Every finding on record at Kiowa Hospital District Manor

The facility identified a census of 21 residents. The sample included 12 residents, with six residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to ensure an environment free of accident hazards for Resident (R)6, when Certified Medication Aide (CMA) R transported R6 in the facility van without safely securing the resident with a seatbelt in her wheelchair. On 05/08/25 CMA R abruptly applied the brakes to avoid a collision, causing R6 to slide out of her chair and fall on the floor, with her leg bent behind her. R6 cried out in pain as Emergency Medical Services (EMS) and facility staff removed R6 from the van. EMS transported R6 to the hospital via ambulance and R6 had severe pain, though the X-rays revealed no injuries. The facility's failure to ensure staff safely secured R6 with a seatbelt in a moving vehicle placed R6 in immediate jeopardy. Findings included:- R6's Electronic Medical record (EMR) under the Physician Orders dated 06/09/25 indicated the following diagnoses: type 2 diabetes (DM- a disease in which the body's ability to produce or respond to the hormone insulin is impaired), vascular dementia (a progressive mental disorder characterized by failing memory, confusion), and hypertension (elevated blood pressure).R6's Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. The MDS noted R6 was dependent on staff for toileting, showers, dressing and transfers. The MDS noted R6 used a wheelchair for mobility.R6's Quarterly MDS dated [DATE] revealed a BIMS score of 15, indicating intact cognition. The MDS noted R6 was dependent on staff for wheelchair propulsion.R6's Care Plan dated 05/02/25 documented the resident had a self-care performance deficit related to limited mobility, back pain, and knee pain. The plan directed staff R6 needed total assistance from two staff and the Hoyer lift (full body mechanical lift) for all transfers. The plan noted R6 had memory loss, which varied day-to-day. On 05/08/25, the plan noted a new intervention that instructed R6 to be transported in the bus instead of the van until further evaluation; evaluation and new seatbelts were placed in the van for safety and comfort. R6's Progress Notes in the EMR dated 05/08/25 at 03:15 PM, CMA R called the facility, explaining she needed assistance with R6. Three certified nurse aides (CNA) and a nurse went out to the van and found R6 on the floor of the van with her left leg bent backward toward her hip and her right leg tucked underneath the passenger chair. The note documented R6 had no active bleeding or protruding bones. R6's wheelchair was pushed up against R6's back and still attached to the floor. R6 yelled, Ow, ow, help me, it's my leg. Someone help me. One of the CNA staff members moved R6's legs to straighten them out, and R6 reported immediate relief. The note documented staff notified the fire department. EMS and emergency services arrived at 3:16 PM and transferred R6 to the hospital for further evaluation. The noted recorded R6 had no fractures upon her return to the facility.The facility's investigation N Adv-Post Fall Evaluation dated 05/08/25 at 06:28 PM documented CMA R was the witness to the fall. CMA R hit the brakes, causing R6 to lean too far forward, and R6 slid out of her wheelchair. The assessment noted R6 had pain rated at a seven (pain rating scale where zero equals no pain and 10 is the worst pain imaginable). R6 had vocal complaints of pain as well that got worse with movement. The assessment documented the root cause was the car in front of the transport van slammed on its brakes without warning, which caused CMA R to hit the brakes, and R6 slid out of her wheelchair onto the floor.CMA R's Witness Statement dated 05/08/25 documented after R6's dental appointment, CMA R loaded R6 back into the van, attached the front strap-downs above the front wheels of the wheelchair, and then attached the back strap-downs to the back bars that crossed underneath the wheelchair. CMA R noted during the drive, a car pulled in front of the van, and CMA R quickly hit the brakes to avoid hitting it. R6 slid forward in her chair, but they were still three blocks from the facility. R6 told CMA R she could feel herself sliding more, so CMA R called the facility to alert them. As they arrived at the facility, R6 slid all the way out of the wheelchair onto the floor with her left leg partially under her and her knee and lower leg turned at an angle. The CMA quickly undid the straps on the front wheels of R6's wheelchair and climbed over the center console to undo the back straps. EMS arrived and finished moving the wheelchair out of the way.On 09/02/25 at 04:25 PM, observation of the facility transportation van revealed hooks for the front and back of the wheelchair. The van also had new seat belts.On 09/03/25 at 09:14 AM, observation revealed R6 in the dining room, eating breakfast. She sat in her wheelchair and wore protective boots with leg wraps. On 09/02/25 at 03:21 PM, CNA M said CMA R came into the facility on [DATE] and told staff she needed help. CNA M reported R6 was on the floor of the van, with her right side up against the front seats, and she looked like a W shape. CNA M said staff called EMS. CMA M said she entered the van from the front door, and the rest of the staff went in through the back. CNA M said she held R6's legs up so they would not be on the metal at the bottom of the seats. CNA M said it took six people to get R6 out of the van. She said R6 did not have a seat belt on, but confirmed the facility made a point of getting seat belts after that incident.On 09/02/25 at 03:31 PM, CNA S said CMA R called and asked for help on 05/28/25. CNA S stated she went out to the van and saw R6's wheelchair tipped over in the van, though it was still latched on the bottom wheels. CNA S said R6 complained about her leg, as she was in a small space and her left leg was bent. CNA S said R6 had an X-ray, and the facility used heat pads to address the pain in R6's leg. CNA S stated the van was updated with seat belts.On 09/02/25 at 04:26 PM CMA R stated, as she and R6 were returning to the facility in the transportation van, a car pulled in front of the van. CMA R stated she applied the brakes to avoid hitting the car, and R6 slid forward, putting her hands on the back of the two seats. CMA R said she placed her hand on R6 to steady her. CMA R verified there were no seatbelts in the van to apply to the resident while she was in her wheelchair, at the time of this incident.On 09/02/25 at 03:34 PM, Administrative Nurse D revealed the facility van did not have seatbelts prior to the incident. Administrative Nurse D stated that after the incident, the facility identified the van did not have seatbelts, so the facility maintenance staff removed seatbelts from the facility's bus and placed them in the transportation van to avoid a recurrence of the situation. Administrative Nurse D stated they notified the Medical Director of the situation and addressed the incident in risk management.The policy Fall and Accident Prevention dated 06/24/25, documented to ensure the resident environment remains as free of accident hazards as possible and to ensure each resident receives adequate supervision and assistive devices to prevent accidents. Accidents refer to any unexpected or unintentional incident that results or may result in injury or illness to a resident that does not include other types of harm, such as adverse outcomes that are direct consequences of treatment or care that is provided in accordance with current professional standards of practice.On 09/03/25 at 09:56 AM, Administrative Nurse D received a copy of the Immediate Jeopardy [IJ] Template and was informed of the IJ for R6, who was identified on the template as R1.The facility completed corrective actions that included installation of seatbelts in the facility's transport van, staff instruction on how to use the seatbelts and review of the incident at Quality Assurance and Performance Improvement (QAPI). The facility completed all corrections by 05/09/25, prior to the onsite visit; therefore, the deficient practice was deemed past noncompliance and remained at a scope and severity of J.

The facility reported a census of 21 residents, and one main kitchen. Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions to prevent the potential for food borne bacteria. This placed the residents at risk for food borne illnesses. Findings included:- During the initial tour of the kitchen on 09/02/25 at 08:40 AM, observation revealed a bag of beef patties, a bag of hash browns, one bag of fish, and one bag of chicken strips were left open to air. Three cutting boards had a black substance around the edges and grooves in the boards.The pans and bowls were not inverted or covered. On 09/04/25 at 11:05 AM, the follow-up kitchen tour revealed a box of beef patties left open in the freezer area, and the cutting boards still had the black substance around the edges of the cutting boards and deep grooves. On 09/02/25 at 11:25 AM, Dietary Staff BB revealed that the staff were reminded to close the bags and to date when the bag was opened. Dietary Staff BB said the cutting boards will be replaced. The policy Food and Nutrition-Food Preparation-Manor and Hospital, dated 06/24/25, documented that all dietary personnel and other persons preparing food for the consumption of residents shall be routinely instructed and evaluated in sanitary food handling techniques, hand washing practice, and personal hygiene.

The facility reported a census of 21 residents. The sample included 12 residents with one resident reviewed for hospitalization. Based on interview and record review, the facility failed to provide Resident (R) 5 a written notification of transfer to the resident and/or his representative as soon as practicable. This placed the resident at risk of impaired rights related to transfer and discharge. Findings included:- R5's Electronic Medical Record (EMR) revealed a diagnosis of heart failure (a condition where the heart muscle is weakened and cannot pump blood effectively enough to meet the body's needs).R5's EMR documented a Progress Note which noted R5 transferred to the hospital on [DATE].R5's EMR lacked documentation of a written notification to the resident and/or his representative, which explained the reason for the transfer to the hospital.On 09/04/25 at 07:55 AM, Social Services Staff X stated the family was provided the bed hold policy, and the Ombudsman was notified of the transfer to the hospital. Social Services Staff X confirmed that staff had not notified the resident and/or his representative in writing of the reason for transfer to the hospital. On 09/04/25 at 11:15 AM, Administrative Nurse D said she was unaware of the requirement to notify the resident and/or his representative in writing of the reason for transfer to the hospital, and confirmed that it was not done for R5's transfer on 07/14/25.The facility policy for Transfer Agreement, last reviewed 12/02/24, included: Before the facility transfers or discharges a resident, the facility shall notify the resident and the resident's representative of the transfer or discharge.

The facility reported a census of 21 residents. Based on interview and record review, the facility failed to electronically submit accurate staffing information through Payroll-Based Journaling (PBJ). Findings included:- The PBJ Staffing Data Report for Fiscal Year (FY) 2025 Quarter 1 (October 1 - December 31) and FY 2025 Quarter 2 (January 1 - March 31) documented the facility failed to have Registered Nurse (RN) coverage on the following dates:10/02/24; 10/08/24; 10/19/24; 10/20/24; 10/22/24; 10/23/24; 10/29/24; 11/08/24; 11/12/24; 11/20/24; 12/03/24; 12/13/24; 12/17/24; 12/24/24; 12/27/24; 01/22/25; 01/28/25; 02/11/25; 02/18/25; 02/19/25; 02/25/25; 02/27/25; 03/04/25.Review of the PBJ Staffing Data Report for Fiscal Year (FY) 2025 for Quarter 1 and FY 2025 Quarter 2the facility failed to have Licensed Nurse (LN) coverage 24 hours a day on the following dates:10/11/24; 10/19/24; 12/03/24; 12/14/24; 12/21/24; 12/27/24.Review of the Daily Nurse Staffing Form and Payroll Data Sheets indicated the days listed above were covered with the appropriate staff with eight consecutive hours of RN coverage and LN coverage 24 hours each day. On 09/04/25 at 10:00 AM, Administrative Nurse D revealed that when she started her new position, the system did not recognize her as working as an RN in the building, so it was not reported as RN staffing hours. Administrative Nurse D stated the problem is fixed.On 09/04/25 at 10:14 AM, Administrative Staff B reported she reports PBJ information each quarter. She manually records staff who were agency and contracted workers. Administrative Staff B verified that there was a period of time during which RN hours were not reported correctly.The facility policy CMS Payroll Based Journal (PBJ) Submission Policy, last updated 07/09/25, documented that the facility was responsible for submitting timely and accurate staffing data through the CMS Payroll-Based Journal (PBJ) system.

The facility reported a census of 26 residents. Based on interview and record review, the facility failed to submit complete and accurate staffing information to the Federal regulatory agency through Payroll-Based Journaling (PBJ) when the facility failed to accurately submit hourly staffing data for all nursing personnel. Findings included: - Review of the Fiscal Year (FY) Quarter 1, 2023 (October 1 - December 31), the facility failed to accurately submit the Licensed Nursing Coverage 24 hours/Day for the following dates: 10/01 Saturday (SA); 10/02 Sunday (SU); 10/08 (SA); 10/09 (SU); 10/15 (SA); 10/22 (SA); 10/23 (SU); 10/27 Thursday (TH), 11/05 (SA); 11/29 Tuesday (TU);12/12 Monday (MO), and 12/16 Friday (FR). FY Quarter 2, 2023 (January 1 - March 31), the facility failed to accurately submit the Licensed Nursing Coverage 24 hours/Day for the following dates: 01/18 Wednesday (WE); 02/18 (SA); 02/26 (SU); 03/11 (SA); 03/12 (SU); 03/18 (SA) and 03/26 (SU). FY Quarter 3, 2023 (April 1 - June 30), the facility failed to accurately submit the Licensed Nursing Coverage 24 hours/Day for the following dates: 04/29 (SA); 04/30 (SU); 05/02 (TU); 05/06 (SA); 05/27 (SA); 05/28 (SU); 06/17 (SA); 06/24 (SA); and 06/25 (SU). Review of the nursing schedule and clocking sheets for the above dates revealed adequate hours to account for 24-hour nursing coverage. Interview on 01/04/24 at 12:30 PM, Administrative Nurse B reported that Human Resource staff (HR) at the hospital was responsible for submission of payroll data and was unable to provide explanation for inaccurate data. The Electronic Staffing Data Submission Payroll-Based Journal for Long Term Care Facilities, dated 06/2022, documented that long term care facilities must electronically submit to Centers for Medicare Services (CMS - the federal regulatory agency) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable date in a uniform format according to specifications established by CMS. The facility failed to submit complete and accurate staffing information to the Federal regulatory agency through PBJ when the facility failed to accurately submit hourly staffing data for all nursing personnel.

The facility had a census of 26 residents, which included 12 residents, that included one resident reviewed for accommodation of needs. Based on observation, record review, and interview, the facility failed to provide reasonable accommodations related to an appropriately sized mechanical lift sling for Resident (R)4. Findings included: - The Electronic Health Records (EHR) for Resident (R)4 included diagnoses of diabetes mellitus type 2 (DM2 - when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), chronic pulmonary edema (a chronic condition in which the lungs accumulate excess extravascular fluid around the lung tissue) and generalized weakness. The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R4 required extensive assistance from two staff for all cares except eating and received hospice services. The ADL (activities of daily living such as walking, grooming, toileting, dressing and eating) Functional / Rehabilitation Potential Care Area Assessment (CAA) dated 10/09/23, documented R4 had an ADL self-care deficit related to multiple diagnoses which included (but not limited to) generalized weakness, non-ambulatory (not walking) status, limited range of motion due to body size and chronic pain. The Care Plan dated 01/03/24, documented R4 had an ADL self-performance deficit and instructed staff to utilize a Hoyer lift (a two-person full-body mechanical lift use to transfer residents) and lacked direction on the size of sling to use. The Physician Orders lacked information related to the full body mechanical lift use. On 01/02/24 at 11:21 AM, R4 revealed that the full body mechanical lift sling that staff had been using caused discomfort during transfers because it was too small for his body. On 01/03/24 at 07:25 AM, Certified Nurse Aide (CNA)C, CNA F and CNA E transferred R4 with a full body mechanical lift. R4 expressed discomfort due to the sling size during the transfer. On 01/04/24 at 09:49 AM, CNA C stated that the Hoyer lift was a little too small for the resident to use and the legs of the mechanical lift could not open wide enough to accommodate R4's wheelchair. Additionally, stated that R4 was recently readmitted to the facility on hospice and that hospice provided the lift and that even though the lift and sling are too small for the resident, staff were to use the hospice lift and not the two lifts owned by the facility. Further stated that R4 used to complain daily about the lift causing discomfort but has given up on saying anything about it. On 01/04/24 at 10:01 AM, CNA D confirmed that R4 was readmitted to the facility on hospice services and that the lift provided by hospice was too small for R4. The facility owned lifts that were larger, but staff were to use the lift provided by hospice even if it was too small because the hospice lift was in the room and the other ones were stored all the way at the end of the hall. On 01/04/24 at 10:23 AM, Administrative Nurse B confirmed that R4 had recently readmitted to the facility on hospice services; however, stated that staff had not been advised to exclusively use the lift provided by hospice rather than the two larger lifts owned by the facility. Administrative Nurse B was not aware R4 expressed discomfort related to the small size of the full body mechanical sling. Stated that her expectation was for staff to utilize appropriately sized equipment to accommodate R4's body size without causing discomfort. The facility's Accommodation of Need policy, dated 02/2004, documented that residents have the right to reside and receive services with reasonable accommodations of individual needs. The facility failed to provide this resident with reasonable accommodations of his needs and preferences for an appropriately sized mechanical lift sling.

