transferred to the nursing facility. The note recorded the facility had some difficulty with adapting their type of tube feeding equipment to the type of device the resident had, therefore, the facility had to cut the end off of his/her feeding tube and replaced it with a different device. The note recorded shortly thereafter, the resident began having significant abdominal pain as well as a fever, so he/she was transferred to the emergency room to assess the tube was still in place. The note recorded the tube was not in place, and a CT scan (CAT scan - special X-ray tests that produce cross-sectional images of the body using X-rays and a computer) revealed peritonitis (inflammation of the peritoneum, the lining of the inner wall of the abdomen and cover of the abdominal organs). The note recorded the resident admitted to the hospital, assessed by the surgical team and taken to the operating room with all appropriate haste where an exploratory laparotomy (a surgical operation where the abdomen is opened and the abdominal organs examined for injury or disease) with abdominal wash out (a complete sweep or clean of the stomach or colon) with [DEVICE] (a surgically placed feeding tube in the stomach) placement. The 7/10/19 surgical lab results documented: WBC (white blood cell) count 21,700 (normal 4,500-11,000), Hemoglobin 10.9 g/dl (grams/deciliter) (normal 12-16 g/dl), platelets 423,000 (normal 150,000-450,000 per microliter). The 7/10/19 surgical abdominal imaging documented extravasated (fluid, especially blood, let or forced out from the vessel that naturally contains it into the surrounding area) contrast and gas pockets throughout the abdomen with a displaced gastric tube. Nurse G's undated witness statement documented the resident arrived at the facility with his/[MEDICAL CONDITION] and dry, gauze dry around PEG tube, PEG tube with 3 access ports, ports need specific supplies for access. The note documented a piston syringe (a tube with a nozzle and piston or bulb for sucking in and ejecting liquid in a thin stream) was cut down to put onto port access to administer pain medication, 1 carton [MEDICATION NAME] 1.5 calorie (nutritional supplement of protein, fiber, key vitamins and minerals) with water flush administered 30 minutes after medications. DON in and out of resident room and assisted with admission, unknown if this nurse communicated the need to adapt syringe to attach to PEG port. Nurse H's 7/11/19 facility witness statement documented on 7/10/19 at approximately 9:00 AM, the floor nurse asked this nurse (Nurse H) to assist with the resident's PEG tube. Upon assessment of the tube, Nurse H noted that the tube was not a standard PEG tube that the facility used or had appropriate supplies. After attempting all available syringes, Nurse H asked the DON to assist. After speaking with the resident, he/she agreed to allow for PEG tube to be modified (distal external end of tube) at that time. The PEG tube was cut just below the port as the resident's ports were not removable. After being cut below the port, staff attached the facility port. After attaching the port, Nurse I checked for residual and slowly administered [MEDICATION NAME], while Nurse H held the distal external end of PEG tube to prevent leaking as a good seal was not made between the PEG and the port. After [MEDICATION NAME] administered, a tip from a sterile catheter was applied over the area of the port and PEG, and secured with tape. The note documented Nurse H left the room, after approximately 30-45 minutes Nurse H was asked to go back to the resident's room as the resident was reporting abdominal pain. Upon assessment, the resident was on the toilet, asked to be assisted back to bed and a fan was placed near him/her, and the resident stated his/her pain was starting to subside. Nurse I's 7/11/19 facility witness statement documented Nurse I took care of the resident on (MONTH) 10 from 6:00 AM to 2:00 PM. Nurse I documented the resident had a tube feeding and medication due via PEG tube at 8:00 AM, so Nurse I gathered supplies and medication from the emergency kit and entered the resident's room at approximately 8:30 AM to administer the items. Nurse I observed the resident's PEG tube had 3 ports, and the ports were too small for the facility's syringes. Nurse H and Administrative Nurse D were called into the resident's room by Nurse J. After deliberating among themselves, Administrative Nurse D cut 3 ports off and replaced with an end the facility had in supply. The port was large enough to administer medication and feedings. Bowel sounds were present before administering. The note documented the resident had not had a feeding since 8:30 PM on (MONTH) 8, so because of this and the fact that Nurse I visualized feeding in the tube, residuals were not checked. Feeding, medications, and water were given by slow push with no difficulty and with no complaints from the resident. The note documented at 10:30 AM, the resident complained of abdominal pain and feeling hot, this continued off and on through the shift as it eased up at times. On 7/17/19 at 3:13 PM, Administrative Nurse D stated the resident was admitted to the facility the evening of 7/9/19. Administrative Nurse D reviewed the PEG tube [MEDICAL CONDITION] with surgical hospital staff to make sure the nursing facility had appropriate knowledge and equipment to care for the resident. Administrative Nurse D stated his/her focus was on [MEDICAL CONDITION] to less experience for staff to provide cares. Surgical hospital staff interview or paperwork did not identify a special PEG tube. Administrative Nurse D stated the PEG tube port was not compatible with any equipment the facility had, the night shift nurses were able to adapt a syringe to administer medications, water and feedings twice during the night but this was not convenient or practical. Administrative Nurse D stated the next morning, the nurses called him/her to the resident's room to examine the PEG tube port, Administrative Nurse D made the decision to cut the port and attach one of the facility's ports to the PEG tube. Administrative Nurse D stated neither the surgical hospital nor the resident's physician were contacted prior to changing the port. On 7/17/19 at 4:18 PM, Consultant GG stated he/she visited the resident at the facility on 7/10/19, performed a brief assessment and assessed no acute abdominal pain or signs and symptoms of infection. Consultant GG stated staff informed him/her that morning about altering the PEG tube, with no mention of cutting off the port. Consultant GG stated he/she would never give an order to cut a PEG tube, when staff cut the tube it compromised the balloon and tube placement. Consultant GG stated the first time staff notified him/her of the resident's pain was when Consultant GG gave the order to send the resident to the emergency room . The facility's 11/30/14 Medication Administration via Enteral Tube policy documented when doing a tube feeding, to document on the Nurse's Notes any problems encountered and any measures taken. (i.e. physician notified, medication held, resident unable to tolerate, etc.) The facility's 11/30/14 Initiating Enteral Feeding policy documented the procedure to perform an enteral feeding: obtain physician order, identify resident and put on gloves, place resident in proper position. To confirm placement of tube in stomach: attach syringe to end of tube and place stethoscope over left quadrant of resident's abdomen. Instill 10 to 30 cc (cubic centimeters) of air into the tube and listen for swooshing sound in stomach and/or aspirate total stomach contents by attaching syringe to end of tube and gently pulling back on plunger. Initiate feeding as ordered by physician. Check for residual per physician order. Assess resident's tolerance to the feeding. Flush the tube per physician order. Document in the medical record. The facility failed to provide competent cares and services to implement the use of a feeding tube for Resident #2, when staff cut off the port end of the resident's feeding tube, which displaced the feeding tube, and caused feeding tube fluids to enter his/her abdominal cavities instead of the stomach. Resident #2 was transported to the hospital with severe abdominal pain, and required emergency surgery for [REDACTED].#2 in immediate jeopardy for pain and worsening infection. The facility implemented in-service education, competency testing for all nurses regarding checking for [DEVICE] placement, ensuring proper supplies are available to care for the resident, notifying the physician prior to any changes, ensuring all admission paperwork with care assessments is on hand prior to admission, on 7/11/19, and audits 7/11/19-7/17/19. This deficient practice was identified as past non-compliance and was corrected on 7/11/19.

The facility had a census of 66 residents. The sample included 22 residents. Based on observation, record review and interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 22 sampled residents reviewed for fecal impaction. Resident #2 went 6 days without a bowel movement, and no interventions, resulting in a fecal impaction (hardened stool that is stuck in the rectum or lower colon due to constipation) which required emergency room care and disimpaction (manual removal of impacted fecal matter from the rectum). Findings included: - Resident #2's (POS) Physician order [REDACTED]. The 11/6/15 quarterly (MDS) Minimum Data Set assessment, dated 11/6/15, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 7 which indicated severely impaired cognition. The assessment revealed the resident required extensive assistance of 2 staff members for transfers, bed mobility, and was totally dependent upon staff for toileting. The assessment further revealed the resident was occasionally incontinent of bowel. The 8/14/15 care plan indicated the resident required assistance with toileting and to follow the bowel protocol as ordered. The care plan further directed staff to monitor for potential side effects of constipation related to the use of Trazadone, (an antidepressant) [MEDICATION NAME], (a high blood pressure medication) [MEDICATION NAME], ([MEDICAL CONDITION] medication) [MEDICATION NAME], (a antipsychotic medication), and [MEDICATION NAME], (a pain medication). The 8/7/15 physician's orders [REDACTED]. The order directed staff to administer (MOM) Milk of Magnesium (a laxative for constipation) 30 (ml) milliliters, by mouth, if no (BM) bowel movement in 3 days. The order further directed the staff to administer a [MEDICATION NAME] suppository (a laxative for constipation inserted in the rectum) if no BM after 8 hours and a Fleets enema (a liquid process inserted into the rectum to help push waste out of the rectum) if still no BM 8 hours after staff administered the suppository. The November 2015 Bowel and Bladder Report revealed no documentation the resident had a BM from 11/15 to 11/20/15 (6 consecutive days). The 11/1/15 physician's orders [REDACTED]. Review of the MAR (Medication Administration Record) for November 2015 revealed the staff had administered MOM to the resident on 11/8 and 11/12 for lack of a BM after 3 days but had not provided interventions for the resident's lack of bowel elimination from 11/15 thru 11/20 until 11/20/15 at 7:00 AM. (day 6 of no bowel movement) The 11/20/15 (untimed), nurse's note indicated the resident complained of an upset stomach and had a temperature of 99.7 degrees after an episode of vomiting. The note further indicated the facility contacted the physician who ordered [MEDICATION NAME], (an antacid) 30 ml, every 6 hours, as needed. The November 2015 MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. The 11/20/15 at 9:30 AM, nurse's note indicated the resident had vomiting twice, and refused his/her medication. The note further indicated at 11:45 AM, the physician directed the staff to send the resident to the ER (emergency room ). The 11/20/15 hospital History and Physical indicated the resident was seen in the ER with complaints of abdominal bloating and coffee ground emesis and had a fecal impaction. The History and Physical stated hospital staff disimpacted (removed the BM) the resident and sent him/her back to the facility. The 11/20/15 Diagnostic X-Ray report impression stated the resident had a mild residual ileus ( blockage of the intestines caused by a lack of peristalsis) is suggested. The report stated there was no evidence for bowel obstruction (a partial or complete blockage in intestines that prevents gas, fluids, solids from moving through normally). On 2/16/16 at 3:15 PM, observation revealed the resident, seated in his/her wheelchair, in the East hallway. On 2/18/16 at 4:15 PM, Nurse A stated the night shift printed the bowel report and if a resident did not have a BM within 3 days, the nurse administered Milk of Magnesium. Nurse A further stated, if the resident did not have a BM after 8 hours, the nurse administered a suppository. If the resident still did not have a BM after 8 hours, the staff administer a fleets enema to the resident. Nurse A verified the resident did not have a BM from 11/15/15- 11/20/15. On 2/18/16 at 4:23 PM, Administrative Nurse H verified the resident did not have a bowel movement during the identified time frame and staff did not implement any interventions for the resident's lack of bowel movements, as directed in the facility's bowel protocol. On 2/23/16 at 12:05 PM, Physician's Nurse R stated the physician would expect the facility to follow the bowel protocol as ordered, and monitor and assess the resident after not having a BM for 6 consecutive days. The undated facility Bowel Protocol directed staff to administer 30 ml of Milk of Magnesium by mouth if the resident does not have a bowel movement in 3 days, if no bowel movement in 8 hours give 10 (mg) milligram [MEDICATION NAME] suppository rectally, if no bowel movement in 8 hours give a fleets enema rectally for constipation as needed. The facility failed to adequately monitor the bowel status, complete an appropriate physical assessment, including bowel sounds, and follow the physician's orders [REDACTED].#2 who had an ileus and required care in the emergency room for disimpaction.