- R10's Electronic Health Record (EHR) revealed the resident had diagnoses that included dementia (a progressive mental disorder characterized by failing memory, confusion) and major depressive disorder (a mood disorder categorized as mental health problems, feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be felt from time to time). The 11/10/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of three, which indicated severely impaired cognition. The resident was dependent on staff for cares. The 11/10/23 Cognitive Loss / Dementia Care Area Assessment CAA, documented that the resident had impaired cognitive function with cognitive decline noted related to her diagnosis of dementia. R10 had chronic episodes of inattention, disorganized thinking, and the appearance of decreased consciousness where she was less responsive to others around her. The 11/10/23 Falls CAA, documented R10 was at risk for falls related to weakness, dementia, medications, aggressive behaviors at times during ADLs (activities of daily living - such as grooming, walking, bathing, and toileting), and had a history of falls. Soft touch call light in place. Directed staff to anticipate and meet R10's needs as she was unable to make them known verbally and that a dycem (a slip resistant pad placed between the buttocks and a chair) pad was to be placed on top of R10's wheelchair cushion to prevent buttocks from sliding forward for fall prevention. The Care Plan, dated 11/16/23, documented that R10 was a moderate risk for falls and instructed staff to perform the following interventions: 1. On 06/08/18, for staff to anticipate and meet R10's needs as she was unable to make them known verbally. 2. On 11/14/2023, for staff to place dycem on top of the wheelchair cushion to prevent buttocks from sliding forward for fall prevention. 3. On 05/26/2021, for staff to ensure that R10 wore appropriate footwear such as non-skid socks, shoes, when ambulating and must have one to two staff assisting with ambulation. R10's primary mode of locomotion was for staff to propel R10's wheelchair, but R10 would sometimes propel herself. 4. On 11/22/2022, that R10 didn't use her call light but instructed staff to make sure R10's call light was within her reach for use by utilization of soft touch call light. 5. On 06/18/18, R10 needed a safe environment with: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in a position that best fits her height; handrails on wall in bathroom and personal items within reach. 6. On 12/31/23, instructed a staff member to face R10 and to maintain visual supervision while resident is using the restroom. 7. On 12/09/23, instructed staff to perform visual safety checks every 15 minutes while awake. The Physician's Orders lacked orders specific to fall prevention. The EHR Assessments documented the following: 1. On 12/09/23, fall risk evaluation of 12, which indicated resident was at risk for falls. 2. On 12/31/23, fall risk evaluation of 12, which indicated resident was at risk for falls. The facility fall report revealed R 10 had an unwitnessed fall on 10/9/2023 with no injury and a witnessed fall on 12/31/23 that resulted in a hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) to her forehead. On 01/03/23 at 08:30 AM, R10's wheelchair lacked a dycem pad. On 01/04/03 at 07:45 AM, Certified Nurse Aide (CNA) G reported that if staff do not look at the resident Kardex (nursing tool that gives a brief overview of the care needs of each resident) each day, they would likely not know that a dycem pad should be in R10's wheelchair. On 01/03/23 at 11:27 AM, Administrative Nurse B revealed that R10 should have dycem pad in her wheelchair per the instructions in the care plan to reduce the risk of falls from R10 sliding out of her wheelchair. The facility's Fall and Accident Prevention Policy policy, dated 08/28/20, documented that the facility would provide an environment that was free from accident hazards that the facility had control, which included supervision and assistance to prevent avoidable accidents. The facility failed to provide a safe environment when staff did not ensure that a dycem pad in R10's wheelchair as documented in the care plan. This deficient practice created an accident hazard related to falls. 46960 The facility reported a census of 26 residents with 12 residents selected for review which included three residents reviewed for accident hazards. Based on observation, interview, and record review, the facility failed to provide a safe environment when staff failed to carry call light pagers hooked to the call light system to alert staff when the resident moved. Resident (R) 25 had a fall with minor injury and staff were unaware the alarm sounded to his movements prior to a fall. Findings include: - R25's Electronic Health Record (EHR) revealed the resident had diagnoses that included dementia (a progressive mental disorder characterized by failing memory, confusion) and benign prostatic hyperplasia (BPH - a non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections). The Admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of two, indicating severely impaired cognition. The resident required moderate assistance of staff for all cares, except eating. The resident utilized a walker or wheelchair for locomotion. The Cognitive Loss / Dementia Care Area Assessment (CAA) dated 10/12/23, documented the resident had impaired cognitive function and short-term memory loss related to dementia. The Falls CAA, dated 10/12/23, documented that the resident was at a moderate risk of falls related to confusion, lack of safety awareness, incontinence, and generalized weakness. The Care Plan dated 01/03/24, documented R25 was at moderate risk for falls and instructed staff to perform the following interventions: 1. On 10/04/23, instructed staff to anticipate and meet R25's needs. 2. On 10/04/23, instructed staff to ensure the call light was within reach and encourage the resident to use it for assistance. (With severely impaired cognition, this is ineffective as the resident would not remember.) 3. On 10/04/23, instructed staff to ensure the resident was wearing appropriate footwear when transferring and ambulating. 4. On 10/04/23 and revised on 11/01/23, instructed staff that the resident ambulated with a gait belt and walker. Staff were to pull the wheelchair behind the resident. 5. On 10/04/23, instructed staff to place a silent fall alarm on the resident's recliner and bed. (A type of alarm hooked to the call light system to alert staff of resident movements.) 6. On 11/21/23, instructed night shift nurses to carry call light pagers to help respond to the silent fall alarms in a timelier manner. The Fall Risk Assessments documented the following: 1. On 10/03/23, fall risk score of 14, which indicated the resident was at risk for falls. 2. On 11/21/23, fall risk score of 11, which indicated the resident was at risk for falls. Review of fall reports revealed that on 11/21/23 at 05:40 AM, R25 had a fall with minor injury. The root cause analysis investigation determined that the staff did not respond to R25's fall alarm in an adequate time to prevent the fall because they failed to carry the call light pagers with them. On 01/04/24 at 10:23 AM, Administrative Nurse B revealed her expectation was for all licensed nursing staff to carry the call light pagers to assist in answering call lights when the Certified Nurse Aides (CNAs) were busy with other call lights. Administrative Nurse B further explained that on the night of 11/21/23 when R25 fell , the nurse on duty was not wearing the call light pager as per her expectation. The facility's Fall and Accident Prevention Policy policy, dated 08/28/20, documented that the facility would provide an environment that was free from accident hazards that the facility had control, which included supervision and assistance to prevent avoidable accidents. The facility failed to provide a safe environment when staff failed to follow care planned interventions including to carry the call light pagers on the night shift when R25 had a fall with minor injury and staff were unaware he had called for help.

The facility census totaled 19 residents with eight residents included in the sample. Based on observation, interview, and record review the facility failed to provide written notice to the State Ombudsman of the 12/13/21 facility-initiated hospitalization transfer of Resident (R) 9. Findings included: - R9's Electronic Health Record (EHR) documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 10/13/21 Admission Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The 01/06/22 Quarterly MDS revealed a BIMS score of 15, which indicated intact cognition. The 12/13/21 Health Status Note documented R9 stated her pain was unbearable and that she would like to be transported to the emergency room . Observation on 02/16/22 at 09:44 AM revealed R9 sat in a recliner in her room, was pleasant, had a smile on her face and did not appear to be in any pain. On 02/16/22 at 11:59 AM, Social Services Designee (SSD) D stated she notified the ombudsman of any residents discharged to the hospital at the beginning of each month. SSD D stated she could not find this notification concerning R9's 12/13/21 hospitalization . On 02/16/22 at 12:16 PM, Administrative Nurse B stated it was her understanding the Social Services Designee (SSD) was the one who notified the ombudsman when a resident was transferred to the hospital. The facility did not provide a policy on ombudsman notification of resident transfer to the hospital. The facility failed to notify the ombudsman when R9 admitted to the hospital on 12/13/21.

The facility census totaled 19 residents with eight residents included in the sample. Based on observation, interview, and record review the facility failed to provide Resident (R) 9 or her representative with a bed hold policy upon transfer to the hospital. Findings included: - R9's Electronic Health Record (EHR) documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 10/13/21 Admission Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The 01/06/22 Quarterly MDS revealed a BIMS score of 15, which indicated intact cognition. The 12/13/21 Health Status Note documented R9 stated her pain was unbearable and that she would like to be transported to the emergency room . Observation on 02/16/22 at 09:44 AM revealed R9 sat in a recliner in her room, was pleasant, had a smile on her face and did not appear to be in any pain. On 02/16/22 at 11:49 AM, Licensed Nurse (LN) C stated R9 was sent to the hospital due to having had bad back pain. LN C stated there was a bed hold included in a hospital transfer packet that was provided at the time of transfer to the hospital, but was not signed by either R9 or her representative. On 02/16/22 at 12:16 PM, Administrative Nurse B stated the nurse should provide the bed hold policy upon transfer, but stated there was no current system to make bed holds were signed by the resident or their representative. The facility's Bed Hold Policy & Resident Return policy dated 02/07/22 documented, At the time a resident is transferred to a hospital .the resident/resident representative will be provided with, and asked to sign, a request for bed hold form. The facility failed to provide R9 or her representative with written notice concerning the facility's bed hold policy when R9 discharged to the hospital.

The facility had a census of 19 residents with 8 residents in the sample. Based on observation, interview, and record review the facility failed to perform blood sugar testing on two residents, Residents (R) 12 and R5 in a sanitary manner when Licensed Nurse (LN) C failed to clean the facility glucometer (instrument used to calculate blood glucose) after using it on the first resident and/or before testing the second resident. Findings included: Observation on 02/16/22 at 08:14 AM revealed LNC as she checked the blood sugar for R12. The nurse donned gloves and cleaned R12's finger with an alcohol pad. LN C then used a lancet (sharp object to pierce skin to obtain blood sample) to draw blood and placed a small drop of blood onto the glucometer strip. LN C then left the glucometer sitting on the counter and failed to clean it after use. Observation on 02/16/22 at 08:23 AM revealed LN C as she checked the blood sugar for R5. The nurse donned gloves and used an alcohol pad to clean R5's finger. Using a lancet to draw R5's blood, she then placed it on the strip in the uncleaned glucometer, which she previously used on R12. LN C then placed the glucometer in the top drawer of the medication cart without cleaning it after using it for both R12 and R5. On 02/16/22 at 08:30 AM LN C reported she probably should have cleaned the glucometer and took it back out of the cart. The nurse then put gloves on and cleaned it with a wet disinfecting wipe. On 02/16/22 at 09:45 AM Administrative Nurse B reported the glucometer should be cleaned after every use. She was of the understanding all residents receiving blood sugar checks had their own glucometer in the medication cart. The facility policy named Blood Glucose Monitoring dated 12/2016 revealed the licensed nurse would test a resident's blood sugar level with the facility provided glucometer. After each resident use, the glucose monitoring device would be thoroughly cleaned. The device would then be placed in a zip-loc bag labeled with that resident's name when appropriate. The facility failed to perform blood sugar testing on two residents in a sanitary manner by the failure to clean the facility glucometer after using it and before testing a second resident.