The facility had a census of 71 residents. The sample included 8 residents. Based on record review and interview the facility failed to adequately follow the physician's order [REDACTED]. Physician admission orders [REDACTED]. Findings included: - Review of the 10/08/2013 physician signed " Transfer Form " for Resident #1, stated the resident had the order for nothing by mouth (NPO), had a feeding tube in his/her stomach and staff should provide [MEDICATION NAME] (a nutritional supplement that has high protein, fiber content and calories) through the feeding tube. The physician's order [REDACTED]. No (MDS) Minimum Data Set 3.0 assessment had been completed due to the resident ' s recent admission. The 10/08/2013 initial care plan informed staff the resident should not receive anything to eat or drink orally and the resident had a " feeding tube " . The care plan further instructed the staff to observe the resident's feeding tube site for signs and symptoms of infection or irritation, elevate the head of the bed 30 degrees, and monitor his/her intake and output every shift. Further care plan review revealed the staff would provide the resident with oral hygiene frequently, before and after feedings. Review of the 10/08/2013 physician's order [REDACTED]. Continued review revealed the physician's order [REDACTED]. Review of the 10/08/2013 Admission/Readmission Data Collection indicated the resident had dysphagia (difficulty swallowing, or the feeling that food is " sticking" in your throat or chest) had limited fluid intake and dependent on staff for provision of fluid intake. The data collection form under the nutritional approach indicated the resident had a feeding tube. Continued review revealed the resident had moderately impaired cognition, and had left sided paralysis. The preliminary restorative screen, dated 10/08/2013, revealed the staff had documented from the " Dining screen " - the resident had chewing and swallowing problems, has a significant unplanned weight loss, and was to receive nothing to eat or drink by mouth. The 10/09/2013 at 7:30 PM, nurse ' s notes indicated the staff provided the resident a regular diet consisting of a patty melt sandwich, french fries, and stewed tomatoes with water at 6:15 PM. The nurse ' s notes also indicated the staff cued the resident to chew and swallow several times. The 10/09/2013 (untimed) nurse ' s notes indicated the family voiced concern for possible aspiration (inhaling small particles of food or drops of liquid into the lungs) after the facility provided the resident a regular diet at supper. The physician acknowledged the family ' s wish to transfer the resident to the emergency room for evaluation and gave an order to do so at 9:30 PM. (EMS) emergency medical service transported the resident to the hospital emergency room at 9:45 PM. The 10/09/2013 hospital visit discharge information verified the hospital evaluated the resident for " possible aspiration " . Continued review of the hospital discharge instructions for aspiration pneumonia, revealed directions to the staff to not provide any food or liquid by mouth to the resident. On 10/15/2013 at 5:17 PM, Nurse Assistant C verified the facility protocol to inform staff of a residents dietary status was from the nurse shift report and the kardex that would document new orders and daily changes in the resident ' s care. On 10/15/2013 at 2:25 PM, Nurse B verified the physician's orders [REDACTED]. Nurse B verified on 10/09/2013, at 6:15 PM a nurse aide transported the resident to the dining room table by a wheelchair. Nurse B recalled one of the staff (name unknown) then went to the kitchen window and obtained a regular diet tray and placed it in front of the resident to eat. Nurse B verified he/she, while seated at the dining room table assisting other residents, had also cued Resident #1 to slow down and swallow his/her meal since he/she had been eating the food too fast. On 10/15/2013 at 2:50PM, Administrative Nurse A verified the physician's order [REDACTED]. Nurse A verified the physician's order [REDACTED]. Nurse A verified the staff had provided the resident a regular meal on 10/09/2013. On 10/15/2013 at 11:05 AM, Administrative Staff D verified on 10/09/2013 the dietary staff served the resident a regular meal tray without a " meal ticket " which the facility uses to ensure the residents received the appropriate physician ordered diet. Administrative Staff D stated the certified dietary manager inputs the physician diet order in the computer and the staff are then able to print the resident meal ticket with the diet order printed on it. On 10/16/2013 at 11:35 AM, Dietary Staff O verified the facility protocol for corresponding diet orders are as follows: the physician writes the diet order, the charge nurse makes a dietary order sheet out and sends a copy of the sheet to the kitchen. Then, Dietary Staff O inputs the information in the computer and that allows the staff to print out a resident's meal ticket with diet order, calories and/or restrictions. On 10/16/2013 at 12:45 PM Registered Dietician E indicated he/she arrived at the facility at 8:30 AM on 10/09/2013 to review new residents' charts for nutritional intake and recommendations. Registered Dietician E verified he/she did not assess Resident #1 because the resident ' s chart was unavailable and he/she would return to the facility in 1 week to do the assessment. Registered Dietician E verified the next time he/she would be at the facility would be on 10/18/2013 (10 days) after the resident ' s admission to the facility. On 10/21/2013 at 8:45 AM, Physician F verified he/she expected the facility to follow the orders provided when the resident entered the facility. The facility's policy " nothing by mouth orders for residents ", dated 9/01/2011, instructed the staff to notify the dietary department regarding which residents are NPO and to monitor them for nutritional needs. Procedure: 1) Nursing would notify dietary, through the Communication Form, of residents who are NPO 2) Dietary will hold trays/snacks/nourishments until further written notice from the nursing department. 3) The Nurse Manager or designee shall keep record of those residents receiving clear liquids or NPO. The Dietician/Director of Dining Services will be notified. 4) The Director of Dining Services/Dietician/Diet Technician will investigate the reason for the diet order and document in the medical record and will assess the continued need. The facility failed to implement and monitor Resident #1 for the physician ordered nutritional/dietary intake restriction of nothing by mouth. This failure placed the resident in immediate jeopardy for serious harm or death to occur when the staff served the resident a regular diet of a patty melt sandwich, french fries, stewed tomatoes and water to drink. The Immediate Jeopardy was abated on October 17, 2013, when the facility implemented an Admission Process, and inserviced their licensed staff on the proper completion of the Data Collection Form, which was designed to provide a comprehensive overview of the resident ' s clinical presentation at the time of admission, including evaluation of the resident ' s physical status and completion of an interim care plan vital information which must be communicated to individuals rendering care and services to the newly admitted resident, such as the Dietary Communication Form sent to the Dietary Department. The facility inserviced the direct care staff on October 16, 2013 regarding assisting the nurse as requested to perform the comprehensive evaluation of the resident upon admission, reading the Resident Kardex and following recommendations, and to elicit and further information from the nursing staff to meet the needs of the residents. The deficient practice remains at a scope and severity of a D.

The facility identified a census of 62 residents. The sample included 36 residents. Based on observation, record review and interview, the facility failed to develop and implement effective interventions to prevent the development of pressure ulcers for 4 of 4 residents sampled for pressure ulcers. (#18, #14, #35, #57) Findings included: - Resident #18's [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) 3.0 assessment, dated 8-16-12, recorded the resident's Brief Interview for Mental Status score (BIMS) of 11 (moderately impaired cognition). The resident required extensive staff assistance with bed mobility and transfers, had limitation in range of motion of the lower extremity on one side, was occasionally incontinent of urine and frequently incontinent of bowel. The resident was at risk for development of pressure ulcers, and had no stage 1 or higher pressure ulcers. The MDS recorded the resident had a pressure reducing device for chair and bed, was on a turning/repositioning plan and nutrition/hydration plan. Rejection of care was not exhibited. The Care Area Trigger (CAT), dated 8-31-12, recorded Activities of Daily Living (ADLs) triggered due to the resident required extensive assist, had impaired balance and a low level of motivation. The resident needed much encouragement and cueing to complete ADLs and participate in therapy. The resident also complained of pain in his/her hip that would not allow him/her to get out of bed. The CAT recorded pressure ulcers triggered related to a decrease in mobility due to a [MEDICAL CONDITION], incontinence of bowel and bladder, and a surgical wound to the resident's hip. An initial care plan was unavailable for this resident in the clinical record. The comprehensive care plan, dated 8-29-12, directed the staff to monitor the resident's skin with all incontinent care for signs or symptoms of excoriation or rash, to check for incontinent episodes and assist as necessary, the resident required staff assistance for all ADLs and to encourage him/her for positioning to not place additional pressure on his/her hip incision. On 9-6-12, staff added the resident had an open area to his/her buttocks and to not place additional pressure on his/her wound. The care plan lacked interventions for staff to turn or reposition this resident who required extensive assist with bed mobility and was at risk for pressure ulcers. The initial nutrition assessment, dated 8-9-12, recorded the resident had a pressure ulcer to his/her buttocks and abdominal fold. The Admission data collection form, dated 8-9-12, recorded the resident required 2 person assistance with transfers and ambulation, the resident had a left hip incision with 27 staples and no other skin alterations. Skin treatments included turning/repositioning and the resident's Braden assessment score revealed the resident was at risk for pressure ulcers. Nurse's notes, dated 8-9-12 at 10:00 PM, recorded the resident required maximum assistance of 2 staff with bed mobility. Nurse's notes, dated 8-11-12 for the 6 AM-2 PM shift recorded the resident required two person assistance. Nurse's notes, dated 8-15-12 for the 2:00 PM-10:00 PM shift, recorded the resident had areas on the buttocks that were open and staff applied zinc oxide to the area. The nurse's note lacked documentation that staff notified the physician or obtained an order for [REDACTED]. The pressure ulcer record revealed staff first observed the resident's right and left buttocks stage two pressure ulcers on 8-15-12. Nurse's notes, dated 8-24-12 for the 2:00 PM-10:00 PM shift, recorded the resident was up with assistance of two staff. Nurse's Notes, dated 8-28-12 for the 6:00 AM-2:00 PM shift, recorded the resident transferred with assistance of 2 staff. Nurse's Notes, dated 8-31-12 for the 6:00 AM-2:00 PM shift recorded the resident transferred with assistance of 2 staff. The clinical record included a physician's orders [REDACTED]. Nurse's Notes, dated 9-7-12 at 3:20 PM, recorded new orders for a multivitamin daily, [MEDICATION NAME] twice a day and Vitamin-C 500 mg daily due to pressure ulcers on the resident's right and left buttocks. Per the Treatment Administration Record (TAR) for 9-1-12, with documentation starting on 9-3-12, an order for [REDACTED]. Observations were unavailable as the resident was discharged from the facility. During an interview on 1-17-13 at 3:47 PM, direct care Staff Y stated the resident needed assistance with transferring, and he/she pretty much slept on his/her back. The resident was not able to reposition him/herself. The resident did not have any skin breakdown that he/she saw but the resident did say his/her bottom was sore. During an interview on 1-17-13 at 5:02 PM, Administrative Nursing Staff A stated the resident had a red perineal area and bottom on admission. Administrative Nursing Staff A confirmed the resident did not have an initial care plan in the clinical record, did not have a turning or repositioning plan on the comprehensive care plan and the resident had two stage 2 pressure ulcers identified on 8-15-12. Administrative nursing staff A confirmed that the clinical record lacked evidence staff notified the physician of the development of the resident's pressure ulcers or obtained orders for treatment of [REDACTED]. Administrative Nursing Staff A stated they had a weekly wound meeting where staff discussed the resident's with pressure ulcers. Administrative nursing staff A continued that the staff updated the care plan on 9-6-12 to include the pressure ulcers on the resident's buttocks. The physician ordered the vitamin supplements on 9-7-12, approximately 3 weeks after the resident developed the pressure ulcers. The TAR revealed the barrier cream started on 9-3-12. The facility provided policy entitled Wound Care Prevention & Treatment Objectives, dated 3/2012, instructed staff to implement appropriate treatment and weekly interdisciplinary meetings to evaluate treatment progress, identification and delivery of services to meet the resident's physical needs. Every treatment will be individualized to each resident's need and specific physician's orders [REDACTED]. The facility-provided policy entitled Introduction to Pressure Sore Protocols, dated 3/2012 instructed staff: early intervention is designed for residents at increased risk for pressure ulcer development. The principal components of early intervention are: identification of at-risk individuals who need preventative intervention and or the specific factors that make the person at risk; protection from adverse effects of friction, shearing, pressure and moisture. The facility policy entitled Positioning, dated 3/2012, recorded some residents were unable to properly position themselves in bed and/or chairs. It is extremely important that residents' positions be changed at least every 2 hours to assist in preventing skin breakdown. The facility policy entitled Care Plan, dated 3/2012, recorded an interim plan of care must be developed within 24 hours of admission to insure that the resident's needs are met appropriately until the comprehensive care plan is completed. An interdisciplinary plan of care will be established for every resident and updated in accordance with state and federal regulatory requirements. The facility failed to implement appropriate interventions to prevent the development of pressure ulcers and failed to obtain a treatment order for the pressure ulcers in a timely manner to promote healing for Resident #18. - Resident #14's admission Minimum Data Set (MDS) 3.0 assessment, dated 10-10-12, recorded the resident with a Brief Interview for Mental Status (BIMS) score of 14 (cognitively intact). The resident rejected care daily. The resident required extensive staff assistance with bed mobility and transfers. The resident used a walker and wheelchair for mobility. The resident was always continent of bowel and occasionally incontinent of urine. The resident was at risk for developing a pressure ulcer, had a pressure reducing device for the chair and bed, and was on a turning/repositioning program. The resident had no stage one or higher pressure ulcer. The Care Area Trigger (CAT), dated 10-14-12, for Activities of Daily Living (ADL) functional/rehabilitation potential recorded the resident required extensive staff assistance. The CAT for pressure ulcers, dated 10-14-12, recorded pressure ulcers triggered because the resident required extensive assistance. The care plan, dated 10-14-12, recorded the resident with actual skin breakdown and with [MEDICAL CONDITION] and the facility would provide pressure relieving mattress/chair/cushion, skin assessment weekly, treatments and supplements per order, turn and reposition as clinically indicated, peri care after each incontinent episode. The care plan lacked a revision to include the development or treatment of [REDACTED]. The Patient Transfer from a local hospital recorded the resident transferred to the facility on [DATE] at 4:22 PM. The resident was without pressure ulcers at that time. The weekly skin assessment recorded staff first observed the resident's stage 2 pressure ulcer on his/her coccyx on 10-27-12. The clinical record lacked evidence the facility notified the physician of the resident's pressure ulcer development or obtained an order to treat the pressure ulcer. The Braden score on 10-3-12, 10-10-12, 10-17-12 and 10-24-12 recorded scores of 14, which indicated the resident was at moderate risk for pressure ulcer development Observations were unavailable as the resident was discharged from the facility. During an interview on 1-17-13 at 11:34 A.M. direct care staff HH stated the resident was pretty much self sufficient. During an interview on 1-17-13 at 1:18 P.M., licensed nursing staff T stated the resident required 2 person assist with bed mobility During an interview on 1-17-13 at 2:29 P.M., licensed nursing staff V stated with the open area on the resident's coccyx was very superficial and he/she confirmed the clinical record lacked evidence that staff notified the physician of the pressure ulcer or obtained an order for [REDACTED]. The facility provided policy entitled Wound Care Prevention & Treatment Objectives dated 3/2012 instructed staff to implement appropriate treatment and weekly interdisciplinary meetings to evaluate treatment progress, identification an delivery of services to meet the resident's physical needs. Every treatment will be individualized to each resident's need and specific physician's orders [REDACTED]. The facility-provided policy entitled Introduction to Pressure Sore Protocols dated 3/2012 instructed staff: early intervention is designed for residents at increased risk for pressure ulcer development. The principal components of early intervention are: identification of at-risk individuals who needed preventative intervention and or the specific factors that make the person at risk; protection from adverse effects of friction, shearing, pressure and moisture. The facility failed to notify the physician to obtain a treatment order to promote healing, for Resident #14, who developed a pressure ulcer in the facility. - Resident #35's medical record face sheet, documented admission to the facility on [DATE], with [DIAGNOSES REDACTED].), hypopotassium (low potassium level), and dementia (A progressive mental disorder characterized by failing memory, confusion.). The 5/29/12 and 10/12/12, quarterly MDS (minimum data set) 3.0 assessment, documented, cognitive impairment with severe impaired decision making ability. The resident required total assistance of 2 staff for bed mobility, transfers, toileting, dressing, and hygiene, did not walk, required total assistance of 1 staff for locomotion. The resident experience limited range of motion ability in bilateral upper and lower extremities, with frequent incontinence of bladder without a toileting plan, at risk for pressure ulcers, without any current pressure ulcers, and utilized a feeding tube for all nutrition/hydration needs. The current undated care plan, included, "Reposition every 2-3 hours. Pressure reducing mattress/cushion. Monitor skin with all incontinent care for signs or symptoms of excoriation or rash." The quarterly collection data tool, dated 10/12/12, identified a moderate risk for skin breakdown, with documentation of a score of 14 for the "Risk for pressure ulcers" assessment section. A score of 13-14 indicated the resident at moderate risk for skin breakdown. On 1/14/13 at 3:00 PM, the resident rested quietly on the bed with (a family member) sitting quietly in the bedside chair visiting. The family member reported visiting frequently at various hours of the days. The only concern the family member voiced included when they visited the resident, the staff did not come into the room to do cares for the resident unless the family member asked the staff to do something for the resident. On 1/15/13 at 2:00 PM, the resident sat at the bedside in a broda chair with elevated footrests and bilateral foot protectors on. The resident was quiet and calm but held