The facility had a census of 21 residents. Based on observation, interview, and record review the facility failed to identify causal factors to develop interventions to prevent avoidable falls for Resident (R) 1 with a fracture to the femur (large bone of upper leg) and Resident (R) 2 with no injury. Findings included: - Review of R1's Physician order [REDACTED]. Review of the Significant Change Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment. The resident required total care of 2 staff for transfers and extensive assistance of two staff for bed mobility. The resident had impaired range of motion (ROM) on both sides of the upper and lower extremities. The resident had balance problems and was only able to stabilize with assistance of staff. The resident had no falls since prior MDS dated [DATE]. The Cognition Care Area Assessment (CAA) dated 03/31/2020 revealed BIM score decreased to 11 from 15 since 12/2019. Care plan interventions focus towards helping the resident's memory improve now that she was back in the facility and her health was more stable. Familiar faces and visits with her daughter who worked in the facility will help assist with improving memory. Provide frequent reorientation during interactions. Other possible interventions to consider are memory games, calendar in room, daily orientation by staff, and encouraging her to come to the dining room for mealtimes. The Activities of Daily Living (ADL) CAA dated 03/31/20 revealed a decline in ADLs. The resident required a Hoyer lift (mechanical lift) for transfers, and assistance for all ADLs including assistance for bed mobility. The resident was non-ambulatory and required total assistance for locomotion, and extensive assistance for dressing. The Quarterly MDS dated [DATE] indicated the resident had a BIMS 15 which indicated intact cognition and had one fall with injury. No other significant changes since the previous MDS dated [DATE]. Review of the care plan dated 4/7/20 included: the following interventions: Resident required supervision to limited assistance of two staff to turn and reposition in bed every 2-3 hours and as necessary. The resident used a grab bar on her bed for repositioning purposes. (04/07/20) The resident required total assistance of two staff and a full Hoyer lift to move between surfaces when transferring. (04/10/2020) Keep the resident's bed in the lowest position and a fall mat beside her bed while she was in it. (07/20/2020) Hourly safety checks were implemented. Ensure personal items remain in reach and positioned safely in bed or recliner. (07/01/20) The resident is at risk for falls and has had actual falls with minor injuries related to poor balance and deconditioning. The resident rolled onto the floor out of bed when reaching for something in June 2020. (07/01/20) The care plan failed to include the safe use of the lift chair by the resident. Review of the Readmission assessment dated [DATE] revealed vital signs within normal range for the resident. She was alert and oriented with some forgetfulness, communicated verbally, speech was clear, can understand and be understood when speaking. Review of the nurse's Progress Notes dated 07/29/20 at 09:58 PM noted when resident the readmitted her [MEDICATION NAME] (diuretic medication that promotes excretion of urine) 1 milligram (mg) daily restarted. Review of the nurse's Progress Notes dated 07/31/20 06:35 PM revealed the nurse walked down the hallway, looked into the resident's room, and the resident was on the floor face down in front of her recliner. The resident denied hitting her head. The nurse assessed resident and she had a large skin tear on her right forearm, a bruise on right knee, and small cut on the bottom of the left foot. Vitals, neurological checks and ROMn WNL (within normal limits) for the resident. Staff lifted the resident with the Hoyer lift to her bed. Staff cleansed and dressed her wounds. Staff notified the physician with no new orders, and the Durable Power of Attorney (DPOA), Director of Nursing (DON), and Administrator notified. The nurse encouraged the resident to always use her call light for staff assistance. She stated she understood. Review of the nurse's Progress Notes dated 08/02/20 at 03:10 AM noted the resident neuro checks, grip and strength WNL for resident with stable vital signs Resident's affect was quite flat (without expression). Denied complaints or needs, but was very quiet. The nurse's Progress Notes dated 08/02/20 at 02:33 PM stated at 10:55 AM Certified Nurse Aide (CNA) D and this nurse (writer of note) went in to reposition the resident. The resident complained of leg pain. The resident requested to be sent to the emergency room (ER) for an x-ray of her right knee. Spoke with her Durable Power of Attorney (DPOA) and it was agreed to send her via ambulance. Left message with the Director of Nursing (DON). Emergency Medical Service (EMS) arrived and with assistance of 2 people and the Hoyer lift with her right leg supported by an EMS worker and transferred her to the gurney with no difficulty. The resident transferred via EMS to the ER at 11:35 AM. Review of the nurse's Progress Notes dated 08/02/20 at 08:52 PM revealed the resident transferred from the local ER to a larger hospital for more care via ambulance with a [DIAGNOSES REDACTED]. Review of the Fall Checklist dated 07/31/20 described a fall the resident had on 07/31/20 at 05:45 PM. The resident was found face down on the floor in front of her lift chair all the way lifted into the standing position. The resident had ROM within normal limits for her. A large skin tear on right forearm, wrist and bottom of left foot. A bruise on her right knee. The resident was alone at time of fall. The resident raised her lift chair up to standing position and fell forward. The fall investigation lacked causal factors or care plan review for new interventions. Review of the resident's electronic record lacked any safety assessment for the use of the lift chair. No observation of the resident obtained due to remaining in a hospital in another city. During an interview on 08/18/20 at 10:30 AM CNA D reported the resident frequently messed with her chair. She would go up and down and up and down. She could reach her controls, so she kept them on her lap most of the time. During an interview on 08/18/20 at 01:45 PM Licensed Nurse C reported she was the nurse on duty at the time of the resident's fall. She reported the resident adjusted her chair often moving her feet up and down. She did not know of any kind of assessment for the safety of using a lift chair and the resident had access to the remote. She reported she never updated the care plan and that was not her job. The DON updated the care plans. During an interview on 08/18/20 at 01:50 PM Administrative Nurse B reported the resident was clear and we go by the residents BIMS scores as to whether she was alert or not. She reported the nurses should be updating the care plans with interventions after falls, and if not them when the DON reviewed she should update it. During an interview on 08/18/20 at 02:00 PM Administrative Nurse A reported there was no assessment done on residents to determine who was safe with a lift chair. Staff tried to keep the controls in the pocket on the side of the chair, but the resident can reach the pocket and get to the controls. Nursing should be revising the care plans as falls happen. She reviewed all falls after they happen. Review of the facility's Falls policy with a revision date of 04/2017 revealed: Residents who have a history of frequent falls or have high risk factors for falling will be identified to prevent falls. If a resident has had a fall when applicable new interventions will be put into place to assist in trying to prevent further falls. Using the facility fall form assess resident to determine risk of falls, toileting habits, medications taken, weakness, confusion, or any other risk factor. Use the information obtained to make new care plan intervention which is related to the cause of that fall that is appropriate for the individual resident, and place on the plan of care. The facility failed to assess R1 for safe use of an electric lift chair. The resident fell from the chair after raising the chair to the high position and sustained a broken leg. - Review of R2's signed Physician order [REDACTED]. The Annual Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating normal cognition. The resident required limited assistance of one staff for toileting. The resident had balance issues and was not steady only with staff assistance. The resident had 2 falls since prior MDS dated [DATE]. Review of the Fall Care Area Assessment (CAA) dated 03/10/20 revealedthe resident had two actual falls during the last quarter because she ambulated much better, was stronger, more confident, and now wanted to get up and ambulate without assistance from staff which was unsafe due to balance problems. Review of the Care Plan dated 07/20/20 revealed: The resident was at risk for falls related to impaired mobility and decreased safety awareness due to [MEDICAL CONDITION] and dementia. The resident had unwitnessed falls. (07/20/20) Maintain call light within reach. (03/15/19) Place resident's table in front of her rather than beside her while she is in the chair, so she has all her personal items in front of her and won't try to get up to look for them. (07/20/20) Re-direct and re-orient the resident to room and facility as needed. (03/15/19) Social Service Designee (SSD) will do 1:1 with resident 1-2 times weekly. (09/16/19) Ensure that resident's call light was in her lap rather than on her table, so she will remember to call before getting up. (04/27/20) Toileting - The resident was incontinent of urine at times, especially at night. Wears pull ups. Needed assist of 1 staff and limited to extensive to toilet due to transfers. Encourage toileting before meals and at bedtime. (12/19/19) Transfers - Required assistance of one staff with use of 4-wheel walker. The resident often required verbal cueing/commands, allow additional time, and resident was slow to respond at times. (09/19/19) No new interventions added to the care plan or evidence of review with falls that occurred on 07/30/20 and 08/01/20. The nurse's Progress Notes dated 06/28/20 at 04:00 PM revealed the resident was found up by herself several times this shift, without using the call light for assistance. Resident stated she needed to go home for different reasons. Staff encouraged the resident to use the call light and wait for staff assistance when wanting to get up. Resident stated, she knew that, but needed to go. Staff was unable to successfully redirect the resident. Review of the nurse's Progress Notes dated 07/01/20 at 03:21 AM stated that earlier in the shift, staff observed the resident attempting to get up out of her chair without calling for assistance. Reminded the resident to call before getting up, then assisted the resident to toilet, change clothes, and go to bed. No further behaviors noted or reported this shift. Review of the nurse's Progress Notes dated 07/05/20 at 04:13 AM stated that earlier this shift, the resident was found up ambulating in her room without assistance and without calling, two separate times. Both times, the resident toileted within an hour before, and she had her personal items and call light in reach. The resident denied needing to toilet again and stated she couldn't remember why she was up. Nurse's Progress Notes dated 07/07/20 at 04:57 AM revealed the resident ambulated with her walker from her room all the way to the living room area last evening. Staff assisted her back to her room without incident. Review of the nurse's Progress Notes dated 07/10/20 at 04:54 AM stated the day shift passed on in report that the resident was found up ambulating in hallway alone and without calling for assistance. Resident was found twice in the night, attempting to get up from her chair and up from her bed without calling for assistance. Review of the nurse's Progress Notes dated 07/17/20 at 05:11 AM noted the resident attempted ambulation independently last evening without using her call light. The nurse's Progress Notes dated 07/18/20 at 06:02 PM revealed a CNA called the nurse to the resident's room. Upon arrival found the resident sitting on the floor between her recliners up against the wall. Resident stated she was reaching for something and fell . Denied any pain currently. Assessment completed head to toe. No injuries noted. Vital signs taken and resident assisted up with gait belt to standing position. Resident ambulated with assist of 1 staff with gait belt to the lobby. Review of the Fall Checklist completed on 07/18/20 at 04:15 PM revealed the resident had an unwitnessed fall while reaching for something and fell . No injury noted. Care plan updated with new interventions to prevent another fall. Review of the nurse's Progress Notes dated 07/18/20 at 10:39 PM noted the resident had a small raised area on her occipital area (back of head). Vital signs and neurological checks within normal limits (wnl). No complaints related to fall. Review of the nurse's Progress Notes dated 07/22/20 at 05:03 AM indicated the resident was up ambulating last evening by herself with no other behaviors noted during the shift The nurse's Progress Notes dated 07/26/20 at 04:03 PM revealed the resident was ambulating in her room and pushing her walker out into the hallway without calling for staff assistance. When asked what she was doing she said she just wanted out of the entertainment. Staff assisted her to her recliner and educated her on use of her push button call light. She promptly used it, with staff in her room. When asked why she pushed it she said she guessed to let everyone know. Review of the nurse's Progress Notes dated 07/27/20 at 04:44 AM documented the resident attempted to get up on her own when her neighbor tried to help her, but otherwise no behaviors noted Review of the nurse's Progress Notes dated 07/30/20 at 05:56 PM stated on 7/30/20 at 03:30 PM staff called the nurse for an unwitnessed fall. Upon arriving the resident sat on the floor with her knees drawn up in between the recliners. Asked resident what happened, and she stated, I was plugging in the extension cords for the tv program. Assessed resident s vitals, neuros, and range of motion (ROM) wnl for the resident. Resident denied pain, but stated she hit her head. Palpated her head without resident distress. No redness, [MEDICAL CONDITION] or bruising noted. Placed gate belt on resident and with 2 staff assisted her to her feet and she used her walker to ambulate. to the living room. When sitting on the couch the resident stated her right knee hurt. Upon assessing, the right inner knee was found to be mildly tender, with no [MEDICAL CONDITION], redness or bruising noted. Notified the physician, Director of Nursing, Administrator, and Durable Power of Attorney. The Fall Checklist completed on 07/30/20 at 03:30 PM revealed the resident had an unwitnessed fall. Resident stated she was plugging in extension cords together for the TV show. The resident had no extension cords in her room. Resident had confusion and reported the inside of her right knee was tender. No injury found. The resident last toileted by staff at 3:00PM. No causal factors identified, and care plan not updated. Nurse's Progress Notes dated 07/30/20 at 05:57 PM stated the resident continued to have tenderness in the knee at dinner time. Staff administered ordered [MEDICATION NAME] (narcotic pain medication) for pain, and the resident stated that made it better. Denied further needs. Encouraged resident to always use call light for assistance. Review of the nurse's Progress Notes dated 08/01/20 at 03:59 PM revealed the nurse went to residents' room where she was found sitting on the floor in between her recliners. When asked what happened she stated she heard somebody yelling help, was getting up to help, lost balance, and fell . Denied hitting anything but her bottom. Assessment completed. Assisted up with gait belt and assist of 2 staff to standing position and the wheelchair. Resident denied any pain or discomfort. Educated the resident on the importance of using her call light when wanting to get up. Call lights were both in reach. Resident stated she would try to remember to use it next time. Review of the Fall Checklist completed on 08/01/20 at 03:05 PM revealed the resident had an unwitnessed fall in her room. She reported she thought she heard someone yell for help and she was getting up to go help them. Causal factors listed as increased confusion and disease process. The care plan failed to address the fall or plan any interventions to prevent her from falling again. Observation on 08/18/20 at 11:29 AM revealed the resident ambulated from the dining room accompanied by a staff member with use of a 4-wheel walker. The resident ambulated to the sofa in the TV area. The resident changed channels on the remote herself. Observation on 08/18/20 at 12:12 pm revealed the resident leaving the dining room following lunch ambulating with CNA E. The resident had a steady gait with walker and gait belt used. CNA E offered the bathroom when they entered the resident's room. Staff walked with the resident into the bathroom to toilet After using the toilet, the resident ambulated to her recliner and the call light placed on her lap. Staff placed the over bed table over the resident so she could easily reach it. During an interview on 08/18/20 at 11:30 AM CNA D reported the resident had falls. She tried to get up on her own. We have started checking her every 15 minutes. Our care guide stated every hour, but we do it more frequent. We make sure the resident had her call light in her lap or on the table by the resident. If the resident was restless staff offered walks down the hall. We also encouraged her to toilet every hour. During an interview on 08/18/20 at 02:16 PM CNA E reported the resident was a one-person assist, so she helped her with about everything. We check her frequently, whenever we walk past her door. To help keep her in bed without getting up we prop her legs up on pillows and she cannot sit up to get out of bed as easily as she is very impulsive. During an interview on 08/18/20 at 01:45 PM Licensed nurse C reported she assessed the resident after a fall, but she did not update the care plan with new interventions. During an interview on 08/18/20 at 01:50 PM administrative nurse B reported the resident was very impulsive and could not remember to use the call light. The nurses should be updating the care plan at the time of the fall. Review of the facility's Falls with a revision date of 04/2017 revealed: Residents who have a history of frequent falls or have high risk factors for falling will be identified to prevent falls. If a resident has had a fall when applicable new interventions will be put into place to assist in trying to prevent further falls. Using the facility fall form assess resident to determine risk of falls, toileting habits, medications taken, weakness, confusion, or any other risk factor. Use the information obtained to make New care plan intervention which is related to the cause of that fall that is appropriate for the individual resident, Place on Plan of Care. The facility failed to identify causal factors of the resident falls to plan new interventions to prevent the resident from falling.

The facility census totaled 21 residents (R) with 12 residents in the sample and four residents reviewed for hospitalization s. Based on observation, interview, and record review the facility failed to ensure staff completed notifications of transfer and discharge hospitalization paperwork for R4's and R15's facility-initiated hospitalization transfer. Findings included: - Review of R4 pertinent [DIAGNOSES REDACTED]. Review of the 11/04/19 Quarterly Minimum Data Set (MDS) revealed a brief interview for mental status (BIMS) score of 15, indicating intact cognition. Review of the 01/14/20 Significant Change MDS revealed a BIMS score of zero, indicating severely impaired cognition. R4 had a [MEDICAL CONDITION] (broken bone) noted. Review of the 01/14/20 Fall Care Area Assessment (CAA) revealed R4 had an actual fall on 12/29/19 with a [MEDICAL CONDITION]. Review of 05/05/16 Fall Care Plan revealed R4 had an unwitnessed fall with injury on 12/29/19. Review of 12/29/19 at 08:55 PM Health Status Note revealed R4 was transferred to Kiowa Hospital for evaluation and treatment after a fall. Review of undated Transfer/Discharge packet revealed incomplete forms and no written notification to the resident's family. Observation of R4 on 02/12/20 at 10:02 AM revealed the resident slept soundly. Interview with Social Services (SS) G on 02/12/20 at 11:06 AM revealed the nurse completed the discharge packets. SS G stated the facility also obtained a signature from the resident or resident's family noting the transfer, as well. Interview with Administrative Nurse B on 02/12/20 at approximately 02:00 PM revealed when residents admitted , SS G created Discharge/Transfer packets that were patient specific. The packets contained all of the resident's personal information and the appropriate paperwork needed to complete a transfer in a timely manner. When staff transferred a resident, the staff gave the packet to the Emergency Medical Services (EMS) or whoever took the resident to the hospital. The facility did no keep a copy of the information provided upon transfer. Interview with Licensed Nurse (LN) G on 02/13/20 at 08:46 AM revealed the LN's filled out the transfer forms and printed them, and she made copies and sent them with the resident upon tranfer. Review of 12/2016 Transfer and Discharge Voluntary and Involuntary policy revealed the purpose of the policy was to ensure proper notice and procedure prior to a resident's discharge. Before the facility discharged a resident, the facility notified the resident/resident representative in writing. The facility failed to ensure staff properly documented R4's discharge paperwork and notifications of transfer when staff transferred the resident to the hospital. - Review of R15's pertinent [DIAGNOSES REDACTED]. Review of the 06/28/19 Significant Change Minimum Data Set (MDS) revealed a brief interview for mental status (BIMS) score of 15, indicating intact cognition. Review of the 01/07/20 Quarterly MDS revealed a BIMS score of 15, indicating intact cognition. R15 had a UTI during the review period. Review of the 06/28/19 Urinary Care Area Assessment (CAA) revealed R15 had a history of [REDACTED]. Review of 01/14/16 UTI Care Plan revealed R15 had a history of [REDACTED]. Review of Transfer/Discharge Packet dated 01/14/20 revealed incomplete forms and no written notice to R15's family. Review of 1/14/20 at 03:56 PM Health Status Note revealed the facility sent R15 to the hospital for evaluation of a UTI. Observation of R15 on 02/12/20 at 10:05 AM revealed the resident in bed, eating breakfast without difficulty. Interview with Social Services (SS) G on 02/12/20 at 11:06 AM revealed the nurses completed the discharge packets. SS G said the facility obtained a signature from the resident or family noting the transfer as well. Interview with Administrative Nurse B on 02/12/20 at approximately 02:00 PM revealed when residents admitted , SS G created Discharge/Transfer packets that were patient specific. The packets contained all of the resident's personal information and the appropriate paperwork needed to complete a transfer in a timely manner. When staff transferred a resident, the staff gave the packet to the Emergency Medical Services (EMS) or whoever took the resident to the hospital. The facility did no keep a copy of the information provided upon transfer. Interview with Licensed Nurse (LN) G on 02/13/20 at 08:46 AM revealed the LN's filled out the transfer forms and printed them, and she made copies and sent them with the resident upon tranfer. Review of 12/2016 Transfer and Discharge Voluntary and Involuntary policy revealed the purpose of the policy was to ensure proper notice and procedure prior to a resident's discharge. Before the facility discharged a resident, the facility notified the resident/resident representative in writing. The facility failed to ensure staff properly documented R15's discharge paperwork and notifications of transfer when staff transferred the resident to the hospital.

The facility census totaled 21 residents (R) with 12 residents in the sample. Based on observation, interview, and record review the facility failed to ensure facility staff documented R12's wound care visits and woudn care assessment and measurements to ensure continuity of care. Findings included: - Review of R12's pertinent [DIAGNOSES REDACTED]. Review of the 09/09/19 Annual Minimum Data Set (MDS) revealed a brief interview for mental status (BIMS) score of 13, indicating intact cognition. R12 had venous/arterial ulcers (ulcers caused by blood flow issues) noted with applications of wound dressings. Review of the 12/03/19 Quarterly MDS revealed a BIMS score of 15, indicating intact cognition. R12 had venous/arterial ulcers noted with applications of wound dressings. Review of the 09/09/19 Care Area Assessments (CAA) revealed no applicable CAA triggered. Review of R12's 09/10/18 Care Plan revealed he had [MEDICAL CONDITION] ([MEDICAL CONDITION], a blood circulation disorder that causes the blood vessels (arteries/veins) outside of the heart and brain to narrow, block, or spasm) related to [MEDICAL CONDITIONS] (a chronic progressive condition that affects the pumping power of your heart muscles). On 12/02/19, R12 was diagnosed with [REDACTED]. On 12/11/19, staff were to complete treatments or dressing changes to the resident's bilateral lower legs as ordered by the physician as indicated. R12 was being monitored through the wound clinic for his BLE wounds. Review of Physician order [REDACTED].>01/25/20, R12 should have Unna boots (compression wraps) to both lower extremities, staff were to wrap BLE with [MEDICATION NAME] (gauze wrap) and change the dressings every 72 hours for legs weeping (draining fluid). 01/24/20, Skin assessments completed weekly by staff on Friday during day shift. Review of (MONTH) 2020 Skin Observation tool revealed a missing weekly skin check between 01/24/20 and 02/04/20. Review of Electronic Medical Records (EMR) dated 12/02/19 to 01/08/20 for R12 revealed no documentation for the wound clinic visits. Review of Health Status Notes/Administration Notes/Skin/Wound Notes dated 12/02/19 to 02/11/20 revealed no wound measurements or descriptions of wounds documented. Observation of R12 on 02/11/20 at 09:23 AM revealed dressings to BLE in place. Interview with Licensed Nurse (LN) G on 02/12/20 at 03:06 PM revealed the nurses replaced his Unna boots every three days and assessed his pedal pulses (pulses on the top of the feet), [MEDICAL CONDITION] (swelling), measured the wound every Wednesday. LN G said the staff charted those on the Treatment Administration Record (TAR), and completed a progress note for health status. LN G said she documented wound measurements and dressings in the progress notes, and she was not sure where the other nurses documented. Interview with Administrative Nurse B on 02/13/20 at 10:57 AM revealed the facility was working on a more structured documentation method for wound care, but she would have expected the nurses to make a progress note with measurements and descriptions of the wounds and the dressings applied. Administrative Nurse B stated R12 went to the wound clinic from 12/02/19 to 01/08/20, and the facility did not have the notes from his visits to the wound clinic. Review of 02/2017 (revision pending for 2020) Significant Skin injury revealed the facility would routinely monitor the skin condition .until resolved. The facility failed to ensure staff documented R12's wound care to ensure continuity of care.