his/her hands/arms tight. On 1/15/13, observations of the resident at 2:45 PM, 3:00 PM, 3:30 PM, 3:50 PM, and 4:30 PM, revealed the resident remained up at the bedside in the broda chair without any change in positioning. On 1/15/13 at 4:30 PM, direct care Staff Z and NN reported no cares provided to the resident since they came to work at 2:00 PM, but explained they would be assisting the resident to the bed soon as it had been 2 hours now and they were told at 2:00 PM, the staff had just assisted the resident from the bed. Both direct care staff verified they repositioned residents that can't reposition themselves every 2 hours. On 1/15/13 at 4:35 PM, direct care Staff NN entered the resident's room and removed the resident's shirt and put on a nightgown. Staff NN removed the protective foot boots. Staff NN reported, "We usually take (the resident's) shirt off and put on a gown before we put (the resident) to bed because it is really hard to get (the resident's ) shirt off when in the bed. At 4:42 PM, direct care Staff K entered the resident's room to assist. At this time, the staff placed a gait belt on the resident and totally lifted the resident onto the bed. During the transfer, observation revealed the entire seat of the resident's pants wet with urine, up to the top and down both thighs. Direct care staff NN reported the lower back of the resident's shirt was also wet when it was removed. The resident's entire incontinent brief contained soaked urine, both back and front sides. The staff failed to provide assistance to reposition the resident from 2:00 PM until 4:42 PM, for at least 2 hours and 42 minutes. On 1/16/13 at 7:20 AM, 7:55 AM, 8:15 AM, and at 9:15 AM, the resident sat up in the bedside recliner with feet up and bilateral foot boot type protectors on and a pillow under the right arm. The resident remained without a change of position during this time. On 1/16/13 at 9:50 AM, direct care Staff R and DD entered the resident's room to provide cares. The staff lifted the resident onto the bed to provide incontinent brief change with perineal hygiene. Following the hygiene and a new incontinent brief applied the staff assisted the resident to sit into the broda chair and assisted the resident towards the therapy/activity area. The direct care staff explained they reposition the resident every 2 hours. However, the resident remained in the bedside recliner without a change in position for at least 2 hours and 30 minutes. On 1/16/13, frequent observations from 9:50 AM through 1:30 PM, revealed the resident remained in the broda chair, sitting on the side of the large therapy/activity area without a change in position. On 1/16/13 at 2:05 PM, Licensed Nurse T stood in the resident's room with the resident now lying on their back in the bed. Nurse T explained, "The staff just put the resident onto the bed approximately 20 minutes ago, at 1:45 PM." The resident remained without a position change for at least 3 hours and 55 minutes while sitting up in the broda chair, before staff assisted the resident into the bed. The head of the resident's bed elevated at this time and the resident moved the head back and forth across the pillow. Nurse T explained currently assessing the resident's scratch/bruise area to the right forearm and felt the resident used the left hand, which frequently moves back and forth to scratch across the right forearm which usually doesn't move very much, to cause the skin area. Nurse T explained the staff should reposition the residents that can't reposition themselves every 2 hours. On 1/16/13, at 3:00 PM, 3:35 PM, 4:30 PM, and at 5:30 PM, the resident remained lying on his/her back in the bed without change in position. At 5:30 PM, direct care Staff Z, M, and OO, responsible for the resident, questioned of any cares provided to the resident since they came to work at 2:00 PM. Direct care Staff Z, M, and OO reported no cares provided by them to the resident. Direct care staff OO reported the resident at 2:00 PM, used a large pillow beside the resident and it was time to take the pillow out of the bed. Staff OO at this time, entered the resident's room to find the resident's large pillow lying in the bedside recliner and not in the resident's bed. Staff OO explained it was time to reposition the resident but failed to do so, and went back to the hallway to serve hallway meal trays. On 1/16/13 at 6:05 PM, Licensed Nurse AA was requested to find staff to provide a skin check of the resident, who went without a change in position for an extended period of time. At 6:25 PM, Licensed Nurse V, and direct care Staff OO and M entered the resident's room to provide cares. The direct care staff removed a urine soaked incontinent brief and provided perineal hygiene and repositioned the resident. The resident remained without assistance to reposition on the bed from 1:45 PM until 6:25 PM, for 4 hours and 20 minutes. On 1/17/13 at 7:05 AM, Licensed Nurse T verified the afternoon prior on 1/16/13 at 2:05 PM, the nurse was in the resident's room and assessed the resident's scratch/bruise to the right forearm, at that time, the resident rested on his/her back without any pillows for repositioning in the bed with the resident. Nurse T further verified he/she did not provide any assistance to reposition the resident during that assessment of the resident's arm. On 1/17/13 at 9:15 AM, Licensed Nurse A, reported the facility policy for repositioning of residents that can't reposition themselves is every 2 hours unless it is a hospice resident actively dying and then the staff don't always reposition the resident every 2 hours. The facility policy and procedure, dated 03/12, for "Positioning" documented, "... Some residents are unable to properly position themselves in bed and/or chairs. It is extremely important that residents' positions be changed at least every 2 hours to assist in preventing skin breakdown and contractures as well as promoting comfort and safety..." The facility failed to provide timely repositioning of dependent Resident #35, who was at risk for skin breakdown. - Resident # 57's 11/27/12 quarterly MDS (minimum data set) 3.0 assessment revealed the resident had modified independence in daily decision making and total dependence on 2 persons for bed mobility and transfers. The resident had functional limitations in range of motion in both upper and lower extremities and used a wheelchair for mobility. The assessment identified the resident as "at risk" for pressure ulcer development and had one stage 3 pressure ulcer and two stage 4 pressure ulcers. Skin and pressure ulcer treatments included pressure reducing devices for the chair/bed, turning/repositioning program, nutritional interventions, ulcer care, application of nonsurgical dressings, application of ointments/medications other than to feet, and application of dressing to feet. Resident #57's 9/4/12 CAT (care area trigger) worksheet for pressure ulcers indicated the resident had stage 4 pressure ulcers on admission to the facility and a [DIAGNOSES REDACTED]. The worksheet stated staff provided dressing changes as ordered with wound measurements weekly. Resident #57's 9/4/12 pressure ulcer care plan directed staff to reposition the resident every 2 hours, wound care per orders, wound measurement weekly, monitor for changes in skin status that may indicate worsening of pressure ulcers and notify physician. The care plan also included the use of a specialty air mattress, pressure reducing cushion in the wheelchair, nutritional supplements to assist with wound healing, pressure boots on at all times except during baths and pillows to keep heels from body. Resident #57's 11/27/12 pressure ulcer risk form had a score of 10 which indicated "high risk" for pressure ulcer development. A nutrition review, dated 11/28/12, indicated the resident received nutrition supplements which included med pass (high protein, high calorie nutritional supplement) twice a day, prostat (high protein nutritional supplement) twice a day, and [MEDICATION NAME] (nutritional supplement to promote wound healing) twice a day. A 12/29/12 physician's orders [REDACTED]. The order sheet also included the following orders for wound care: * [MEDICATION NAME] plus 4x4 dressing, apply to left heel after cleansing with normal saline and applying pixie dust. Cover with foam and secure to left ankle and change 3 times weekly on Tuesday, Friday, and Sunday. * Cleanse sacral wound/ischium (tailbone and hips areas) wounds, pat dry and apply sure prep to edges. Apply [MEDICATION NAME] to fluffed gauze and insert into wound bed and apply flat 4x4 and secure with [MEDICATION NAME] tape. Change every day and as needed. Review of weekly wound measurements revealed the pressure ulcer to the left heel had improved from 3 cm (centimeters) by 3 cm with a depth of less than 0.1cm on 11/12/12, to measurements of 2 cm by 2.5 cm with a depth of less than 0.1 cm on 1/16/13. Measurements of the right ischium wound on 9/24/12 of 5 cm x 3.5 cm with depth of 2.5 cm and tunneling of 3.5 cm improved to 1.8 cm x 2.5 cm with a depth of 2.5 cm with tunneling of 2.5 cm on 1/9/13. Measurements of the coccyx wound on 9/4/12 of 4 cm x 3 cm with a depth of 2.5 cm and tunneling of 2.8 cm improved to 1 cm x 1.2 cm with a depth of 1.5 cm with tunneling of 1.5 cm. Throughout the days of the survey on 1/14/13, 1/15/13, 1/16/13 and 1/17/13, Resident #57's bed had a "DermaFloat" advanced alternating pressure mattress in place. According to the manufacturer's description the mattress provided pressure redistribution for treatment and prevention of pressure ulcers up to Stage 4. During an observation on 1/15/13 at 2:39 PM, Licensed Nurse L assembled dressing supplies on resident #57's bedside table. Licensed Nurse L cleansed the left heel wound with skin integrity wound cleanser and skin prep. Licensed Nurse L then used scissors from his/her scrub top pocket to cut the dressings for the heel. After cutting the dressing materials he/she placed the scissors back in his/her pocket. He/she then applied the "pixie dust" as ordered. While wearing gloves, Licensed Nurse L tore a piece of purocol material and placed it on the wound bed and covered the area with hydrofoam and profix. Licensed Nurse L then retrieved the scissors from his/her pocket and cut the dressing supplies for the wound on the ischium and coccyx, then placed the scissors back in his/her pocket. After exposing the wound with the assistance of direct care Staff Z, Licensed Nurse L cleansed the wounds as ordered, then applied the fluffed/[MEDICATION NAME] gauze into the wound and covered the wound with a dressing and [MEDICATION NAME] tape. Licensed Nurse L dressed the coccyx wound in the same manner, as ordered by the physician. During observations on 1/16/13 at 7:15 AM, at 8:46 AM, 8:56 AM, 9:01 AM, 10:21 AM, and at 12:00 PM, Resident #57 remained in bed in the same position (a period of 4 hours and 45 minutes) without the benefit of a position change. The resident had rolled towels in place between the upper arms and forearms. During observations throughout the days on 1/15/13, 1/16/13, and 1/17/13, Resident #57 did not have pressure boots in place. On 1/17/13 at 4:05 PM, direct care Staff Z looked in the resident's room for the pressure boots and could not find them. Direct care Staff Z stated the resident needed new boots because the old ones were soiled with drainage from the heel wound. He/she did not know how long the resident did not have the boots available. During an interview on 1/15/13 at 3:00 PM, Licensed Nurse L stated that he/she had a habit of placing the scissors in his/her pocket and had not thought about the pocket not being a clean area. Licensed Nurse L stated he/she also kept pens and other items in the same pocket. Licensed Nurse L stated he/she usually cleaned the scissors after the dressing change, then placed them back in his/her pocket. On 1/17/13 at 1:31 PM, direct care Staff W stated they should reposition Resident #57 every 2 hours. He/she stated the resident had heel protectors but did not like to wear them. During an interview on 1/16/13 at 3:47 PM, direct care Staff M stated they should reposition Resident #57 every 2 - 3 hours and it may be 3 hours if staff cannot get to him/her. During an interview on 1/17/13 at 9:13 AM, Administrative Nurse A confirmed a resident who cannot reposition themselves should be repositioned every two hours. He/she had no awareness that resident #57 did not have pressure boots available for use as ordered by the physician. Administrative Nurse A further added that scissors used for dressing changes should be cleaned before and after the treatment and should not be taken in and out of the nurse's pocket while changing the dressing. The facility failed to ensure that Resident #57 received necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing when staff failed to reposition the resident in a timely manner, failed to provide pressure reducing boots as ordered by the physician, and failed to provide a dressing change in a manner to prevent infection.