The facility census totaled 21 residents (R) with 12 residents in the sample, and one resident sampled for catheterization. Based on observation, interview, and record review the facility failed to ensure facility staff documented R4's urinary output and catheter care to ensure continuity of care. Findings included: - Review of R4's pertinent [DIAGNOSES REDACTED]. Review of the 11/04/19 Quarterly Minimum Data Set (MDS) revealed a brief interview for mental status (BIMS) score of 15, indicating intact cognition. Review of the 01/14/20 Significant Change MDS revealed a BIMS score of zero, indicating severely impaired cognition. The MDS noted R4 with an indwelling catheter. Review of the 01/14/20 Urinary Care Area Assessment (CAA) revealed R4 re-admitted on [DATE] with an indwelling catheter placed on 01/04/2020 at the hospital due to [MEDICAL CONDITION]. Review of 01/08/20 Indwelling Catheter Care Plan revealed R4 had an indwelling catheter placed on 01/04/20 while at the hospital due to significant [MEDICAL CONDITION] which was an issue in the past as well. Staff were to complete catheter care with peri-care three times daily and as needed and were instructed to empty and record the amount of urine in the catheter bag three times daily with cares. The staff were also instructed to monitor and document output as per the facility policy. Review of Bowel & Bladder Catheter Care three times a day (TID) dated 01/23/20 to 02/12/20 revealed three missing areas documentation since R4 had her catheter in place. Review of Catheter Output TID dated 01/24/20 to 02/12/20 revealed 11 missing areas of documentation since R4 had her catheter in place. Observation of R4 on 02/13/20 at 10:02 AM revealed appropriate catheter care completed. Interview with Certified Nurse Aide (CNA) I on 02/13/20 at 09:17 AM revealed the CNA's completed the catheter care every shift and should document that care every shift along with the urine output from the catheter bag. Interview on 02/13/20 at 08:06 AM with Licensed Nurse (LN) G revealed the CNA's documented the catheter care and completed it every shift, and she double checked their documentation. Interview with Administrative Nurse B on 02/13/20 at 07:06 AM revealed she expected the CNAs to document urinary catheter output and catheter care every shift after completion. Review of 10/2016 Indwelling Catheter policy revealed the facility would ensure ongoing comprehensive care for resident's with indwelling catheters. The facility failed to ensure facility staff documented R4's urinary output and catheter care to ensure continuity of care.

The facility census totaled 21 with 12 Residents (R) sampled. Based on observation, interview, and record review the facility failed to have to the Survey Book (a book or folder containing the facility survey and/or complaint results for the last three years) readily accessible for all residents, family members, and legal representatives to view. Findings included: - On 02/11/20 at approximately 12:00 PM Administrative staff A asked the surveyors if they had taken the Survey Book and stated the book was missing from the posted location (a bookshelf in the living room area). She reported she did not know how long the survey results book were missing and needed to add information to it. Observation on 02/11/20 with Administrative Staff A confirmed the book was missing and not on the bookshelf and the posted sign read the survey book location would be on the bookshelf. During the Resident Council meeting (with R8, R10, R12, R16, R17, and R22) 02/11/20 at 01:04 PM all residents denied knowledge of the Survey Book or its location. Review of Resident Council Minutes from (MONTH) 2019 through (MONTH) 2020 revealed the facility did not discuss the location of the Survey Book during the monthly meetings. During the Exit Meeting on 02/12/20 at approximately 01:00 PM Administrative Staff A revealed she found the book in her office. She reported she had removed the book the previous Friday to add her Fire Inspection results to it and forgot to put it back. She stated she would ensure the Survey Book location and education of what it entailed would be added to the Resident Counsel minutes list. Review of the facility policy Examination of Survey Results dated 01/24/20 revealed the facility would make survey results available for examination in a place readily accessible to residents, by either posting the results themselves or a notice of their availability. The facility failed to have to the Survey Book readily accessible for residents, family members, and legal representatives to view.

The facility reported a census of 25 residents. Based on observation, interview, and record review the facility failed to monitor and follow up on a right lower extremity wound dressing in place for cognitively impaired resident #1 with a history of [MEDICAL CONDITION] (skin infection caused by bacteria characterized by heat, redness and swelling) and poor tissue perfusion (decreased supply of [MEDICATION NAME] blood to a body part). The right lower extremity wound dressing remained in place for 11 days (2/11/19-2/22/19) and the resident's skin grew into the dressing and required 2 days of treatment to remove the full dressing (fully removed on 2/24/19). From 2/11/19-2/21/19 the facility nursing staff did not document on the unchanged dressing to the resident's right lower extremity, even though the nursing staff monitored an area on the resident's right pinky toe daily due to [MEDICAL CONDITION]. Findings included: - Review of resident #1's medical record revealed the following Diagnoses: [REDACTED].) pain, [MEDICAL CONDITION] (skin infection caused by bacteria characterized by heat, redness and swelling), and history of a 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) on his/her buttock. Review of the significant change minimum data set ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 4, indicating severe cognitive impairment. The resident required extensive assistance of 1 staff with bed mobility and assistance of 2 staff with transfers. The resident experienced functional limitations in range of motion (ROM) on one side of his/her lower extremities and used a wheelchair for mobility. The resident received routine and as needed (PRN) pain medications and non-medication interventions for moderate pain which made it hard for him/her to sleep and limited his/her day-to-day activities for 5 days out of the look back period. The resident was at risk for pressure ulcers and had no current unhealed pressure ulcers. The resident had 4 venous/arterial ulcers, no foot [MEDICAL CONDITION], and a surgical wound present. The resident received a pressure reduction device for his/her chair and bed, a turning and repositioning program, nutrition/hydration interventions to manage skin problems, pressure ulcer/injury care, and applications of dressings to his/her feet. Review of the care plan dated 1/20/19 revealed the resident had a [DIAGNOSES REDACTED]. 8/28/18: The resident's right lower extremity ultrasound revealed occlusions (the blockage or closing of a blood vessel) in the mid and distal superficial femoral artery (blood vessel of the leg which supplies blood to the lower extremity). 1/20/19: The resident followed up his/her right foot care at a clinic. The care plan did not address wound care to his/her right foot before 2/22/19. Based on interview with administrative nursing staff A, physician extender staff D, and from review of the progress notes in the resident's medical record, an unknown person placed a dressing on resident #1's right lower extremity 11 days prior to 2/22/19. Administrative nursing staff A reported the resident's wound dressing had a date of 2/11/19, when discovered on 2/22/19 embedded in the resident's skin. Review of the resident's medical record lacked evidence of a wound treatment order, placement of a dressing, monitoring of the wound, or any staff identification of the wound dressing placed on the resident. Review of the 2/14/19 at 8:09 p.m. orders administration note (generated with the Medication Administration Record [REDACTED]. Review of the 2/15/19 at 6:43 a.m. orders administration note revealed the resident received [MEDICATION NAME] 5-325 milligrams (mg) for complaints of pain to right lower extremity/foot and the resident rated his/her pain and stated, it's a 10! Review of the 2/15/19 at 10:48 a.m. orders administration note revealed the resident received Tylenol 650 mg as needed for pain, given prior to getting out of bed as was too early for [MEDICATION NAME]. Review of the 2/15/19 at 7:40 p.m. orders administration note revealed the resident receive [MEDICATION NAME] 5-325 mg for complaints of his/her foot hurting. Review of the 2/16/19 at 5:16 a.m. orders administration note revealed the staff administered [MEDICATION NAME] 5-325 milligrams (mg) due to the resident yelling out that his/her foot hurt. Review of the 2/16/19 at 2:07 p.m. orders administration note revealed the staff administered [MEDICATION NAME] 5-325 milligrams (mg) given prior to the resident getting out of bed to prevent extreme pain on his/her right foot. Review of the 2/17/19 at 11:12 p.m. order administration note revealed the staff administered [MEDICATION NAME] 5-325 mg to the resident due to the resident complaint his/her right foot pain. Review of the 2/18/19 at 8:44 p.m. order administration note revealed the staff administered [MEDICATION NAME] 7.5-325 mg to the resident due to the resident complaints of pain to his/her right lower extremity/foot. Review of the 2/20/19 at 8:23 a.m. physician's progress note revealed the resident was very lethargic and difficult to arouse and if the resident had any decline the nursing staff would let the physician know. Review of the progress note dated 2/22/19 at 4:43 p.m. revealed the nursing staff notified the physician extender of the resident's right lower extremity being very purple. The resident did have chronic [MEDICAL CONDITION] (abnormal condition affecting the blood vessels). The nurse reported the resident dressing appeared to have grown into the skin and the nurse could not remove the dressing because it's so stuck. The progress note read: Based on electronic charting it appeared the dressing had been in place for 11 days without being checked or bandages changed. The physician extender ordered the nurse to soak the area with triple antibiotic ointment (TAO) and Santyl (enzymatic [MEDICATION NAME] ointment) to detach the dead superficial skin from the dressing in order to completely remove the dressing and apply fresh dressings. The physician extender noted the resident's dressings needed to be changed daily. Review of the 2/22/19 at 5:44 p.m. progress note revealed the resident's dressing on his/her right foot was stuck on his/her sock and on his/her dressing wrap. The unidentified nursing staff instructed the shower aide to soak the area with water. The nursing staff then removed the sock with some of the scab sticking to the sock and was not able to totally remove the wrap due to it being stuck to the wound bed. The staff cut around the dressing to remove as much as possible, applied [MEDICATION NAME] to scabbed area, applied TAO, [MEDICATION NAME] (specialized gauze pads used to cover wounds), and wrapped with gauze wrap. The staff notified the physician extender of the dark purple color to the resident's foot. Staff noted the resident was very lethargic and the dressing change was very painful to the resident. Staff administered [MEDICATION NAME] to the resident. Review of the 2/23/19 at 4:26 p.m. progress note revealed staff went to change the resident dressing to his/her right foot and ankle and the resident seemed warm to touch. The resident temperature was 101.4 degrees Fahrenheit. Staff noted the resident was very confused and talked in circles. Review of the 2/24/19 at 4:48 p.m. progress note revealed the staff changed the dressing on the resident' right foot and ankle. The staff noted they removed the old dressing and the imbedded small dressings removed easily. Staff cleansed wound bed with [MEDICATION NAME] by pouring it over wound beds, applied TAO, covered with [MEDICATION NAME] and wrapped with gauze wrap. Review of the 2/27/19 at 6:00 p.m. progress note revealed the staff changed the dressing to the resident's right foot and noted the tips of the resident's toes were black and cool to the touch, tops of the toes were blanchable and cool to the touch, and staff marked areas of black with a permanent marker to better track the progression of blackened areas. The progress note contained measurements to the wound inner right ankle measured 6 centimeters (cm) length x 4.1 cm width x 0.2 cm depth with moderate amounts of purulent (producing or containing pus) drainage. The wound to the outer side of right foot wound measured 5 cm in length x 9.1 cm in width and 0.1 cm in dept with minimal serous (clear) drainage. Review of the (MONTH) (YEAR) treatment administration record (TAR) revealed the staff monitored the resident's right pinky toe wound until completely healed and used a dressing, as needed (PRN), daily related to [MEDICAL CONDITION] of unspecified part of limb with a start date of 11/4/18 and had been documented as completed daily. The (MONTH) (YEAR) TAR revealed 7 days which lacked monitoring of the right pinky toe. The TAR did not address the right lower extremity wound noted from 2/22/19. review of the resident's medical record revealed [REDACTED]. On 2/22/19 an order read: Until the old dressing was able to be removed, saturate the affected area on the right lower extremity with TAO and Santyl (make sure not to apply to any healthy skin). After removal of the old adhered dressing, apply [MEDICATION NAME] AG (soft antimicrobial foam dressing that absorbs exudate and maintains a moist wound environment) to affected sores on right lower extremity, cover with sterile 4 inch x 4 inch gauze and secure with an ACE wrap. Change and monitor daily. Review of the treatment administration record (TAR) from 2/22/19-2/28/19 revealed the staff administered the treatment daily for 5 days and did not change the dressing on 2/28/19. Review of the 3/8/19 physician visit form from the resident's 3/7/19 appointment with the wound care physician revealed the resident right foot was necrotic (pertaining to the death of tissue in response to disease or injury) and the physician recommended amputation. Review of the TAR from 3/1/19-3/17/19 revealed an order to cleanse all eschar areas of the resident's right foot with [MEDICATION NAME], apply non-adherent pads and secure with gauze, change daily and as needed (PRN), every day shift related to [MEDICAL CONDITION] (abnormal condition affecting the blood vessels). The staff did not document completion of the treatment on 3/11/19 or 3/16/19. Review of the progress note from 3/16/19 at 3:03 p.m. revealed the resident's foot remained black form tips of toes past bases. The skin on the toes were peeling and shriveling. The wound to the top of the foot was dry, black, and leathery. The inner ankle had a yellow, thick, sticky consistency and the heel and tendon on the back of the ankle were still intact, but dark. Observation on 3/21/19 at 8:55 a.m., licensed nursing staff B removed the dressing to the resident's right foot. The entirety of the right foot and all the toes were black eschar and the eschar appeared dry and cracked. There was a very large open, draining wound on the interior right ankle. The resident was non-verbal and did not indicate pain via expressions/sounds during removal of dressing or exposure to air. There was wound drainage, but no odor. The right heel had a small circular area of eschar/hardened blister. Observation on 3/21/19 at 2:00 p.m. revealed the the resident appeared to be actively dying, and the unidentified hospice nurse stated the resident appeared to be actively dying. Interview with licensed nursing staff B on 3/21/19 at 8:55 a.m. revealed the foot issues began with a little sore between two toes on the resident's right foot. Staff B stated after the area healed there was an open area on both sides of the resident's right foot. Staff B stated the resident sat with his/her feet crossed over each other all the time and thought that was where those areas came from. The resident had stents placed to improve his/her circulation and which worked really well initially, but the circulation quickly decreased shortly thereafter. The dressings were ordered for twice weekly changes and PRN. Staff B stated staff effectively pre-medicated the resident prior to dressing changes and stated staff watched the resident closely. Interview with administrative nursing staff A on 3/21/19 at 1:45 p.m. revealed he/she was aware of the dressing that did not get changed for 11 days. Staff A knew it was 11 days because he/she pulled the dressing out of the trash and saw the date on it. Staff A said when he/she checked to see how that possibly could have happened, every single nurse at the facility missed it and all missed changing it. Staff A really did not investigate any further than that. We did not report it as neglect and he/she did not have an investigation into the dressing change getting missed. Interview with administrative staff C on 3/21/19 at 4:30 p.m. revealed it was a really bad time when the dressing was not done for the resident. Staff C stated he/she was not at the facility much due to a car accident. Staff C said it was not reported and the facility did not have an investigation available. During an interview on 3/28/19 at 10:45 a.m. with the former administrative nursing staff A revealed he/she did not know who placed the dressing on the resident. An unidentified staff member brought the concern over the resident's dressing to the nurse on 2/22/19, and the nurse told staff A about it. He/she went and retrieved the dressing from the resident's trash and noted it was dated from 11 days prior (2/11/19). He/she researched to find an order for [REDACTED]. Staff A thought the resident had wound care clinic orders. The facility discovered the dressing on a Friday and he/she had a surgical appointment on the Tuesday prior (which was missed). During an interview 3/28/19 at 11:07 a.m. with physician extender D revealed he/she knew about the situation with the dressing. He/she did not know who applied the dressing and staff notified him/her on the day it had been on for 11 days. Staff D stated he/she ordered to remove the stuck dressing with TAO and Santyl and said the dressing was adhered in the resident's skin. Staff D said the staff soaked the dressing to get the old bandage off all of the way. Staff did not see an order for [REDACTED]. Staff D said the physician increased dosage on 2/17/19 due to an increase in the pain, but did not see where the order stated the location of the increased pain. Staff D stated the increase made the resident drowsy, so they reverted to the PRN. Staff D expected staff to notify him/her off any dressing not changed within 48 to 72 hours. Staff D stated this situation boggled us and he/she did not know where the dressing came from. Review of the facility policy regarding skin assessments, revised 9/2017, revealed the staff would document findings on skin/wound note in the electronic charting system, in progress notes, and incorporate into the plan of care. The wound characteristics should be assessed throughout the healing process to assure the treatments and dressings being used are appropriate to the nature of the wound. Review of the facility policy regarding abuse, neglect and exploitation revised 3/2018 revealed neglect was the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The facility failed to monitor and follow up on a right lower extremity wound dressing in place for cognitively impaired resident #1 with a history of [MEDICAL CONDITION] (skin infection caused by bacteria characterized by heat, redness and swelling) and poor tissue perfusion (decreased supply of [MEDICATION NAME] blood to a body part). The right lower extremity wound dressing remained in place for 11 days (2/11/19-2/22/19) and the resident's skin grew into the dressing and required 2 days of treatment to remove the full dressing (fully removed on 2/24/19). From 2/11/19-2/21/19 the facility nursing staff did not document on the unchanged dressing to the resident's right lower extremity, even though the nursing staff monitored an area on the resident's right pinky toe daily due to [MEDICAL CONDITION].

The facility reported a census of 25 residents. Based on interview and record review the facility failed to report an allegation of neglect to the state survey and certification agency as required by federal regulation, when the facility staff neglected the care of the right lower extremity wound dressing in place for cognitively impaired resident #1 with a history of [MEDICAL CONDITION] (skin infection caused by bacteria characterized by heat, redness and swelling) and poor tissue perfusion (decreased supply of [MEDICATION NAME] blood to a body part). The right lower extremity wound dressing remained in place for 11 days (2/11/19-2/22/19) and the resident's skin grew into the dressing and required 2 days of treatment to remove the full dressing (fully removed on 2/24/19). From 2/11/19-2/21/19 the facility nursing staff did not document on the unchanged dressing to the resident's right lower extremity, even though the nursing staff monitored an area on the resident's right pinky toe daily due to [MEDICAL CONDITION]. Findings included: - Review of resident #1's medical record revealed the following Diagnoses: [REDACTED].) pain, [MEDICAL CONDITION] (skin infection caused by bacteria characterized by heat, redness and swelling), and history of a 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) on his/her buttock. Review of the significant change minimum data set ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 4, indicating severe cognitive impairment. The resident required extensive assistance of 1 staff with bed mobility and assistance of 2 staff with transfers. The resident experienced functional limitations in range of motion (ROM) on one side of his/her lower extremities and used a wheelchair for mobility. The resident received routine and as needed (PRN) pain medications and non-medication interventions for moderate pain which made it hard for him/her to sleep and limited his/her day-to-day activities for 5 days out of the look back period. The resident was at risk for pressure ulcers and had no current unhealed pressure ulcers. The resident had 4 venous/arterial ulcers, no foot [MEDICAL CONDITION], and a surgical wound present. The resident received a pressure reduction device for his/her chair and bed, a turning and repositioning program, nutrition/hydration interventions to manage skin problems, pressure ulcer/injury care, and applications of dressings to his/her feet. Review of the care plan dated 1/20/19 revealed the resident had a [DIAGNOSES REDACTED]. 8/28/18: The resident's right lower extremity ultrasound revealed occlusions (the blockage or closing of a blood vessel) in the mid and distal superficial femoral artery (blood vessel of the leg which supplies blood to the lower extremity). 1/20/19: The resident followed up his/her right foot care at a clinic. The care plan did not address wound care to his/her right lower extremity before 2/22/19. Based on interview with administrative nursing staff A, physician extender staff D, and from review of the progress notes in the resident's medical record, an unknown person placed a dressing on resident #1's right lower extremity 11 days prior to 2/22/19. Administrative nursing staff A reported the resident's wound dressing had a date of 2/11/19, when discovered on 2/22/19 embedded in the resident's skin. Review of the resident's medical record lacked evidence of a wound treatment order, placement of a dressing, monitoring of the wound, or any staff identification of the wound dressing placed on the resident. Review of the 2/14/19 at 8:09 p.m. orders administration note (generated with the Medication Administration Record [REDACTED]. Review of the 2/15/19 at 6:43 a.m. orders administration note revealed the resident received [MEDICATION NAME] 5-325 milligrams (mg) for complaints of pain to right lower extremity/foot and the resident rated his/her pain and stated, it's a 10! Review of the 2/15/19 at 10:48 a.m. orders administration note revealed the resident received Tylenol 650 mg as needed for pain, given prior to getting out of bed as was too early for [MEDICATION NAME]. Review of the 2/15/19 at 7:40 p.m. orders administration note revealed the resident receive [MEDICATION NAME] 5-325 mg for complaints of his/her foot hurting. Review of the 2/16/19 at 5:16 a.m. orders administration note revealed the staff administered [MEDICATION NAME] 5-325 milligrams (mg) due to the resident yelling out that his/her foot hurt. Review of the 2/16/19 at 2:07 p.m. orders administration note revealed the staff administered [MEDICATION NAME] 5-325 milligrams (mg) given prior to the resident getting out of bed to prevent extreme pain on his/her right foot. Review of the 2/17/19 at 11:12 p.m. order administration note revealed the staff administered [MEDICATION NAME] 5-325 mg to the resident due to the resident complaint his/her right foot pain. Review of the 2/18/19 at 8:44 p.m. order administration note revealed the staff administered [MEDICATION NAME] 7.5-325 mg to the resident due to the resident complaints of pain to his/her right lower extremity/foot. Review of the 2/20/19 at 8:23 a.m. physician's progress note revealed the resident was very lethargic and difficult to arouse and if the resident had any decline the nursing staff would let the physician know. Review of the progress note dated 2/22/19 at 4:43 p.m. revealed the nursing staff notified the physician extender of the resident's right lower extremity being very purple. The resident did have chronic [MEDICAL CONDITION] (abnormal condition affecting the blood vessels). The nurse reported the resident dressing appeared to have grown into the skin and the nurse could not remove the dressing because it's so stuck. The progress note read: Based on electronic charting it appeared the dressing had been in place for 11 days without being checked or bandages changed. The physician extender ordered the nurse to soak the area with triple antibiotic ointment (TAO) and Santyl (enzymatic [MEDICATION NAME] ointment) to detach the dead superficial skin from the dressing in order to completely remove the dressing and apply fresh dressings. The physician extender noted the resident's dressings needed to be changed daily. Review of the 2/22/19 at 5:44 p.m. progress note revealed the resident's dressing on his/her right foot was stuck on his/her sock and on his/her dressing wrap. The unidentified nursing staff instructed the shower aide to soak the area with water. The nursing staff then removed the sock with some of the scab sticking to the sock and was not able to totally remove the wrap due to it being stuck to the wound bed. The staff cut around the dressing to remove as much as possible, applied [MEDICATION NAME] to scabbed area, applied TAO, [MEDICATION NAME] (specialized gauze pads used to cover wounds), and wrapped with gauze wrap. The staff notified the physician extender of the dark purple color to the resident's foot. Staff noted the resident was very lethargic and the dressing change was very painful to the resident. Staff administered [MEDICATION NAME] to the resident. Review of the (MONTH) (YEAR) treatment administration record (TAR) revealed the staff monitored the resident's right pinky toe wound until completely healed and used a dressing, as needed (PRN), daily related to [MEDICAL CONDITION] of unspecified part of limb with a start date of 11/4/18 and had been documented as completed daily. The (MONTH) (YEAR) TAR revealed 7 days which lacked monitoring of the right pinky toe. The TAR did not address the right lower extremity wound noted from 2/22/19. review of the resident's medical record revealed [REDACTED]. On 2/22/19 an order read: Until the old dressing was able to be removed, saturate the affected area on the right lower extremity with TAO and Santyl (make sure not to apply to any healthy skin). After removal of the old adhered dressing, apply [MEDICATION NAME] AG (soft antimicrobial foam dressing that absorbs exudate and maintains a moist wound environment) to affected sores on right lower extremity, cover with sterile 4-inch x 4 inch gauze and secure with an ACE wrap. Change and monitor daily. Review of the treatment administration record (TAR) from 2/22/19-2/28/19 revealed the staff administered the treatment daily for 5 days and did not change the dressing on 2/28/19. Observation on 3/21/19 at 8:55 a.m., licensed nursing staff B removed the dressing to the resident's right foot. The entirety of the right foot and all the toes were black eschar and the eschar appeared dry and cracked. There was a very large open, draining wound on the interior right ankle. The resident was non-verbal and did not indicate pain via expressions/sounds during removal of dressing or exposure to air. There was wound drainage, but no odor. The right heel had a small circular area of eschar/hardened blister. Observation on 3/21/19 at 2:00 p.m. revealed the resident appeared to be actively dying, and the unidentified hospice nurse stated the resident appeared to be actively dying. Interview with administrative nursing staff A on 3/21/19 at 1:45 p.m. revealed he/she was aware of the dressing that did not get changed for 11 days. Staff A knew it was 11 days because he/she pulled the dressing out of the trash and saw the date on it. Staff A said when he/she checked to see how that possibly could have happened, every single nurse at the facility missed it and all missed changing it. Staff A really did not investigate any further than that. We did not report it as neglect and he/she did not have an investigation into the dressing change getting missed. Interview with administrative staff C on 3/21/19 at 4:30 p.m. revealed it was a really bad time when the dressing was not done for the resident. Staff C stated he/she was not at the facility much due to a car accident. Staff C said it was not reported and the facility did not have an investigation available. Review of the facility policy regarding abuse, neglect and exploitation revised 3/2018 revealed neglect was the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The policy revealed any staff or person providing services within the facility must report any knowledge of alleged violations immediately to the charge nurse/director of nursing. All alleged violations will be reported and all substantiated incidents reported to the administrator, state agency, adult protective services and to all other agencies as required, and law enforcement when applicable. Reporting of all alleged violations should occur within 2 hours if abuse or serious bodily injury occurs or within 24 hours if no abuse and no bodily injury occurred, to the proper authorities - the state agency complaint hotline. The facility failed to report an allegation of neglect to the state survey and certification agency as required by federal regulation, when the facility staff neglected the care of the right lower extremity wound dressing in place for cognitively impaired resident #1 with a history of [MEDICAL CONDITION] (skin infection caused by bacteria characterized by heat, redness and swelling) and poor tissue perfusion (decreased supply of [MEDICATION NAME] blood to a body part). The right lower extremity wound dressing remained in place for 11 days (2/11/19-2/22/19) and the resident's skin grew into the dressing and required 2 days of treatment to remove the full dressing (fully removed on 2/24/19). From 2/11/19-2/21/19 the facility nursing staff did not document on the unchanged dressing to the resident's right lower extremity, even though the nursing staff monitored an area on the resident's right pinky toe daily due to [MEDICAL CONDITION].

The facility reported a census of 25 residents. Based on interview and record review the facility failed to investigate an allegation of neglect, when the facility staff neglected the care of the right lower extremity wound dressing in place for cognitively impaired resident #1 with a history of [MEDICAL CONDITION] (skin infection caused by bacteria characterized by heat, redness and swelling) and poor tissue perfusion (decreased supply of [MEDICATION NAME] blood to a body part). The right lower extremity wound dressing remained in place for 11 days (2/11/19-2/22/19) and the resident's skin grew into the dressing and required 2 days of treatment to remove the full dressing (fully removed on 2/24/19). From 2/11/19-2/21/19 the facility nursing staff did not document on the unchanged dressing to the resident's right lower extremity, even though the nursing staff monitored an area on the resident's right pinky toe daily due to [MEDICAL CONDITION]. The facility did not conduct an investigation regarding the neglect of resident #1. Findings included: - Review of resident #1's medical record revealed the following Diagnoses: [REDACTED].) pain, [MEDICAL CONDITION] (skin infection caused by bacteria characterized by heat, redness and swelling), and history of a 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) on his/her buttock. Review of the significant change minimum data set ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 4, indicating severe cognitive impairment. The resident required extensive assistance of 1 staff with bed mobility and assistance of 2 staff with transfers. The resident experienced functional limitations in range of motion (ROM) on one side of his/her lower extremities and used a wheelchair for mobility. The resident received routine and as needed (PRN) pain medications and non-medication interventions for moderate pain which made it hard for him/her to sleep and limited his/her day-to-day activities for 5 days out of the look back period. The resident was at risk for pressure ulcers and had no current unhealed pressure ulcers. The resident had 4 venous/arterial ulcers, no foot [MEDICAL CONDITION], and a surgical wound present. The resident received a pressure reduction device for his/her chair and bed, a turning and repositioning program, nutrition/hydration interventions to manage skin problems, pressure ulcer/injury care, and applications of dressings to his/her feet. Review of the care plan dated 1/20/19 revealed the resident had a [DIAGNOSES REDACTED]. 8/28/18: The resident's right lower extremity ultrasound revealed occlusions (the blockage or closing of a blood vessel) in the mid and distal superficial femoral artery (blood vessel of the leg which supplies blood to the lower extremity). 1/20/19: The resident followed up his/her right foot care at a clinic. The care plan did not address wound care to his/her right lower extremity before 2/22/19. Based on interview with administrative nursing staff A, physician extender staff D, and from review of the progress notes in the resident's medical record, an unknown person placed a dressing on resident #1's right lower extremity 11 days prior to 2/22/19. Administrative nursing staff A reported the resident's wound dressing had a date of 2/11/19, when discovered on 2/22/19 embedded in the resident's skin. Review of the resident's medical record lacked evidence of a wound treatment order, placement of a dressing, monitoring of the wound, or any staff identification of the wound dressing placed on the resident. Review of the 2/14/19 at 8:09 p.m. orders administration note (generated with the Medication Administration Record [REDACTED]. Review of the 2/15/19 at 6:43 a.m. orders administration note revealed the resident received [MEDICATION NAME] 5-325 milligrams (mg) for complaints of pain to right lower extremity/foot and the resident rated his/her pain and stated, it's a 10! Review of the 2/15/19 at 10:48 a.m. orders administration note revealed the resident received Tylenol 650 mg as needed for pain, given prior to getting out of bed as was too early for [MEDICATION NAME]. Review of the 2/15/19 at 7:40 p.m. orders administration note revealed the resident receive [MEDICATION NAME] 5-325 mg for complaints of his/her foot hurting. Review of the 2/16/19 at 5:16 a.m. orders administration note revealed the staff administered [MEDICATION NAME] 5-325 milligrams (mg) due to the resident yelling out that his/her foot hurt. Review of the 2/16/19 at 2:07 p.m. orders administration note revealed the staff administered [MEDICATION NAME] 5-325 milligrams (mg) given prior to the resident getting out of bed to prevent extreme pain on his/her right foot. Review of the 2/17/19 at 11:12 p.m. order administration note revealed the staff administered [MEDICATION NAME] 5-325 mg to the resident due to the resident complaint his/her right foot pain. Review of the 2/18/19 at 8:44 p.m. order administration note revealed the staff administered [MEDICATION NAME] 7.5-325 mg to the resident due to the resident complaints of pain to his/her right lower extremity/foot. Review of the 2/20/19 at 8:23 a.m. physician's progress note revealed the resident was very lethargic and difficult to arouse and if the resident had any decline the nursing staff would let the physician know. Review of the progress note dated 2/22/19 at 4:43 p.m. revealed the nursing staff notified the physician extender of the resident's right lower extremity being very purple. The resident did have chronic [MEDICAL CONDITION] (abnormal condition affecting the blood vessels). The nurse reported the resident dressing appeared to have grown into the skin and the nurse could not remove the dressing because it's so stuck. The progress note read: Based on electronic charting it appeared the dressing had been in place for 11 days without being checked or bandages changed. The physician extender ordered the nurse to soak the area with triple antibiotic ointment (TAO) and Santyl (enzymatic [MEDICATION NAME] ointment) to detach the dead superficial skin from the dressing in order to completely remove the dressing and apply fresh dressings. The physician extender noted the resident's dressings needed to be changed daily. Review of the 2/22/19 at 5:44 p.m. progress note revealed the resident's dressing on his/her right foot was stuck on his/her sock and on his/her dressing wrap. The unidentified nursing staff instructed the shower aide to soak the area with water. The nursing staff then removed the sock with some of the scab sticking to the sock and was not able to totally remove the wrap due to it being stuck to the wound bed. The staff cut around the dressing to remove as much as possible, applied [MEDICATION NAME] to scabbed area, applied TAO, [MEDICATION NAME] (specialized gauze pads used to cover wounds), and wrapped with gauze wrap. The staff notified the physician extender of the dark purple color to the resident's foot. Staff noted the resident was very lethargic and the dressing change was very painful to the resident. Staff administered [MEDICATION NAME] to the resident. Review of the (MONTH) (YEAR) treatment administration record (TAR) revealed the staff monitored the resident's right pinky toe wound until completely healed and used a dressing, as needed (PRN), daily related to [MEDICAL CONDITION] of unspecified part of limb with a start date of 11/4/18 and had been documented as completed daily. The (MONTH) (YEAR) TAR revealed 7 days which lacked monitoring of the right pinky toe. The TAR did not address the right lower extremity wound noted from 2/22/19. review of the resident's medical record revealed [REDACTED]. On 2/22/19 an order read: Until the old dressing was able to be removed, saturate the affected area on the right lower extremity with TAO and Santyl (make sure not to apply to any healthy skin). After removal of the old adhered dressing, apply [MEDICATION NAME] AG (soft antimicrobial foam dressing that absorbs exudate and maintains a moist wound environment) to affected sores on right lower extremity, cover with sterile 4-inch x 4 inch gauze and secure with an ACE wrap. Change and monitor daily. Review of the treatment administration record (TAR) from 2/22/19-2/28/19 revealed the staff administered the treatment daily for 5 days and did not change the dressing on 2/28/19. Observation on 3/21/19 at 8:55 a.m., licensed nursing staff B removed the dressing to the resident's right foot. The entirety of the right foot and all the toes were black eschar and the eschar appeared dry and cracked. There was a very large open, draining wound on the interior right ankle. The resident was non-verbal and did not indicate pain via expressions/sounds during removal of dressing or exposure to air. There was wound drainage, but no odor. The right heel had a small circular area of eschar/hardened blister. Observation on 3/21/19 at 2:00 p.m. revealed the resident appeared to be actively dying, and the unidentified hospice nurse stated the resident appeared to be actively dying. Interview with administrative nursing staff A on 3/21/19 at 1:45 p.m. revealed he/she was aware of the dressing that did not get changed for 11 days. Staff A knew it was 11 days because he/she pulled the dressing out of the trash and saw the date on it. Staff A said when he/she checked to see how that possibly could have happened, every single nurse at the facility missed it and all missed changing it. Staff A really did not investigate any further than that. We did not report it as neglect and he/she did not have an investigation into the dressing change getting missed. Interview with administrative staff C on 3/21/19 at 4:30 p.m. revealed it was a really bad time when the dressing was not done for the resident. Staff C stated he/she was not at the facility much due to a car accident. Staff C said it was not reported and the facility did not have an investigation available. Review of the facility policy regarding abuse, neglect and exploitation revised 3/2018 revealed neglect was the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The policy revealed any staff or person providing services within the facility must report any knowledge of alleged violations immediately to the charge nurse/director of nursing. All alleged violations will be reported and all substantiated incidents reported to the administrator, state agency, adult protective services and to all other agencies as required, and law enforcement when applicable. Reporting of all alleged violations should occur within 2 hours if abuse or serious bodily injury occurs or within 24 hours if no abuse and no bodily injury occurred, to the proper authorities - the state agency complaint hotline. The facility failed to investigate an allegation of neglect, when the facility staff neglected the care of the right lower extremity wound dressing in place for cognitively impaired resident #1 with a history of [MEDICAL CONDITION] (skin infection caused by bacteria characterized by heat, redness and swelling) and poor tissue perfusion (decreased supply of [MEDICATION NAME] blood to a body part). The right lower extremity wound dressing remained in place for 11 days (2/11/19-2/22/19) and the resident's skin grew into the dressing and required 2 days of treatment to remove the full dressing (fully removed on 2/24/19). From 2/11/19-2/21/19 the facility nursing staff did not document on the unchanged dressing to the resident's right lower extremity, even though the nursing staff monitored an area on the resident's right pinky toe daily due to [MEDICAL CONDITION]. The facility did not conduct an investigation regarding the neglect of resident #1.