The facility had a census of 60 residents. The sample included 13 residents of which 4 were reviewed for pressure ulcers. Based on observation, record review and interview, the facility failed to develop and implement effective interventions to promote healing and prevent the development of pressure ulcers for 1 of 4 residents sampled for pressure ulcers. (#105) Findings included: - Resident # 105's significant change (MDS) Minimum Data Set 3.0 assessment, dated 3/5/13, indicated the resident ' s (BIMS) Brief Interview for Mental Status score was 13 (cognitively intact). The MDS also indicated the resident required extensive assistance from the staff for all (ADLs) Activities of Daily Living, except for supervision with eating. The MDS further indicated the resident was at risk for pressure ulcers, and currently had 1 unstaged pressure ulcer and 1 venous or arterial ulcer. The MDS indicated the resident had a pressure reducing device for his/her chair and bed, received pressure ulcer care, application of dressings, and application of ointments and/or medications. The (CAT) Care Area Trigger, dated 3/5/13, indicated the resident was admitted to the facility with an unstageable pressure ulcer on his/her coccyx, and the resident was at risk for further decline in skin integrity related to decreased mobility and incontinence. The 2/28/13 care plan directed the staff to follow the facility skin care protocol, turn and reposition the resident every 2 hours and as needed, report any redness or skin breakdown to the charge nurse, treatment per physician's order [REDACTED]. The 1/28/2013 lab report indicated the resident had an [MEDICATION NAME] level of 3.5 ( normal range 3.5-4.8). The transfer sheet from a local hospital, dated 2/26/13, stated the resident had a [MEDICATION NAME](a treatment dressing for pressure ulcers) in place on an open wound on his/her coccyx. The pressure ulcer record and measurement sheet, dated 2/26/13, indicated the resident's pressure ulcer was first observed on 2/26/13. The unstageable wound measured 1.5 (cm) cubic centimeters by 0.5 cm with a depth of 0.01 cm, no drainage, no tunneling and pink tissue present. The record indicated the initial treatment was a [MEDICATION NAME] dressing which was to be changed every 3 days. There was no documentation of the wound containing slough. The Minimum Data Set Assessment definition of slough is a yellow or white tissue that adheres to the ulcer bed in strings or thick clumps or is mucinous. The 2/26/13 at 4:30 PM, nurse ' s notes indicated the facility admitted the resident and a skin assessment indicated there was an open area on his/her coccyx covered with [MEDICATION NAME]. The 2/26/13 Braden Scale (used for determining pressure ulcer risk) score indicated the resident had a score of 20, which indicated he/she was not at risk for developing a pressure ulcer. The 3/1/13 physician's order [REDACTED]. The initial nutrition assessment, dated 3/1/13, indicated the resident had a pressure ulcer on his/her coccyx, and recommended the resident have [MEDICATION NAME] ( vitamin B complex medication) daily, Prostat (a protein supplement), 30 cc, twice a day, and Vitamin C daily. There was no documentation in the clinical record that indicated the physician had been contacted regarding the dietician ' s recommendations. The pressure ulcer record and measurement sheet, dated 3/1/13, indicated the wound was unstageable and measured 3.9 cm by 1.9 cm with yellow slough and the slough in the wound bed area was superficial but large. The record indicated the wound had increased in size since 2/26/13, and now contained yellow slough. The Minimum Data Set 3.0 Assessment definition of slough is a yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous. Review of the medical record revealed no further interventions or physician contact was made through 3/7/13, although the wound had increased in size .Further review of the medical record revealed the 3/1/13 dietician recommendations were not implemented through 3/13/13. The pressure ulcer record and measurement sheet, dated 3/9/13, indicated the wound was unstageble and measured 3.9 cm by 1.9 cm, and indicated the wound bed was yellow and contained yellowish slough. The record also indicated the facility had received an order for [REDACTED]. The 3/10/13 at 7:10 AM nurse ' s notes indicated the resident had an open area on his/her coccyx and right buttock, a Stage 2,and [MEDICATION NAME] was applied. The notes further indicated the wound on the resident ' s coccyx extended onto the right buttock, and the area was unstageable due to slough present on the wound bed. The note indicated the presence of pink areas in the wound bed with areas of redness around the wound, and a moderate amount of yellow drainage was present on the incontinent pad. The area was cleaned and dressed with [MEDICATION NAME] per the physician's order [REDACTED]. The 3/13/13 dietician ' s note indicated he/she was waiting on a response from the physician for the admission transfer sheet and 3/1/13 original treatment order for the Nephrite Vitamin, Prostat and Vitamin C that he/she had recommended on 3/1/13.(12 days with no action taken on the dieticians recommendations.) The 3/13/13 pressure ulcer record and measurement sheet indicated the resident ' s wound was unstageable and measured 4.2 cm by 3.0 cm, with 0.2 cm depth. The record also indicated the wound contained yellow slough, had deteriorated, increased in size, and the physician was aware. The 3/13/13 consultant physician's wound care orders directed the staff to apply [MEDICATION NAME] to the resident ' s coccyx and change every 3 days and PRN (as needed) until healed. The 3/13/13 at 11:10 AM, nurse ' s notes indicated an order for [REDACTED]. On 3/13/13 at 4:10 PM, observation revealed Nurse H and Nurse G providng treatment to the resident's coccyx wound. Nurse H cleansed the wound with wound cleanser and a gauze 4 by 4. The wound had a pink/red wound bed with a center area of yellow slough, no odor or drainage noted on the bed pad. Nurse H applied a [MEDICATION NAME] dressing and wrote the date on the [MEDICATION NAME]. At 4:10 PM Nurse H and Nurse G, removed the [MEDICATION NAME] dressing from the residents coccyx wound which now measured 4.5 cm x 2.0 cm with 0.1cm depth. On 3/13/13 at 2:20 PM,Consultant Registered Dietician I verified he/she had recommended supplements for Resident #105 on 3/1/13 and as of his/her assessment today, the resident had not yet received the supplement as he/she recommended on 3/1/13. On 3/13/13 at 1:21 PM, Administrative Nurse G verified the resident had a pressure ulcer on his/her coccyx that was present on admission to the facility. Administrative Nurse G also verified the facility had received verbal orders from the physician by telephone for treatment. Administrative Nurse G further verified the wound care physician would see the resident for an initial consult assessment at the facility on 3/14/13. Administrative Nurse G stated the wound had increased in size from the time the resident was admitted to the facility to the present time when staff had informed the physician and received a consult for wound care. On 3/14/13 at 12:00 PM (initial visit) the wound consultant physician's note indicated the resident's coccyx wound extended to the outer right buttocks noted with decreased slough due to autolytic debridement secondary to [MEDICATION NAME] dressing. The measurement of 3/12/13 indicated an increase in the size of the wound which is expected due to ongoing antilytic/enxymatic debridement and " speak to the poor underlying skin integrity and comorbidities" listed on the guideline sheet. On 3/18/13 at 1:17 PM, Physician K verified he/she received a request from the resident ' s primary physician for a wound consult on 3/7/13 and saw the resident for an initial consult on 3/14/13 at the facility. Physician K verified the wound had increased in size from 2/26/13 to 3/14/13 as he/she would expect from the [MEDICATION NAME] dressing. The facility policy, Wound Care Prevention and Treatment Objectives, dated 3/2012, instructed the staff to implement appropriate treatment and weekly interdisciplinary meetings to evaluate treatment progress, identification, and delivery of services to meet the resident ' s physical needs. Every treatment will be individualized to each resident ' s need and specific physician's order [REDACTED]. The facility policy, Pressure Sore Protocols, dated 3/2012, instructed the staff: early intervention is designed for residents at increased risk for pressure ulcer development. The principal components of early intervention are: identification of at-risk individuals who need preventative intervention and/or the specific factors that make the person at risk; protection from adverse effects of friction, shearing, pressure and moisture. The facility failed to implement appropriate interventions in a timely manner, including dietician recommendations to promote the healing and prevent the increase in size of pressure ulcers, and failed to inform the physician when the pressure ulcer became worse for a possibly a new treatment order to promote healing for Resident # 105.