The facility reported a census of 24 residents with 13 in the sample. Based on observation, interview and record review the facility failed to ensure cognitively impaired dependent resident #15 received ordered diagnostic testing in relation to the resident's swallowing issues as ordered by the physician and weight loss interventions to include weight monitoring and nutritional supplements to address the residents severe weight loss of 7.74% in one month (#15). The facility further failed to follow the physician's order for Ensure supplements according to meal percentage eaten for 2 of 2 residents reviewed. (#15, #7) Findings included: - Review of resident #15's [DIAGNOSES REDACTED]. stomach pain or discomfort, nausea, bloating and belching), gastro [MEDICAL CONDITION] reflux (the backflow of stomach contents to the esophagus), anxiety (a mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), [DIAGNOSES REDACTED] (low level of potassium in the blood), heart failure ([MEDICAL CONDITIONS] is a condition with low heart output and the body becomes congested with fluid), and muscle wasting and atrophy (decrease in size of a part of the body). Review of the admission minimum data set ((MDS) dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 3, which indicated severe cognitive impairment. The resident required limited assistance of one staff with eating. The resident had no swallowing issues indicated and his/her weight was noted at 87 pounds (lbs.) on admission. The resident had no natural teeth. Review of the care area assessment (CAA) dated 12/19/18 revealed care areas triggered for further evaluation included cognitive loss/dementia, visual function, communication, psychosocial well-being, activities, nutritional status, and dental care. Review of the CAA revealed all were blank and incomplete. Review of Nutritional Risk assessment dated [DATE] revealed a score of 14, indicating the resident was at high risk for nutrition needs. Review of care plan dated 12/20/18 revealed the following: The resident had a nutritional problem or potential nutritional problem related to history of chronic idiopathic constipation, [MEDICAL CONDITION], fluid overload, Parkinson disease, [DIAGNOSES REDACTED]. Interventions dated 12/21/18 directed staff to: Invite the resident to activities that promote additional intake. Monitor/document/report as needed any signs or symptoms of dysphagia (difficulty or discomfort in swallowing): pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, if the resident appeared concerned during meals. Monitor/record/report to physician signs and symptoms of malnutrition: emaciation (the state of being abnormally thin or weak), muscle wasting, significant weight loss: 3lbs in 1 week, greater than 5% in 1 month, greater than 7.5% in 3 months, greater than 10% in 6 months. Obtain/monitor lab/diagnostic work as ordered, report results to physician and follow-up as indicated Provide and serve diet as ordered. Monitor intake and record every meal. Registered Dietician to evaluate and make diet change recommendations as needed. Encourage small frequent feedings for the resident instead of large meals, give supplements if needed to maintain adequate nutrition, and encourage good fluid intake. Intervention initiated 1/9/19 revealed the resident required assistance of 1 staff member to eat. Intervention initiated 1/9/19 revealed the staff would monitor/document for signs or symptoms of malnutrition, did not force the resident to eat, offered small frequent feedings and monitor/document food preferences. A care planned approach dated 1/17/19 indicated that the resident had a swallowing problem related to complaints of difficulty or pain with swallowing, coughing, choking during meals or swallowing medications and included the following interventions: All staff informed of residents' special dietary and safety needs. Diet to be followed as prescribed. Staff would instruct resident to eat in an upright position, to eat slowly, and to chew each bite thoroughly. Staff would monitor for shortness of breath, choking, labored respirations, lung congestion. Staff would monitor/document/report as needed any signs or symptoms of dysphagia (difficulty or discomfort in swallowing): pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, if resident appeared concerned during meals. Refer to speech therapist for swallowing evaluation. Resident to eat only with supervision. Review of weights (in pounds) revealed a weight loss of 6.5 lbs. in a month, which is a 7.74% weight loss. No weights completed in (MONTH) (YEAR) due to the scale was broken. Other weights noted include: 12/20/18 (weight noted on prior facility paperwork) - 87 lbs. 1/9/19- 84 lbs. 1/16/19- 83.5 lbs. 1/23/19- 87.5 lbs. 2/1/19- 79.5 lbs. 2/8/19- 77.5 lbs. Review of the health status note dated 12/21/18 revealed the resident did not eat well, and staff offered him/her a strawberry shake for lunch. Review of the physician order dated 12/21/18 revealed an order for [REDACTED]. Review of the health status note dated 12/26/18 revealed the resident ate a shake for breakfast and drank a couple glasses of water. Review of progress note dated 1/8/19 at 9:40AM revealed the resident had trouble swallowing breakfast. Staff noted the resident coughing up a moderate amount of mucus while attempting to cough up a bite of food. Review of health status note dated 1/8/19 at 1:13PM revealed to monitor for possible choking and aspiration. The resident struggled with breakfast foods that morning (waffle with syrup, ground meat, juice). He/he made gurgling sounds as though he/she was attempting to clear his/her throat for over an hour. The staff reported he/she was shoving food in rapidly and would not slow his/her pace. Staff offered water and the resident took small sips. The dietary managers notified the dietitian for recommendations. The dietician recommended a swallow study to be performed-and it was possible the appointment could not be performed on the date. Preventative measures for the resident were to change his/her diet to pureed today, offer smaller portions at a time, yet more portions in attempts to relieve residents' hunger, and included staff presence/assist at each meal throughout the meal. Review of a late entry note dated 1/8/19 revealed dietary staff notified the Medical Director and Director of Nursing the resident had signs and symptoms of possible aspiration. In an email communication, staff reported the resident needed a swallow study S.T.A.T (as soon as possible/immediately) and to inform the physician or provider immediately of swallowing issues. Recommended pureed diet until further evaluation via swallow study. Order dated 1/9/19 indicated a need for Modified [MEDICATION NAME] Swallow (A video fluoroscopic swallowing exam (VFSE), also referred to as a modified [MEDICATION NAME] swallow exam (MBS), or sometimes a speech swallow exam, is a radiologic examination of swallowing function that uses a special movie-type x-ray called fluoroscopy) for dysphagia. Review of the physician's verbal and phone document dated 1/9/19 revealed an order for [REDACTED]. Review of nutrition note dated 1/24/19 at 2:55 PM revealed new diet orders continued with conflicting textures 'regular diet, mechanical soft, regular consistency'. The kitchen currently served pureed diet texture with thin liquids until swallow study results. Nutrition note revealed no swallow study had been completed. Review of the resident's medical record lacked evidence of a completed swallow study. Review of Progress note dated 1/31/19 indicated a regular diet, pureed texture, regular consistency; conflicting diet orders noted. Review of Dietary Meal sheets revealed: Meal sheet dated 2/3/19 notes that resident refused lunch, no Ensure given. Meal sheet dated 2/6/19 notes that resident ate 25% of dinner, no Ensure given. Meal sheet dated 2/7/19 notes that resident refused breakfast, no Ensure was given. Meal sheet dated 2/8/19 notes that resident ate 30% for breakfast and lunch, and no Ensure was given. Meal sheet dated 2/12/19 reveals that resident ate 25% of lunch, no Ensure was given. Observation on 2/12/19 at 11:30 AM of Resident # 15 revealed the resident was in the dining room and received assistance from direct care staff G. The resident ate 25% of his/her pureed meal and staff failed to offer the resident a nutritional supplemental shake/Ensure. Review of the dietary sheet dated 2/12/19 lacked evidence the facility offered the resident Ensure with lunch. Interview with Direct Care Staff A on 2/13/19 at 2:15 PM revealed staff encouraged the resident to feed him/herself when possible, but stated the resident got off track easily. The nurse gave supplements, if ordered. The dietary staff recorded meal intakes, nurses and dietary both administered supplements. Staff weighed all residents monthly except for specific weight orders, those weights could be obtained weekly or sooner. Staff A never saw the resident refuse a meal, but he/she had refused a supplement before. Staff A did not think he/she has refused weights. If the resident refused, the staff might try to offer something else to eat or give him/her an Ensure. Staff A thought the resident had gained weight but stated the facility scales were broken in (MONTH) (YEAR). The nurse usually notified the direct care staff if there was a change to the treatment plan and direct care staff could look at care plans but was not sure if anything had changed with the resident. Staff A said the resident had an issue with swallowing and that is why they put the resident on the pureed diet, and he/she was supposed to have a swallow evaluation. Interview with Licensed Staff B on 2/13/19 at 10:54 AM revealed the facility scale was broken in (MONTH) when the resident admitted . Staff B stated the facility used the weight from where the resident had admitted from. The ensure should populate on the MAR/TAR and sometimes they would give an Ensure. Dietary document the supplements given. As far as his/her [MEDICATION NAME] swallow test, Staff B called for clarification on the type of swallow study ordered. After receipt of the clarification, staff B contacted the local clinic and asked them what was needed and gave the order to Staff D and it was rescheduled due to the weather. Staff B stated it was scheduled for 1/30/19, but someone cancelled/rescheduled, and staff B did not see anything scheduled sooner. When the resident first admitted he/she was on [MEDICATION NAME] (medication used to treat anxiety with a common side effect of lethargy) and was lethargic and would not eat or anything. The facility contacted the physician for a dose reduction that amount and noted the resident ate better now. Interview with Consulting Dietary Staff C on 2/13/19 at 10:15 AM revealed the dietary aides usually filled out the dietary meal sheets, and the nurse looked at the sheets and gave the Ensure accordingly-- depending on the percentage and the order. Interview with Social Service Staff D on 2/13/19 at 11:53 AM revealed the dietician dealt with the supplements (Ensures) given, along with nursing. The resident should always get the supplement if he/she had not eaten more than 50% while he/she was still in the dining room. Staff D reported the resident had a STAT [MEDICATION NAME] swallow ordered and it was delayed due to the need for clarification of the order and insurance had to approve it. Staff D stated the nursing notes should have documentation of notifying the doctor about the delay and why. Interview with Nursing Staff E on 2/14/19 at 11:45AM revealed the facility did not have a speech therapist and the resident would have to be sent out of the facility for a swallow study. Staff E stated he/she expected a swallow study to be completed immediately upon order. Staff E stated he/she expected the local clinic to contact the facility if there were any issues in scheduling, so the facility could make other arrangements. Staff E expected staff to document meal intake and offer an Ensure, as per the care plan and orders. Interview with physician Staff F on 2/14/19 at 12:05 PM revealed he/she was not aware the resident had significant weight loss and stated with his/her [DIAGNOSES REDACTED]. Staff F was aware of the residents swallowing issues but was not aware the resident needed a STAT swallow study. Staff F expected to be notified within 24 hours when addressing aspiration concerns and a resident's inability to tolerate the diet consistency. Staff E expected the facility staff to call if the appointment was scheduled/ rescheduled within the next working day. Staff E was not contacted about problems with scheduling. Review of Food and Nutrition Services Policy dated (MONTH) (YEAR) revealed the purpose and scope of the dietary department was to provide a program that met the nutritional needs of all patients and residents. Standardized methods and practiced in the preparation and presentation of therapeutic and/or modified diets in accordance with the attending physician's orders. Consideration was given to the patients' physical, psychological and social needs. Recognition was also given to the patients' individual eating habits, which were sometime influenced by cultural or religious background. The dietary program was based on a nutritional review of the needs of the individual resident. The recommended standards were adjusted as to age, sex, and activity of the individual. Procedures indicated that all nutritional care was recorded in the medical record in accordance with facility policy with timely and periodic assessment of patient/resident tolerance and acceptance of their prescribed diet conducted. The registered Dietician would participate in the monitoring and evaluation of the quality and appropriateness of nutritional care. Follow-up notes would serve as the re-assessment of the patient's nutritional needs and nutrition care plan. The facility failed to ensure cognitively impaired resident #15 received ordered diagnostic testing in relation to the resident's swallowing issues as ordered by the physician, failed to implement timely and effective weight loss interventions to include weight monitoring and nutritional supplements to address the residents severe weight loss of 7.74% in one month for this cognitively impaired dependent resident (#15). - Review of resident #7's signed physician orders dated 1/7/19 revealed the following Diagnoses: [REDACTED]. Review of the significant change in status minimum data set ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 6 indicating severe cognitive impairment. The resident required limited assistance of 1 staff for eating. The resident was dependent on a wheelchair for locomotion. The resident weighed had no weight loss. Review of the quarterly MDS dated [DATE] revealed a (BIMS) score of 7 indicating severe cognitive impairment. The resident required limited assistance of one with eating. The resident had significant weight loss since the previous assessment. Review of the care area assessment (CAA) dated 4/25/18 revealed: Nutrition CAA- resident was on a mechanical soft diet and required supervision with meals and set-up help. She/he had no weight loss and ate most of meals but was at risk for weight loss due to altered diet. The resident was ok with diet. Review of the care plan dated 10/28/18 revealed: The resident had unplanned/unexpected weight loss related to poor food intake. Give the resident supplements as ordered. Alert nurse/dietitian if not consuming supplement on a routine basis. The resident had potential for a nutritional problem related to [MEDICAL CONDITION], Anxiety Disorder, Major [MEDICAL CONDITION], and [MEDICAL CONDITION] Approaches included- Monitor/record/report to practitioner as needed, signs or symptoms of malnutrition, including emaciation (Cachexia), muscle wasting, and significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. 2/15/17. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Provide and serve a diet of his/her choice. Oral intake varied some; offer healthy choices. Give him/her foods that have a mechanical soft texture due to chewing difficulty. Resident enjoyed eating in room. 7/31/18 Registered dietician (RD) to evaluate and make diet change recommendations as needed (PRN). 7/13/18 Recommend Ensure three times a day (TID) PRN if resident ate less than 50% of a meal due to varying oral (PO) intake- 10/28/18 Review of the physician order dated 8/28/18 revealed regular mechanical soft diet with regular liquids. Review of the dietician recommendation dated 10/23/18 revealed Ensure supplement PRN if resident ate less than 50% of a meal. Review of the physician orders dated 10/29/18 revealed an order for [REDACTED]. Review of the dietary supplement list provided by the facility, which identified all residents with orders for nutritional supplements at the time of the survey revealed the resident was not included as receiving any supplement. Review of the meal documentation for last 30 days revealed 53 meals in which the resident ate less than 50% of the meal. Observation on 2/11/19 at approximately 3:30 p.m. revealed the resident sat in a recliner with feet elevated. the resident was sleeping with a plate of food on his/her chest partially eaten. The rest of the food tray sat untouched on the bedside table. Observation on 2/12/19 at 10:00 a.m. revealed 2 unidentified direct care staff in the resident's room obtained vitals and offered the resident a snack. Observation on 2/13/19 at 9:00 a.m. revealed the resident sat in the dining room with a plate of 2 pieces of French toast. The food was cut in bite size pieces and the resident had the fork in his/her hand but did not eat. A staff member sat by the resident and another resident and encouraged him/her to eat. Further observation at 10:00 a.m. revealed the resident consumed a few bites of food and staff did not offer a nutritional supplement to the resident. During an interview on 2/13/19 at 10:05 a.m. direct care staff G reported he/she encouraged the resident to eat but could not force him/her to eat. When asked what he/she did if the resident did not eat, Staff G stated he/she did not do anything more, but encouraged the resident. Staff G stated he/she offered the resident a snack sometimes, but did not offer a nutritional supplement and he/she did not know what the care plan addressed regarding nutritional supplements. During an interview on 2/13/19 at 8:30 a.m. licensed nurse E reported the resident picked at his/her food during meals, and it required time for him/her to eat. Staff E stated there was no excuse for the resident's plate to be set on his/her chest and remain in the room until close to the evening meal. During an interview on 2/13/19 at 10:00 a.m. with dietary manager L he/she reported the resident was never put on the supplement list and had not been receiving any supplement. During a follow up interview on 2/13/19 at 11:10 a.m. dietary manager L reported he/she looked up the physician order for [REDACTED]. During an interview on 2/13/19 at 10:30 a.m., licensed nurse E did not know staff were to provide Ensure to the resident. Review of the facility policy for Food and Nutrition Services dated 12/2018 revealed the policy did not include the use of supplements. The facility failed to provide ordered supplements when the resident ate 50% or less of meals.

The facility census totaled 24 with 13 sampled. Based on observation, interview and record review the facility failed to properly assess, obtain a physician order [REDACTED].#15. Findings included: - Review of resident #15's signed physician orders [REDACTED]. Review of the admission minimum data set ((MDS) dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 3, which indicated severe cognitive impairment. The assessment further lacked evidence the resident used a restraint during the observation period for the assessment Review of the resident's assessments lacked any evidence the facility assessed the resident for a lap buddy(a device that fits in a wheelchair and assists with reminding a person not to get up by him/herself)/use of restraints. Review of care plan initiated 12/21/18 lacked any evidence or direction regarding the resident's use of a lap buddy or any restraint Observation of the resident on 2/12/19 at 11:30 AM revealed the resident sat in his/her wheelchair with tray/lap buddy in place. Observation of the resident on 2/12/19 at 2:19 PM with Administrative Staff E present revealed the resident could not verbalize or demonstrate how to open his/her lap buddy. The resident could remove the Velcro part of the lap buddy device, with direction from Staff E, however could not open the tray. Staff E stated he/she saw the resident lift the tray prior to this observation, however the resident could not lift the tray at this time. The resident's record lacked evidence the facility assessed the resident's ability to apply/remove the lap buddy. Observation of the resident on 2/13/19 at 10:32 AM revealed the resident with his/her head on the lab buddy tray. Interview with resident #15's family member on 2/13/19 at 12:46 PM revealed he/she had prior falls when he/she attempted to stand up independently. Facility staff reported to the resident's family the lap buddy would help the resident stay in his/her wheelchair and would give him/her a table to do activities on. Interview with direct care staff G on 2/13/19 at 1:24 PM revealed the facility implemented a lap buddy for the resident in (MONTH) (YEAR) for safety when the resident had a high risk for falls. The facility had an in-service/training on how to use the lap buddy. Staff G stated the resident used the lap buddy when he/she used his/her wheelchair. The resident remained in his/her wheelchair with the lap buddy in place up to 2 hours due to his/her risk of skin breakdown. Staff G reported he/she did not know if the resident's lap buddy was identified on his/her care plan. Staff G stated there was no charting in place to document the use of the lap buddy and he/she stated the lap buddy would not be a restraint due to the way it was being used for resident #15 (to prevent falls). Staff G stated he/she did not know what the facility policy on restraints said. Staff G further reported the risk of the resident using the lap buddy would be the resident would not be able to get out of it without assistance, if he/she wanted to. Interview with Direct Care Staff A on 2/13/19 at 2:15 PM revealed the resident had a lap buddy in place as a precaution because he/she liked to lean over, and it kept him/her from falling forward. Staff A did not know if there were interventions on the resident's care plan related to the use of the lap buddy. Staff A further stated he/she did not chart on the use of the lap buddy. Staff A stated a risk of using the lap buddy was it could be considered a restraint. The resident lifted the lap buddy tray at times but did not fully remove the tray. Interview with Licensed Staff B on 2/13/19 at 10:54 AM revealed the facility implemented a lap buddy for the resident to prevent falls. Staff B stated he/she did not know if the lap buddy was on resident #15's care plan or identified on the resident's MDS. Staff B stated the facility did not have a physician's orders [REDACTED]. Staff B acknowledged the need for assessing and charting use of a lap buddy if the resident had an order for [REDACTED]. Interview with administrative Staff E on 2/18/19 at 2:08 PM revealed the residents lap buddy should not be considered a restraint. A restraint was considered to be anything a person is not able to move, lift up or take away to be able to get out. Any discussion about restraints should involve the resident's family. A physician's orders [REDACTED]. The Facility failed to provide a policy regarding Restraint use as requested on 2/13/2019. The facility failed to properly assess, obtain a physician order [REDACTED].#15.

The facility census totaled 22 residents with 14 sampled and 2 of those residents reviewed for accidents. Based on interview and record review the facility failed to ensure staff were trained to use the mechanical lifts and followed the care as planned for 1 resident (#6) who received a fracture. Findings included: - Review of resident #6's signed physician progress notes [REDACTED]. Review of the annual MDS (minimum data set) dated 5/27/15 revealed a BIMS (brief interview for mental status) score of 10 indicating moderate cognitive impairment. The resident had no behaviors or rejection of cares. The resident required total assistance of 2 staff for bed mobility, transfers, dressing, toileting, and personal hygiene. The resident had frequent incontinence of urine, occasional pain, and no falls since the previous MDS. Review of the quarterly MDS dated [DATE] revealed the resident's status was the same as the MDS completed on 5/27/15. Review of the CAT (care area triggers) dated 5/27/15 revealed cognition and ADL function/rehabilitation triggered for further assessment. Review of the CAAs (care area assessment) revealed none of the CAAs were completed. Review of the care plan revised on 9/24/15 revealed the resident required a mechanical lift with the use of a full sling and 2 staff assistance for transfers. The care plan was then revised on 11/23/15 with the following interventions: The staff needed to monitor/document/report as needed, any changes in cognitive function, specifically changes in recall and general awareness, level of consciousness, and mental status. Anticipate his/her need for pain relief and respond immediately to any complaint of pain. Notify physician if interventions were unsuccessful or if current complaint of pain is a significant change from his/her past experience of pain. The care plan was revised on 1/29/16 with suspected DVT (deep vein thrombosis, a blood clot in a deep vein) related to immobility. Interventions included to inspect legs and feet for skin color and temperature. The care plan notebook also included an undated piece of paper with multiple interventions for different residents titled HOT TOPIC which directed staff they needed to use a full mechanical lift for resident #6 at all times. Review of the nurse's notes revealed the following documentation: 1/26/16 - At 1:26 PM staff gave the resident 2 - 500mg (milligram) Tylenol tablets due to complaints of right leg pain. 1/26/16 - At 2:16 PM the nurse wrote the resident stated I hope it did (meaning hope it helped) and the nurse documented the Tylenol was effective. 1/26/16 - At 2:24 PM the resident complained of pain to his/her right leg and staff noted resident #6's right calf and ankle were swollen. The nurse aides reported a possible twisting of the resident's ankle when they used the lift to transfer the resident that morning. The resident had been lethargic even though he/she called out in pain when staff moved his/her ankle. The nurse gave the resident 1000mg of Tylenol and applied ice. 1/26/16 - At 4:00 PM - 2 other nurses assessed the resident's ankle with no mention of notification to the physician of the accident with possible injury and new onset of pain. 1/26/16 - At 7:15 PM another nurse documented staff reported to him/her the resident had an injury to his/her right ankle during the morning transfer. The morning charge nurse was not notified until 1:30 PM at which time he/she assessed the resident and notified administrative staff A and administrative nursing staff D and staff iced and elevated the resident ' s ankle. Evening charge nurse had staff transfer the resident into bed using the mechanical lift so he/she could assess the resident. The nurse noted the resident had red discoloration and swelling from below his/her right knee to the top of his/her right foot. The resident also had skin off the top of his/her toes on the right foot and a softball sized dark blue bruise beneath his/her left elbow with a skin tear covered with an adhesive bandage. Staff elevated the resident's leg on a pillow and placed a cool gel pack on the resident's shin between the knee and ankle. Staff notified the resident ' s DPOA (durable power of attorney) of the resident's current condition. The note lacked any evidence that the staff notified the physician of the accident, and the possibility of injury to the resident. 1/27/16 - At 6:22 AM the nurse documented the resident had a quiet night as long as staff did not move him/her due to the pain it caused to his/her lower right extremity. The nurse wrote staff kept the resident's right lower leg elevated above heart all night with cool gel packs. The area just below the resident's right knee to ankle was red, swollen and painful to touch with the most pain being around the resident's ankle area. The nurse wrote he/she notified the resident ' s physician of the resident's status. 1/27/16 -At 6:31 AM the nurse left a message for the physician through the electronic computer program regarding the resident's complaint of right lower extremity pain with redness and swelling. The communication did not include information about possible twisting of the resident ' s ankle during a lift transfer earlier in the day. The staff notified the physician of the resident ' s symptoms approximately 21 hours after the injury occurred. 1/27/16 - At 7:40 AM when asked the resident stated he/she had pain to the right lower leg. The assessment revealed bruising below right knee area and swelling noted to right lower leg. 1/27/16 - At 9:10 AM staff received a call from the physician with an order to send the resident to the emergency room (ER). 1/27/16 - At 1:30 PM the physician started the resident on Lovenox and Coumadin for DVT of right lower leg. 1/27/16 - At 4:00 PM the resident returned from ER in wheelchair, transferred to bed using lift and assist of 3 staff. 1/28/16 - At 5:47 AM the resident had a restful night. Staff elevated his/her right leg on pillows to keep above heart during this shift. The resident's leg remained red with blue discoloration from knee to ankle on the front of his/her shin with swelling and extreme tenderness around the ankle area. 1/28/16 - At 8:43 AM the resident complained of right lower leg and ankle pain and staff gave the resident Tylenol. The resident's right lower leg was swollen and warm to the touch, bruising noted right below the resident's right knee. 1/28/16 - At 5:53 PM the resident's right leg continued to be swollen and warm to the touch, skin tight and shiny. Staff offered the resident pain medication but he/she refused at that time. 1/29/16 - At 2:00 PM the physician assistant was at the facility and ordered antibiotic medication for an acute upper respiratory infection. 1/29/16 - At 6:37 PM the resident's right lower extremity continued to be swollen and warm to the touch with bruising noted to the extremity. The resident refused to get out of bed and stated it hurt to move his/her leg. Staff noted the resident was lethargic but would respond to verbal stimuli. 1/29/16 - At 11: 54 PM staff contacted the physician's assistant by phone with an update on the resident ' s weakened condition. Staff was instructed to offer fluids however they could and the physician ' s assistant would call the next day for an update. 1/30/16 - At 9:37 AM the staff contacted the physician's assistant staff W and gave an order to send the resident to the hospital via EMS (emergency medical services). 1/31/16 at 6:17 AM the nurse wrote the resident had been admitted to the hospital. Review of the radiology report dated 2/1/16 revealed the resident had a comminuted non-displaced fracture (a break in the bone in in which the bone is splintered or crushed, with three or more fragments) of the right upper tibia (the larger of the two leg bones) with displacement of fracture fragments. It also noted the resident had diffuse osteopenia (thinning of the bone) with degenerative (normal) changes to his/her knee and ankle. Review of direct care staff K's notarized statement revealed he/she went to get the resident up in the morning and the resident felt clammy to touch and did not act him/herself. Direct care staff T came into the room to help get the resident up and staff T and staff K sat the resident on the side of the bed. Direct care staff T wanted to do a 2 person pivot transfer with the resident and the resident was not alert and could not stand so the staff laid the resident back across the bed. Staff T went to get the lift and returned with activity staff L to help with the transfer. Staff sat the resident back up on the side of the bed; put the lift sling behind the resident. Staff L held onto the resident's wheelchair, staff T controlled the lift and staff K held the resident in the sling. While staff T raised the resident, staff K noticed the resident's right ankle got caught on the box on the base of the lift and told staff L to stop going up. Staff T removed the resident' s leg out from under the box and staff proceeded to transfer the resident into his/her wheelchair. Staff K wrote the resident did not complain of pain at the time of the incident. The staff failed to transfer the resident using the full sling as planned. Review of direct care staff T' s notarized statement revealed staff T and staff K assisted the resident to get up in the morning. Staff T wrote they sat the resident on the side of the bed and put on the gait belt and tried to stand the resident up but the resident started to feel uncomfortable so they sat him/her back on the side of the bed and staff T noticed the resident ' s legs were crossed as they sat the resident down. Staff T went to get help and returned with staff L and they decided to use the sling lift that was in the resident's room. Staff T and K hooked the sling onto the resident as he/she sat on the bed and then raised the resident with the lift. As staff T raised the lift staff K said to hold on and staff K then moved the resident ' s right foot over because it had gotten caught on the lift. The resident did not complain of pain at that time. Review of activity staff L's notarized statement revealed about 9:50 AM he/she went into the resident's room to help get the resident up. Staff L wrote he/she said to put the sling on the resident so staff T and K put the sling around the resident's back and pulled the bottom of the sling up between his/her legs and criss- crossed the leg sling. Review of the notarized statement for licensed nursing staff P revealed the nurse was informed by staff T that the resident had leg pain at 1:15 PM on the day of the incident. Staff P noted the resident was lethargic but stated no, no when staff P attempted to move the resident ' s leg. Staff P noted the resident had edema to his/her lower right calf and ankle with no redness but was lightly warm to touch. Staff K told staff P the injury could have happened during a transfer this morning when the resident's foot twisted and his/her shoe came off. Staff P wrote 2 other nurses had also looked at the resident's leg. Staff P wrote that staff T thought the injury might have happened during the morning transfer when the resident caught his/her foot under the bar and twisted it during the transfer. Review of the certificates from the online training that was completed in April 2015 revealed none of the staff that transferred the resident using the mechanical lift had completed the training on how to use the mechanical lift. During an interview on 2/25/16 at 11:10 AM direct care staff G stated the facility's nurse aides showed him/her how to use the mechanical lifts. Staff G stated the resident used to use the sit-to-stand lift (a type of mechanical lift) for transfers but the first part of September 2015 he/she needed the full sling lift for transfers. The resident was tall and he/she had to be careful so the resident's feet did not hit the lift or get under the bar. During an interview on 2/25/16 at 11:17 AM direct care staff H stated the staff used a full sling lift with the mechanical lift, the long blue one with a small circle cut out for the residen's bottom for transfers. Staff stated the resident was tall and one of the things staff needed to make sure was that the lift sheet was properly under him/her and to watch his/her legs and feet and make sure he/she crossed his/her arms over his/her chest so they don't hit anything. During an interview on 3/1/16 at 7:36 AM licensed nursing staff O stated it was his/her understanding the 3 different RN's (registered nurses) assessed the resident and the decision was made by the 3 nurses to monitor the resident. Staff O stated during that night the resident's right leg was a little swollen and the resident did not complain of much pain. Staff O stated he/she explained to the oncoming nurse the need to contact the physician in the morning. Staff O stated the resident used the full lift for transfer. During an interview on 3/1/16 at 10:01 AM licensed nursing staff P stated he/she did not find out about the possible injury until 1:30 PM the afternoon of 1/26/15 and should have contacted the physician right away and requested an x-ray based on what might have cause the injury. During an interview on 3/2/16 at 8:06 AM administrative nursing staff B stated he/she expected staff to use the lift according to how it is to be used and to use the proper sling as planned. During an interview on 3/1/16 at 3:04 PM administrative staff A stated the staff did not transfer the resident like they were supposed to when they attempted to do a 2 person pivot transfer. During an interview on 3/3/16 at 12:06 PM physician assistant W reported if the initial communication from the facility had included the incident with the twisting of the resident ' s ankle when staff tried to transfer the resident without a lift and the incident when his/her feet were caught in the lift the physician would have ordered an x-ray. Staff V stated had the fracture been identified, then the resident may have had a brace and did not know if he/she would have been a candidate for surgery or not. Review of the accident prevention program policy dated 7/14/15 revealed the first employee to discover an injury or suspected injury needed to complete an incident/accident report and turn it over to the Director of Nursing or designee. An accident is defined as any happening, not consistent with the routine operation of the facility that results in bodily injury other than abuse. The facility failed to provide resident #6 with appropriate supervision when staff attempted to transfer the resident manually instead of using a mechanical lift as planned. The facility also failed to provide proper staff training for use of assistive devices to prevent accidents to ensure resident #6 did not get his/her feet tangled and twisted on the mechanical lift and was later diagnosed with [REDACTED].