The facility had a census of 64 residents. The sample included 26 residents. Based on observation, record review and interview, the facility failed to provide necessary care and services for 4 of 26 sampled residents. The staff failed to assess/reassess and provide effective pain management for Resident #62 who made moaning noises and grimaced when staff provided care. The staff failed to provide resuscitation as requested by Resident #85 when the staff found him/her without respirations, pulse and blood pressure. Resident #78 received [MEDICAL TREATMENT] and the staff failed to monitor the shunt or fluid intake and lacked communication between the facility and the [MEDICAL TREATMENT] center. Resident #10 who had recently started [MEDICAL CONDITION] experienced a hypoglycemic episode when the staff administered his/her insulin and failed to ensure the resident was eating as directed by the physician's orders [REDACTED]. Findings included: - Resident #62 ' s medical record revealed [DIAGNOSES REDACTED]. The Medicare 14 day MDS (Minimum Data Set 3.0 assessment) with an (ARD) Assessment Reference Date of 11/21/2011, indicated the resident had a (BIMS) Brief Interview Mental Status score of 13 which indicated intact cognition. Further review of the MDS indicated the resident received scheduled pain medication and no PRN (medication as needed) pain medication. The MDS indicated no non medication interventions for pain. Review of the medical record revealed no care plan for the resident ' s pain management. The 11/08/11 physician's order [REDACTED]. Review of the December 2011 (MAR) Medication Administration Record [REDACTED]. continued review of the MAR indicated [REDACTED]. On 12/06/2011 at 10:45 AM, Nurse N provided personal cares as the resident moaned and hollered out when repositioned in bed. On 12/06/2011 at 11:15 AM to 11:35 AM, during the observation of personal care the resident hollered out throughout cares. Continued observation revealed orals swabs at the bedside with oral care provided as the resident hollered out anytime the nursing staff touched the resident ' s mouth. Further observation revealed the resident to be unshaven and a substance caked around his/her mouth. Observation revealed the resident with dry mouth and cracks noted to the tongue and mouth. On 12/06/2011 at 3:35 PM, observation revealed the resident rested intermittently with occasional moaning out and respirations at 24 per minute. On 12/07/11 at approximately 7:40 AM, observation revealed the resident hollering out and moaning which could be heard at the nurse ' s station approximately 20 feet from the resident ' s bed. On 12/07/2011 at approximately 8:15 AM, observation revealed dried white particles on the resident ' s tongue. Nurse R verified the white particles were " dried Tylenol " the staff had attempted to administer to the resident during the night. On 12/07/2011 at 09:10 AM, Nurse R verified comfort measures included repositioning the resident and ensuring the resident was free from pain. Nurse R further verified staff were unable to touch the resident without him/her hollering out. Nurse R verified he/she contacted the resident ' s on call physician since the resident had excruciating pain, and had received orders for [MEDICATION NAME] ([MEDICATION NAME] Immediate Release) 20 mg/ml, 1 ml (milliter), SL (under the resident ' s tongue), every 2-3 hours prn pain. On 12/07/2011 at 9:40 AM, observation revealed Nurse R administered [MEDICATION NAME] 20 mg/ml 1 ml (milliliter) given SL (liquid given under the resident ' s tongue). Continued observation revealed staff attempted oral care as the resident hollered out. On 12/07/2011 at 10:30 AM, observation reveals resident is resting being calm and quiet. On 12/22/2011 at 10:00 AM, Nurse B verified they had have no policy and procedure on comfort measures. The facility failed to assess and provide timely interventions for pain relief for Resident #62, who hollered out with pain on several occasions. - Review of Resident #78's medical record revealed the 10/30/11 physician's orders [REDACTED]. The readmission (MDS) Minimum Data Set 3.0 assessment, with an (ARD) Assessment Reference Date of 9/20/11, indicated the resident had moderately impaired cognition and required extensive assistance of one staff with his/her activities of daily living. The MDS indicated the resident weighed 175 pounds and received a therapeutic diet. The MDS indicated the resident received [MEDICAL TREATMENT] Therapy. The 9/23/11 care plan indicated the resident required [MEDICAL TREATMENT] and directed the staff to coordinate transportation to the [MEDICAL TREATMENT] center as scheduled. The care plan directed staff to monitor the resident ' s fluid intake and monitor the resident ' s shunt for patency. Continued review of the care plan revealed no specific direction to staff that regarded monitoring of the resident ' s fluid intake, how to monitor for shunt for patency and the site and monitoring specific for a [MEDICAL TREATMENT] resident. The facility's Clinical Program Manual, dated August 2010 for [MEDICAL TREATMENT] communication, indicated a form to be used by the facility staff, or a comparable process of communication as may be recommended by the [MEDICAL TREATMENT] center for recording information. The manual instructed the facility's nursing staff to document information prior to the resident's departure to the [MEDICAL TREATMENT] center and upon return to the nursing facility. The manual indicated the following information to be included: 1) Resident's room number 2) Transportation and phone number 3) Vital signs 4) Departure time 5) Last blood sugar if applicable 6) Dietary concerns 7) Any medications given pre [MEDICAL TREATMENT] and medications to be taken at [MEDICAL TREATMENT] 8) Any change since last [MEDICAL TREATMENT] 9) Special instructions to [MEDICAL TREATMENT] if any The manual directed the facility nurse to sign and date the information and send it with the resident to the [MEDICAL TREATMENT] center. The manual indicated the following information be provided by the [MEDICAL TREATMENT] nurse that included: 1) Pre and post [MEDICAL TREATMENT] weight 2) Vital signs 3) Access/shunt information 4) Labs/results 5) Any non-routine mediation administered 6) Any complications during treatment 7) Any dietary instructions 8) Condition of resident upon discharge 9) Signature of the [MEDICAL TREATMENT] nurse The manual instructed the facility nurse to review the information upon the resident's return to the facility and record the following information: 1) Arrival time 2) Vital signs 3) Status of shunt/catheter 4) Signature of the facility nurse The manual instructed the facility staff to maintain information in the resident's medical record. review of the resident's medical record revealed [REDACTED]. On 12/6/11 at 10:43 AM, observation revealed the resident positioned in bed with the head of the bed elevated approximately 30 degrees and oxygen in place. On 12/8/11 at 10:20 AM, Nurse C verified no documentation available on the resident ' s record between the [MEDICAL TREATMENT] unit and the facility. The facility failed to accurately monitor Resident #78, who received [MEDICAL TREATMENT] treatment, to prevent potential complications. - Resident #10 ' s medical record revealed the 11/11/11 physician's orders [REDACTED]. The quarterly (MDS) Minimum Data Set 3.0 assessment, with an (ARD) Assessment Reference Date of 10/10/11, indicated the resident had intact cognition and required extensive to total assistance of 1 to 2 staff with his/her activities of daily living. Review of the resident ' s care plan revealed no plan of care for diabetes management. The 11/11/11 physician's order [REDACTED]. The 11/28/11 physician progress notes [REDACTED]. The progress notes revealed the resident would receive (IV) intravenous) [MEDICATION NAME], as a pre-medication, with each [MEDICAL CONDITION] treatment. The progress notes revealed the [MEDICATION NAME] would elevate the resident ' s blood sugars the evening after the morning of [MEDICAL CONDITION] treatment and may require adjustments in the resident ' s insulin. The 12/14/11 at 9:00 AM, nurse's notes revealed the staff observed the resident in the large dining room, with his eyes closed and sweat soaked shirt. The notes revealed the resident hard to arouse, and a blood sugar, when checked, at 43 (normal range 80 to 120). The notes revealed staff administered to the resident, 5 ounces of 2 Cal (a protein supplement) with a resulting blood sugar of 34. The notes revealed staff repeated the 5 ounces of 2 Cal and gave 6 ounces of orange juice with sugar with a resulting blood sugar of 40, and the resident continued to drink orange juice with a resulting blood sugar of 38. The notes revealed staff administered to the resident, [MEDICATION NAME], (a [DIAGNOSES REDACTED] medication), 1 (mg) milligram, as the resident continued to consume orange juice. The notes revealed the resident closed his/her eyes and fell asleep, although easily aroused, after 7 minutes since receiving the [MEDICATION NAME] Injection, with a resulting blood sugar of 43. The notes revealed 15 minutes after the [MEDICATION NAME] IM injection, the resident's blood sugar was 50. The notes revealed the resident awake and alert and able to eat a lunch meat sandwich. The 12/14/11 at 9:37 AM, nurse ' s notes revealed the resident ' s blood sugar at 123 after consuming ? of the lunch meat sandwich. The notes at 10:00 AM, revealed staff called the physician's office nurse with an update on the resident ' s status and requested a sliding scale insulin and as needed hard candy for the resident. The notes revealed staff further requested 1 mg [MEDICATION NAME] IM injections as needed for low blood sugar. The notes revealed staff awaited a return call from the physician. The 12/14/11 at 10:20 AM, the change in condition evaluation revealed the resident outside smoking and unable to hold his/her cigarette. The notes revealed the resident slow to respond and his/her lips were pale. The notes revealed the resident ' s oxygen saturations at 80% without oxygen, as the staff initiated oxygen use at 2 Liters per minute per nasal cannula, resulting in an increase of the resident ' s oxygen saturations to 94%. The notes revealed the resident ' s vital signs of 103/56 blood pressure, pulse at 104 beats per minute, respirations at 24 per minutes, temperature of 94.3 and a blood sugar of 245. The 12/14/11 at 11:00 AM, nurse's notes revealed at 10:25 AM, the resident ' s skin cold to touch. The notes revealed the resident ' s family requested staff send the resident to the hospital for evaluation. The nurse ' s notes revealed staff contacted the physician and received an order to transport the resident to the hospital per Emergency Medical Service. The hospital's history and physical, dated 12/14/11, revealed the resident brought to the hospital for decreased level of consciousness. The Lexi-Comp ' s Drug Reference Handbook, 16th Edition, Copy Right 2011, indicated Humalog Insulin, (a hyperglycemic diabetic medication), equal to regular insulin, but had a more rapid onset. The Handbook indicated the institute for safe medication practice included the medication had a heightened risk of causing significant patient harm when used in error. On 12/14/11 at 9:10 AM, observation revealed the resident in his/her wheelchair at the end of the hall, surrounded by several staff. Observation revealed the resident ' s skin pain and diaphoretic, and the resident not responding to the staff. At that time, Nurse B reported the resident's blood sugar at 32. Continued observation revealed the staff proceeded with [MEDICATION NAME] administration and the resident became more alert. Continued observation revealed Nurse B stayed with the resident as he/she ate a sandwich. On 12/14/11 at 10:45 AM, Nurse F reported he/she checked the resident's blood sugar at approximately 7:30 AM with results of 93. Nurse F reported he/she then administered to the resident, Humalog, 12 units, and took the resident to the dining room for breakfast. Nurse F could not recall if the resident's breakfast tray was on the dining room table. Review of the physician's order [REDACTED]. On 12/14/11 at 11:00 AM, Nurse B verified no care plan in the resident's record for diabetes management. On 12/14/11 at 11:45 AM, Nurse GG verified staff should not have administered the fast acting Humalog to the resident with a blood sugar at 93 and the resident not eating breakfast. The facility failed to follow the physician's order [REDACTED]. - Resident #85 ' s medical record revealed [DIAGNOSES REDACTED]. The quarterly (MDS) Minimum Data Set 3.0 assessment with an (ARD) Assessment Reference Date, 9/6/11, indicated the resident cognitively intact and independent with activities of daily living. The 7/5/11 care plan directed the staff to monitor the resident for mental status changes, confusion, disorientation, lethargy and restlessness. The care plan further directed the staff to observe the resident for any signs/symptoms clinical changes, and to administer medications as ordered by the physician. The 11/15/11 at 12:10 PM interdisciplinary note indicated the resident had refused to go to his/her eye appointment and had complained of not feeling good. The note indicated the physician came to the facility to see the resident and no new orders were given by the physician. The note revealed no further assessment by the nursing staff. Review of the medical record revealed no nursing notes from 11/15/11 at 12:10 PM, through 11/17/11 at 7:45 AM, at which time the staff found the resident not breathing and no pulse or blood pressure and " cold to touch " . The 11/17/11 at 7:45 AM, interdisciplinary progress note indicated a medication aide reported to the nurse the resident needed to be assessed by the nurse. The note indicated when the nurse responded to the resident ' s room the resident had no respirations, no pulse et no blood pressure. The note further indicated the resident was " cold to touch". On 12/14/11 at 10:05 AM, Nurse E verified no documentation regarding further assessment of the resident until the next note which was dated 11/17/11 at 7:45 AM when the staff found the resident not breathing, no pulse and no blood pressure and "cold to touch". On 12/14/11 at 11:19 AM, Nurse N reviewed the interdisciplinary notes and verified no nursing documentation in the medical record after the resident had complained of not feeling well on 11/15/11. Nurse N verified the nursing staff had not reassessed the resident the medical record revealed no progress note made by the physician during the 11/15/11 visit to the facility to assess the resident. The facility did not provide a progress note from the physician upon request. On 12/14/11 at 11:25, Nurse GG reviewed the medical record and verified no documentation the staff had reassessed the resident after the resident had complained of not feeling well until the staff found him not breathing and without a pulse or blood pressure. Nurse GG further verified the most current care plan on the medical record was dated 7/5/11 and no documentation the staff had reviewed the care plan after that date. On 12/28/11 at 1:45 PM, Nurse X indicated the resident had increased diarrhea and she/he had educated the resident on the increased [MEDICATION NAME] was prescribed for decreasing the resident's elevated ammonia levels. Nurse X verified the alert and oriented resident had been up in a chair in his/her room on different occasions on several days before his/her death. The LPN indicated the night nurse had reported the resident had been incontinent during the night and the staff had provided personal care around 2:00 PM. Nurse X verified he/she had not documented the resident's assessment in the medical record and he/she should have done. The facility failed to assess and reassess Resident #85 who complained of not feeling well. The facility failed to document in the resident's medical record the assessment and reassessment of a resident.

The facility had a census of 66 residents. The sample included 11 residents. Based on observation, record review and interview the facility failed to provide the necessary assessments/reassessments and treatments for pain for 1 of 11 sampled residents. (#1007) Findings included: - The January 2012 physician order [REDACTED]. The quarterly (MDS) Minimum Data Set 3.0 assessment, with an (ARD) Assessment Reference Date of 11/8/2011, indicated the resident had a (BIMS) Brief Interview Mental Screen score of 14 which indicated his/her cognition intact. The MDS indicated the resident usually understood but may miss some part/intent of a message but possessed the ability to comprehend most conversations. The resident had the ability to make concrete requests. The assessment revealed the resident received (PRN) as needed pain medications, non-medication interventions for pain and the staff had conducted a pain assessment with the resident. The resident had described the pain as occasional at a moderate level which made it hard to sleep. The 11/3/11 care plan directed the staff to ask direct questions which could be answered with one or two word answers or questions that the resident could answer with a yes/no head nod. The care plan encouraged the staff to monitor the resident's non-verbal communication by monitoring his/her body language for his/her needs/wants including pain and to administer pain medications as ordered by the physician. The care plan further directed the staff to monitor the resident for increases or changes in his/her pain and to notify the physician as needed. The January 2012 physician's orders [REDACTED]. Review of the medical record revealed no documentation the staff had followed up on the resident's report of pain to his/her left arm on 1/25/12 from 10:50 AM to 5:00 PM. (6 hours and 10 minutes since the resident had first complained of pain) On 1/25/12 at 5:00 PM, the (MAR) Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The note indicated the staff had offered the resident two tablets but the resident had only taken one tablet. At 5:30 PM, the staff had documented the resident's pain had been relieved by the Tylenol. Review of the medical record revealed no documentation the staff had followed up on the resident's report of pain to his/her left arm from 1/25/12 at 5:30 PM to 1/26/12 at 12:00 PM. (18 hours and 30 minutes since the resident had continued to complain of pain) The facility's 8/2010 Pain Management policy indicated pain management included addressing underlying causes of pain, evaluation of effectiveness of interventions, and progress towards goals. The policy directed the staff to communicate changes to the care giving team and to evaluate the effectiveness of interventions daily and modify as needed. On 1/25/12 at l0:50 AM, observation revealed the resident had his/her call light on. Further observation revealed (CNA) Certified Nurse Aide A and B assisted the resident to the toilet and provided personal hygiene care to the dependent resident. During the observation the resident gestured to his/her left arm and indicated he/she had pain in the left arm. CNA B told the resident he/she would report the resident's pain to the nurse. On 1/25/12 at 5:00 PM, observation revealed the resident seated in a recliner, in his/her room, with his/her legs elevated on the footrest with a pillow under them. Further observation revealed a nurse aide answer the resident's call light and the resident indicated "pain too much" and pointed to his/her left arm which had fallen off the pillow and rested beside him/her on the seat of the recliner. The resident stated, "not sleep, too much" while pointing to his/her left arm. On 1/25/12 at 5:30 PM, (CMA) Certified Medication Aide O and Nurse N were interviewed regarding the resident's report of left arm pain. Review of the MAR indicated [REDACTED]. The RN verified the resident had not received any pain medication earlier in the day and indicated no one had reported the resident had any pain earlier in the day. CMA O stated he/she was aware that a nurse had to assess a resident for pain, but he/she had just documented what the resident had reported. Further observation revealed Nurse N went to the resident's room to assess the resident. When Nurse N asked the resident if she/he had pain in his/her left arm by pointing to the resident's left arm which had slipped off the pillow and now rested on the left side of the recliner seat. When Nurse N reached for the resident's left arm he/she prevented the nurse from touching the arm. Nurse N asked the resident if she/he had any pain and the resident's pointed to his/her left arm and leg. Nurse N verified the Tylenol had not relieved the pain to the resident's left arm and acknowledged the resident continued to have pain at this time. On 1/26/12 at 12:00 PM, CMA P and Nurse J verified no information through report regarding the resident's complained of arm pain last night or if the pain was ever relieved. The facility failed to accurately reassess and to monitor for the effectiveness of as needed pain medication for Resident #1007's continued complaint of pain.

The facility had a census of 64 residents. The sample included 26 residents of which 2 had pressure sores. Based on observation, record review and interview, the facility failed to provide necessary treatment and services to prevent the development of, facility acquired avoidable, pressure ulcers for 1 of 2 sampled residents. (#62) Findings included; - Resident ' s #62 ' s medical record revealed [DIAGNOSES REDACTED]. The Medicare 14 day MDS (Minimum Data Set 3.0 assessment) with an (ARD) assessment reference date of 11/21/2011 indicated the resident had a (BIMS) Brief Interview Mental Status score of 13 which indicated intact cognition. Further review of the MDS indicated the resident required limited assistance of one staff with (ADL ' s) activities of daily living. The MDS revealed the resident weighed 228 pounds and received a therapeutic diet. The MDS revealed the resident at risk for pressure ulcers and had no pressure ulcers at the time of the MDS assessment. The 12/03/2011 care plan indicated the resident had the potential for alteration in skin integrity related to decreased mobility and occasional incontinence. The care plan indicated no open areas noted to the residents bilateral buttocks. The care plan directed staff to provide the following: 1) Treatment per Doctor ' s orders. 2) Encourage the resident to keep off of his/her buttocks. 3) Ensure an anti-pressure pad in recliner or wheel chair and a low air loss mattress on the bed. 4) Encourage fluid and oral intake. 5) Measure weekly and notify the physician as condition warrants. The 12/03/2011 physician's order [REDACTED]. The order directed staff to change the dressing every 3 to 4 days and PRN (as needed) until healed. On 12/06/2011 at 11:15 AM, observation revealed Nurse Aide TT, Nurse Aide U, and Nurse N provided care to the resident, who had a large loose bowel movement. Continued observation revealed Nurse Aide U used the same wipe several times in providing peri-care to the resident. Nurse Aide U folded each personal wipe several times and wiping over the resident ' s peri-rectal and open area with the soiled personal wipes. Further observation revealed one [MEDICATION NAME] dressing intact to the residents right buttock area, without the physician ordered [MEDICATION NAME] dressing to the resident ' s left buttock area. Observation revealed the pressure ulcer on the resident ' s left upper middle buttock measured 1.2 cm (centimeters) by 1.4 cm and the right buttock areas measured 0 .7 cm by 0.7 cm and 1.1 cm by 1.2 cm. Further observation revealed red drainage from each wound. Nurse N verified the resident ' s pressure ulcers at a Stage II and [MEDICATION NAME] dressings were not in place to all the resident ' s pressure ulcers as physician ordered. Nurse Aide U verified only one [MEDICATION NAME] dressing to the resident ' s buttock prior to providing care to the resident. On 12/07/2011 at 9:50 AM, observation revealed Nurse Aide V, Nurse Aide W and Nurse N repositioned the resident. Observation revealed no [MEDICATION NAME] Dressings to the resident ' s Stage II pressure ulcer on his/her right and left buttock areas as physician ordered. Nurse N verified the resident now had five Stage II pressure ulcers. Nurse N further verifies the low air loss mattress was not applied to the residents bed until after the weekend of 12/03/2012. Observation revealed the resident ' s pressure ulcers red with red drainage. Observation revealed the pressure ulcer on the resident ' s left upper middle buttock area measures 1.2 cm by 1.2 cm and 0.1 cm deep. Further observation revealed the resident had two new Stage II pressure ulcers, one that measured 1.2 cm by 1.4 cm on the left middle buttock area and one that measured 0.6 cm by 0.7 cm on the left lower buttock area. Observation revealed the resident ' s Stage II pressure ulcer on his/her right upper buttock measured 1.3 cm by 1.2 cm and the right lower buttock area measured 0.6 cm by 0.8 cm. (Indicating an increase in the previous pressure ulcer sizes and a development of two new pressure ulcers from the previous day.) During the observations on 12/06/2011 at 11:15 AM and 12/07/2011 at 9:50 AM, Nurse N verified the physician's order [REDACTED]. Nurse N further indicated the resident had developed 2 more stage II pressure ulcers and now the Resident had 5 Stage II pressure ulcers. The facility failed to provide the necessary treatment for [REDACTED].

The facility had a census of 64. The sample include 26 residents. Based on observation, record review and interview the facility failed to maintain acceptable parameters of nutritional status, such as body weight and protein levels, for 1 of 26 sampled residents. Resident #70 had a significant weight loss of 12.8 # or 8.98% in 66 days or 17.4 # or 11.7% in 6 months and the staff failed to implement interventions to stabilize the resident ' s weight. Findings included: - Resident #70 ' s medical record revealed a physician order [REDACTED]. The annual (MDS) Minimum Data Set 3.0 assessment, with an (ARD) Assessment Reference Date of 10/3/11, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 15 which indicated the resident cognitively intact. The assessment further indicated the resident thought it very important to have between meal snacks to be available, required only set up for eating, and received a therapeutic diet. The MDS further indicated the resident had no swallowing problems, was 5 feet, 2 inches tall and weighed 142 pounds. The 10/7/2011 care plan directed the staff to ensure the resident ' s glasses fit appropriately and were in good repair, to interact with the resident when assisting him/her and to provide set up assistance with his/her meal tray. Further review of the care plan revealed no documentation or interventions regarding nutrition or significant weight loss. The 10/5/11 registered dietician ' s note on Nutrition Data Collection Tool indicated the resident currently weighed 140.4 (#) pounds which was down 1.4% in on month or 4.7% in 3 months, 5% in 6 months and 13% in one year. The registered dietician ' s note further indicated the resident received a regular diet and his/her intake had been variable but the resident received a snack between meals. The registered dietician ' s note recommended a highly dense nutritional supplement, 2 cal, 2 (oz) ounces, four times a day to stabilize the resident ' s weight. The 11/17/11 fax to physician indicated the resident had 6.13% decrease in his/her weight over the past month. The fax further indicated the registered dietitian recommended nutritional health shakes, three times a day, for maintenance of the resident ' s weight to which the physician agreed and provided the order. The 11/18/11 physician ' s telephone order directed the staff to provide the resident with nutritional health shakes two times daily. Review of the resident ' s weight record revealed the following weights: 9/2/11 142.4 10/3/11 140.4 10/10/11 138.0 10/17/11 137.2 10/24/11 136.4 10/31/11 131.8 11/7/11 129.6 (a loss of 12.8 # or 8.98% significant weight loss in 66 days) 11/15/11 128.4 Review of the second weight logs provided by the staff indicated the following weights; 7/4/11 147.8 8/2/11 142.0 9/2/11 142.2 10/3/11 140.4 11/1/11 131.8 12/5/11 130.4 (17.4 # or 11.7 % weight loss in 6 months. On 12/12/11 at 8:00 AM, observation revealed the resident seated in a wheelchair at the dining room table independently eating breakfast which included scrambled eggs, toast, sausage coffee and water. On 12/ 8/11 at 7:10 AM, upon entering the facility, observation revealed a snack cart sitting in the center hall between the dining room and the west hall. A metal container on a shelf on the cart had 4 sandwiches and 2 nutritional Mighty Shakes which were both warm to touch. Observation revealed one of the Mighty Shakes had this resident ' s name on it. On 12/8/11 at 8:15 AM, observation revealed Nurse Aide AA assisting the resident up for the day. Nurse Aide AA indicated the resident usually independent with his/her activities of daily living but recently had eye surgery so staff currently assisted the resident. During the observation the Nurse Aide and the resident discussed the weight the resident had recently lost. On 12/8/11 at 8:30 AM, Dietary staff EE verified the nutritional Mighty Shake on the snack cart had the resident ' s name on it and the staff had not given the shake to the resident last evening. Dietary staff EE indicated the dietary department frequently received evening snacks that had not been passed to the residents on the snack cart in the mornings. The 12/8/11 registered dietician ' s note indicated the resident currently weighed 130.4# a decrease of of l.06# in one month, 8.3 % in 3 months and 10.81 % in 6 months. The note indicated he/she had recommended the implementation of nutritional shakes three times a day last month to stabilize the resident ' s weights. The note directed the staff to continue to continue to monitor the resident ' s weights and he/she would make further recommendations as needed. On 12/8/11 at 11:15 AM, Nurse E verified the medical record had no documentation the staff forwarded the registered dietician ' s recommendation, dated 10/5/11, for an order for [REDACTED].[REDACTED]. Nurse E further indicated each unit coordinator discussed the registered dietician ' s recommendations and then is responsible to carry through with the recommendations. Nurse E further verified the resident ' s care plan had no acknowledgement of the resident ' s significant weight loss or included no interventions for his/her nutritional status or weight loss On 12/8/11 at 11:20 AM, Consultant FF indicated he/she had become aware of the resident significant weight loss in October and had recommended the Med Pass 2.0 on 10/5/11. Consultant FF indicated he/she reviewed his/her findings with the administrative nursing staff. Consultant FF verified through his/her review the medical record had no documentation the staff had implemented the Med Pass in October, however, the staff had reported to him/her the resident had not liked the taste of the supplement. The consultant verified no documentation in the medical record regarding the implementation of the recommendation or the resident refusing the supplement. The facility failed to provide the necessary dietary interventions to maintain acceptable parameters of nutritional status and prevent a severe weight loss for Resident #70.

The facility had a census of 77 residents. The sample included 26 residents. Based on observation, record review and interview, the facility failed to provide adequate supervision and assistive devices to prevent accidents for 1 of the 26 sampled resident. On 3/15/2011, conditions in the facility constituted immediate jeopardy for Resident #39 when the independently mobile resident wheeled over to the elevated unsteady coffee pot in the dining room and obtained a cup of hot coffee. The temperature of the coffee in the coffee pot measured at 134 degrees Farenheit (F). The facility failed to ensure the residents' environment remained as free of accident hazards as possible in the main dining room. Findings included: - Resident #39's medical record revealed [DIAGNOSES REDACTED]. The annual (MDS) Minimum Data Set 3.0, (ARD) Assessment Reference Date 12/22/2010, indicated Resident #39 had a BIMS (Brief Interview for Mental Status) summary score of 10, which indicated the resident was moderately cognitively impaired. The MDS further indicated the resident required extensive assistance with transfers, walking in the room and corridor, dressing, toilet use, and total dependence for personal hygiene. Continued review revealed the resident was not steady during transition and walking and only able to stabilize with human help. The 12/30/2010 care plan directed the staff to assist the resident with ADL's ( Activities of daily Living ) transfers, and toileting. Continued review revealed the staff were directed to observe the resident for a change in cognition or increased confusion. On 3/15/2011 at 12:27 PM, observation revealed the resident in the main dining room propelling their wheelchair from the dining room table to the "fluid bar" across the dining room. Observation revealed the resident's wheelchair sat approximately 6 to 8 inches (") lower than the fluid bar. While seated in the wheelchair, Resident #39 reached up and poured the coffee in their coffee cup into the ice machine overflow water catcher. While seated in the wheelchair, Resident #39 reached up to obtain a cup of coffee from the large 48-cup coffee pot which sat on a black stand on the fluid bar. The black stand elevated the coffee pot's spigot up another approximately 6 ". While continuing to sit in his/her wheelchair, Resident #39 pressed down on the spigot lever, which caused the large coffee pot to tilt towards the resident and when the resident released the spikot lever the coffee pot returned to a proper upright stable position. Resident #39 then brought the coffee cup down to look in the cup and raised it to obtain more coffee 2 more times. The large coffee pot rocked forward each time the spigot lever was pushed down. Observation revealed two staff members in the dining room delivering food trays to the resident's tables and no attempts were made to assist Resident #39 with his/her coffee. At that time two surveyors went across the dining room to prevent the coffee pot from possibly spilling hot coffee onto the resident and the other residents who were seated at the table in close proximity to the unsteady coffee pot. Further observation revealed the resident had approximately 1/2 cup full of new coffee in his/her right hand and propelled the wheelchair with their left hand and feet and returned to the table in the dining room. The Surveyor then requested a reading of the coffee temperature that dispensed directly from the large coffee pot. The temperature of the coffee was 134 degrees Farenheit on the dietary manager's thermometer. On 3/15/2011 at 4:40 PM, observation revealed 12 residents were in the main dining room of which 4 residents were drinking coffee with no staff present. Continued observation revealed the 48-cup coffee pot approximately 3/4 full of coffee. Additional observation revealed the facility dietary staff were preparing for the 5:30 PM supper meal. On 3/16/2011 at 3:28 PM, Nurse Aide A verified Resident #39 spent a lot of time drinking coffee in the main dining room. On 3/16/2011 at 5:07 PM, Administrative Staff Z verified the 48-cup coffee pot on the "Fluid Bar" was an accident hazard to the residents and the pot was immediately removed. The facility failed to provide adequate supervision and assistive devices to prevent accidents and the facility failed to ensure the resident's environment remained as free of accident hazards as possible in the main dining room. This failure placed the resident at risk for injury. The facility abated the immediate jeopardy on 3/16/11, when they implemented the following: 1) The facility initiated a protocol of immediately removing the 48-cup coffee pot from the main dining room. 2) Inserviced staff on 3/15/11 regarding the coffee pot with completion of training on 3/16/11. 3) The 48-cup coffee urn will be available at the kitchen door during meal service only. Dietary staff will ensure insulated carafes and/or air pots are kept in the dining room at other than meal times. 4) Residents informed of the change in coffee service on 3/16/11 at the special Resident Council Meeting. 5) Administrator, CDM or designee will visually monitor location of the large coffee urn and complete a daily audit. 6) The issue will be addressed at the QA&A meeting for the next 3 months. The deficient practice remained at a scope and severity of an D.

The facility had a census of 77 residents. The sample included 26 residents. Based on observation, record review and interview, the facility failed to ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individuals clinical condition demonstrates that they were unavoidable and ensures a resident who had pressure sores received necessary treatment and services to promote healing, prevent friction and prevent new sores from developing for 1 of the 26 sampled residents. Resident #22 developed an avoidable facility acquired Stage 2 pressure ulcer. Findings included: - Resident #22's medical record revealed [DIAGNOSES REDACTED]. The Medicare Admission (MDS) Minimum Data Set 3.0 assessment (ARD) Assessment Reference, dated 2/18/2011, revealed the resident had a BIMS score of 13 which indicated the resident had no cognitive impairment. The MDS further indicated the resident required extensive assistance with transfer and toilet use. The 2/11/2011 care plan indicated the resident had the potential for skin breakdown and directed the staff to turn and reposition the resident as needed with bed mobility and use care not to cause shearing or friction. Continued review of the care plan directed the staff to monitor the resident for skin breakdown and report redness, gaulding and breakdown to the physician. The 3/13/2011 West Hall Skin Sweep weekly check revealed the resident had no skin issues. On 3/17/2011 at 1:30 PM, observation revealed Nurse C assisted the resident from their wheel chair to the shower chair in the shower room. Further observation revealed the staff removed the resident's depends and exposed the resident's buttocks. The resident had two small reddened areas with the skin removed on their right buttocvk area. On 3/17/2011 at 1:35 PM, Nurse C exited the shower room and the Surveyor asked if the resident had a "sore" on their bottom. Nurse C examined the resident's buttocks and stated "yes" the resident had a Stage II pressure ulcer on their buttocks. Nurse C verified the pressure ulcer was in the shape of a B and the skin open and exposed. The 3/17/2010 nurse's notes indicated the resident had a Stage II pressure ulcer on their right inner buttocks. The faxed note to the physician indicated the resident had a 4 (cm) centimeters x 2 cm x 0.1 cm Stage II pressure ulcer with no sign or symptoms of infection and good granulation in the wound bed. Resident #22 developed a facility acquired avoidable Stage II pressure ulcer.