The facility census totaled 22 residents with 15 sampled and two reviewed for pressure ulcers. Based on interview, record review, and observations the facility failed to ensure resident who entered the facility without pressure ulcers did not develop avoidable pressure ulcers after admission. Resident #21 developed two open, stage three, avoidable pressure ulcers after admission to the facility. The facility also failed to develop and implement interventions for resident #19 after he/she admitted to the facility with a pressure ulcer. Findings included: - Review of resident #21's admission MDS (minimum data set) dated 10/13/14 revealed a BIMS (brief interview for mental status) score of 15, indicating cognitively intact. The MDS revealed the resident did not have any behaviors or resist cares. The resident required limited assist, with one staff for transfers, locomotion on and off the unit, personal hygiene, toilet use, and dressing. The resident was always continent of urine and bowel. The MDS revealed the resident was at risk for developing a pressure ulcer did not have any interventions in place to prevent development. Review of the Pressure Ulcer CAA (care area assessment) dated 10/13/14 revealed the resident was able to change positions without assist in the chair and his/her bed. The resident only needed stand by assist to ambulate and a care plan would be developed. Review of the ADL (activities of daily living) CAA dated 10/13/14 revealed the resident required stand by assistance and supervision for most ADLs. The ADL CAA also stated the resident was not high risk for pressure ulcer as he/she was very functional and able to change positions without assist. Review of the resident's care plan signed on 9/30/14 revealed the resident occasionally had episodes of urinary incontinence related to the loss of bladder muscle tone. The facility failed to implement a care plan based on the resident's two facility acquired stage 3 pressure ulcers and lacked instruction for the staff to implement care for his/her pressure ulcer. Review of the pressure ulcer assessment dated [DATE] indicated a total score of 17 indicated the resident was at medium risk for developing a pressure ulcer. The 9/30/14 admission assessment indicated the resident's skin was dry and did not have any open wounds. Nursing note dated 9/30/14 indicated the resident admitted with general weakness. He/she had no redness noted to skin, the skin turgor (the expected resiliency of the skin caused by the outward pressure of the cells and interstitial fluid) was slow, and he/she required one staff to assist with gait belt and walker for all ambulation. The note also revealed the resident was continent of bowel and bladder and he/she was oriented to call light, bathroom, mealtimes, and activities. Review of the pressure ulcer assessment dated [DATE] revealed the resident had a total score of 15 which indicated medium risk for a pressure. The 10/19/14 skin assessment revealed the resident had [MEDICAL CONDITION] (swelling) to his/her bilateral feet and his/her turgor was loose. The facility failed to provide a pressure ulcer assessment after the resident acquired 2 open stage 3 pressure ulcers. Review of the weekly bath skin sheet dated 11/11/14 indicated the resident had an open area to his/her coccyx. Staff assessed and cleansed the area and applied Crisco which was not a standard treatment or a physician order. The bath sheet dated 11/21/14 indicated an open area to the coccyx, the nurse reviewed the bath sheet, applied Zinc to the area that had discoloration and was blanchable (to press blood away and wait for return to determine blood circulation) redness. The bath sheet dated 11/25/14 thru 12/2/14 revealed the resident continued to have an open area to the coccyx with ongoing treatment. Review of the 12/1/14 wound assessment revealed the wound to the coccyx measured 1.2 cm (centimeters) x 6.5 cm, and was 100% granulation (appearance of a wound healing) and had serous (clear) color of exudate (drainage) to the wound. The current treatment was Crisco. Review of the 12/2/14 wound care clinic orders revealed the wound to the coccyx measured 2.5 cm x 2.7 cm in length, 1.8 cm x 2.0 cm in width, 0.1 cm x 0.1 cm depth, the wound had full thickness, macerated (softened) appearance, and was staged at a stage 3 with no drainage. The new physician orders [REDACTED]. The facility were to consider a nutritional supplement to assist with wound healing. The staff was instructed to keep weight off his/her coccyx and if he/she must sit then to use a good gel pad or excellent foam pad, but to limit sitting as much as possible until the wound healed. A nursing note dated 11/23/14 at 5:00 p.m. revealed the resident had a small white/gray area to his/her coccyx that measured 1.5 cm x 1 cm wide, the tissue was firm, and was not open at the time. The nursing staff applied a barrier cream and triple antibiotic cream and dressed the wound. A nursing note dated 12/1/14 revealed the resident had an open area to the coccyx measuring 0.5 cm x 1.5 cm. The wound had no depth and no drainage noted. The tissue was macerated to the area with surrounding tissue. The resident was currently receiving Crisco to the area with brief changes. He/she had an appointment scheduled for 12/2/14 to see the wound clinic doctor. Review of the nursing note dated 12/2/14 revealed the resident saw the wound care clinic physician and had new orders for dressing changes. Review of the physician telephone order dated 12/4/14 revealed a new order for Santyl (a type of medication applied to the wound for healing) to be changed to [MEDICATION NAME] (a medication applied to the wound for healing) and to be applied daily to the wound in a dressing change. An observation on 12/2/14 started at 1:52 p.m. revealed the resident sat in his/her recliner. The resident remained in the recliner in the same position at 2:05 p.m., 2:25 p.m., 2:40 p.m., and 2:55 p.m. At 3:05 p.m. the resident awoke and started watching his/her television and remained in the same position in his/her recliner. At 3:20 p.m. the resident remained in the same position with his/her feet elevated in the recliner until 4:00 p.m. The resident continued in the same position in the recliner until 4:45 p.m. when he/she was checked on by the direct care staff checked the resident to get him/her ready to take to dinner. An observation on 12/3/14 at 8:00 a.m. revealed the resident sat in the dining room eating breakfast. He/she consumed 100% and drank 100% of his/her fluids. He/she was then ambulated back to his/her room with two staff, walker, and gait belt. Staff offered to take him/her to the bathroom. The resident declined and staff assisted him/her to the recliner. The recliner had a cushion with a sheep skin covering; covered with a urinary incontinence pad, and appeared to be ? to 1 inch thick until he/she sat on it and it decompressed. The resident had a regular mattress on his/her bed. An observation on 12/2/14 at 8:15 a.m. revealed the resident sat in his/her recliner until 10:15 a.m. when direct care staff H ambulated the resident to the restorative room for exercise. An observation on 12/4/14 at 3:16 p.m. administrative nurse A ambulated the resident from his/her recliner into the bathroom for his/her dressing change to the coccyx. Administrative nurse A removed the old dressing, cleansed the wound using normal saline, and applied skin prep. The one large coccyx wound measured 4 cm across x 5.5 cm wide and had an open area measuring 3 cm x 1.5 cm on the left inner buttocks and 2 cm x .25 cm on the right inner buttocks. The wound was then dressed with new order of [MEDICATION NAME]. The wound increased in size from the nursing note dated 11/23/14 which measured the wound to be 1.5 cm x 1 cm. An interview on 12/2/14 at 4:45 p.m. with the resident's DPOA (durable power of attorney) reported the resident did not have any wounds prior to coming into the facility. An interview on 12/3/14 at 2:43 p.m. with direct care staff I revealed the resident was a one person assist with gait belt for ambulation. Staff I reported the resident had an open wound on his/her coccyx. He/she did not have the wound when he/she came into the facility. Staff I reported he/she mostly stayed in his/her chair and staff were to reposition him/her every two hours with a pillow. Direct care staff I was not sure if the resident even had a pillow in his/her room at the current time and reported nothing was on the bed to help with the pressure ulcer. An interview on 12/3/14 at 3:19 p.m. with direct care staff J revealed the resident had a pressure ulcer on his/her coccyx. Staff J tried to get him/her up, he/she had a cushion in the chair, and staff were supposed to rotate him/her, but he/she moved himself/herself. Staff also reported the resident did not have any special device on his/her bed. An interview on 12/4/14 at 11:53 a.m. with licensed nursing staff D revealed the resident had a pressure ulcer that developed in the facility. Staff D reported the resident sat in the recliner and would use the call light when he/she needed to go to the bathroom. Staff D reported they were encouraging the resident to lie down throughout the day. He/she also reported the resident did not have an air loss mattress on the bed, he/she was not on a positing schedule, and no special cushion was in the recliner. Staff D reported the facility did not have anyone doing skin checks on residents and the direct care staff only wrote down concerns on bath sheets and reported them to the nursing staff to sign off on. An interview on 12/4/14 at 5:43 p.m. with administrative nurse A revealed the resident's stage 3 pressure ulcer was facility acquired and the wound care doctor recorded it as a stage 3. The resident now required protein shakes twice a day, a foam cushion was in the recliner, and no pressure relieving mattress was in place. When administrative nurse A looked at the cushion in the resident's room, he/she reported it was not acceptable and was not the same cushion that was there last week. He/she also stated the facility had ordered a gel cushion with the new treatment orders when the resident arrived back from his/her wound appointment. Nursing staff A revealed the resident did not have a care plan done for the pressure ulcer. As of 3:20 pm, the survey staff had not heard back from the wound care physician, although they left a message at 9:58 am. Review of the pressure ulcer policy dated 12/2005 revealed a stage 3 was a full thickness skin loss involving damage to, or necrosis (death) of, subcutaneous (just beneath the skin) tissue that may extend down to, but not through, underlying fascia (connective tissue fibers). The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. It also stated repositioning plans should be addressed in the comprehensive plan of care and the resident who can change positions independently may need supportive devices to facilitate position changes. When the resident was in a chair, staff were to repositioned and checked for reddened areas every hour. When the resident was in bed he/she was to be placed on a pressure-reducing mattress and turned every two hours. The facility failed to develop and implement interventions to ensure resident #21 who entered the facility without pressure ulcers did not develop two open, stage 3, avoidable pressure ulcers after admission. - Review of resident #19's Annual MDS (minimum data set) dated 11/7/14 revealed a BIMS (brief interview for mental status) score of 7 indicating severe cognitive impairment. The MDS revealed the resident required limited assistance for bed mobility with 1 staff assist for transfers, locomotion, dressing, toilet use, and personal hygiene. The MDS also revealed the resident was frequently incontinent of urine and occasionally incontinent of bowel. The resident was at risk for developing a pressure ulcers; and had 2 stage one pressure ulcer and stage 1 pressure ulcer on re-entry on 10/27/14. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 14 indicating the resident was cognitively intact. The resident required limited assist with one staff for bed mobility, dressing, toilet use, and personal hygiene. The MDS revealed the resident was incontinent of urine, occasionally incontinent of bowel, and was on a toileting program. The resident was at risk for pressure ulcers and currently did not have any. Review of the ADL (activities of daily living) CAA (care area assessment) dated 11/14/14 revealed the resident was independent with ADLs and had improved. Review of the pressure ulcer CAA revealed the resident repositioned him/her self, was ambulatory, was incontinent of urine, and would care plan. Review of the admission care plan dated 10/27/14 revealed the resident was at risk for impaired skin integrity related to urinary incontinence. On 11/13/14 the resident had a wound to his/her coccyx with treatment and dressing changes per the wound specialist. Staff was to monitor skin condition daily with routine cares and report findings to the charge nurse. The resident required a pressure relieving cushion be place in the recliner and the wheel chair, along with position change no longer the every two hours until the abrasion resolved. The staff was to complete a Braden assessment, provide good incontinent care, and use lotions and moisturizer to prevent skin from drying out. The resident required assistance with ADLs, used a gait belt with assist of two staff for ambulation of short distances. On 10/27/14 the nursing assessment revealed the resident had a small 1 cm open are to the right buttocks just about the sacrum and a dark red are to the lumbar spine. The resident's skin was dry and pale. He/she required two staff assist with transfers, and used a walker to ambulate. Pressure ulcer assessment dated [DATE] revealed the resident scored a 16 indicating he/she was at medium risk for a pressure ulcer and his/her skin assessment revealed the skin was dry and flaky with the skin turgor was firm. Pressure ulcer assessment dated [DATE] revealed the resident had a score of 16 indicating a medium risk for pressure ulcer. The skin assessment dated [DATE] indicated the resident had a bruise on the back of his/her sacrum, an open area or blister to the right buttock, and his/her skin turgor was firm. Review of the physician wound care clinic record dated 11/18/14 revealed the wound to the coccyx measured 3.0 cm (centimeters) x 3.2 cm length, 3.5 cm x 3.7 cm width, and 0.1 x 0.1 depth and was a stage 2 pressure ulcer with full thickness. Review of the physician wound care clinic record dated 11/25/14 revealed the wound to the coccyx measured 1.5 cm x 1.6 cm length, 1.5 cm x .8 cm width, and less than 0.1 x 0.1 cm depth and was a stage 2 pressure ulcer with full thickness. Review of the physician wound care clinic dated 12/2/14 revealed the wound to the coccyx measured 0.8 cm x 0.9 cm length, 0.5 cm x 0.6 cm width, and less than 0.1 x 0.1 cm in depth and was a stage 2 pressure ulcer with full thickness. Staff was instructed to avoid pressure to the area until completely healed. The treatment continued to use skin prep, change the dressing 3 x week, to keep the wound clean and dry, and to change the bandage frequently if it was soiled. Review of the facility weekly bath skin book dated 11/2/14 revealed the resident had a reddened area to his/her coccyx. On 11/13/14 staff noted an open area to the coccyx and notified the physician. On 11/27/14 staff changed the dressing to a small sore on the coccyx. Review of the skin sheet dated 12/1/14 revealed an open area to the coccyx with an ongoing treatment, and staff notified the physician. A nursing note dated 12/2/14 at 7:00 a.m. revealed the resident continued to have an open area to the coccyx measuring 1 cm x 1 cm and had no drainage noted. The tissue was intact with slight redness noted. Nursing staff noted no breakdown surrounding the area and to continue to get dressing changes. A nursing note dated 12/2/14 revealed the resident had returned from an appointment with the wound clinic and staff were to continue current orders until a follow up appointment on 12/9/14 at 10:00 a.m. An observation on 12/2/14 at 1:54 p.m. revealed the resident lying in bed. At 2:15 p.m. direct care staff F and I entered the room and they ambulated the resident with a walker and a gait belt to the bathroom. The resident had a bandage covering the wound to his/her left buttocks. Direct care staff then took the resident to the dining room for lumch. The resident had been at a wound clinic appointment earlier and was out of the building. The resident sat in the dining room in his/her wheel chair that did have a cushion for him/her to sit on. The resident sat in the dining room from 2:15 p.m. until 4:00 p.m. in his/her wheelchair. The resident consumed 100% of his/her lunch. At 4:15 p.m. staff then ambulated the resident back to his/her room where they assisted him/her to the recliner. An observation on 12/3/14 at 7:35 a.m. revealed staff ambulated the resident to the dining room for breakfast. He/she consumed 100% of his/her meal and then at 8:45 a.m. was taken back to his/her room. Staff assisted the resident to the bathroom and then assisted to the recliner. At 9:00 a.m., the resident remained in his/her recliner reading a book, the radio was on, and his/her feet elevated. At 9:15 a.m., 9:30 a.m., 9:45 a.m., 10:00 a.m., 10:15 a.m., 10:30 a.m., the resident remained in the same position in his/her recliner. The resident still remained in the same position at 10:45 a.m., in his/her recliner with a book in his/her hand, the radio on, and his/her legs elevated. An observation on 12/4/14 administrative nurse A went in the shower room to change the resident's dressing after his/her shower. Administrative nurse A cleaned the resident's wound with normal saline, patted dry with 4 x 4 gauze, and measured. The wound measured 2 cm x 2 cm with purple discoloration. The open area measured 1 cm x 1 cm round. An interview on 12/3/14 at 2:43 p.m. with direct care staff I revealed the resident ambulated using a walker, a gait belt, and sometimes required two staff assist. He/she also reported the resident had a decube which meant the resident had an open wound to his/her bottom. He/she also reported the resident had a cushion in the wheelchair, in his/her recliner, and when staff laid him/her in bed they would put him/her on his/her side. Direct care staff I revealed the resident was to be checked on every couple of hours, but he/she could reposition himself/herself. An interview with direct care staff J on 12/3/14 at 3:19 p.m. revealed the resident required two staff assist for ambulation, was incontinent of bowel and bladder, and had a pressure ulcer to his/her bottom. Staff J reported the resident had a cushion in the wheelchair and in the recliner. Staff J also reported the resident had come back to the facility with the open sore after he/she was at the behavioral unit. Staff J reported the direct care staff had a CNA (certified nursing assist) communication book and a care plan hanging in the closet. He/she was unaware of any other interventions in place for the resident. An interview on 12/4/14 at 11:53 p.m. with licensed nursing staff D revealed the resident required the use of two staff with a walker and a gait belt for ambulation. He/she also reported the resident was to be toileted every two hours. Staff D reported the resident came back to the facility with the pressure ulcer from the behavioral unit in October. Staff D revealed the interventions in place for the pressure ulcer for the resident was a treatment from the wound clinic in place with a special dressing, he/she required a brief instead of a pull-up, no special cushion in his chair, and he/she did not have an air loss mattress on his/her bed. An interview with administrative nurse A on 12/4/14 at 5:50 p.m. revealed the resident had returned to the facility with a pimple type sore on his/her bottom and was at risk for pressure ulcers. The facility had first tried ointments and then decided to take him/her to the wound care clinic. Nurse A reported when the resident returned to the facility nothing was put on the care plan for interventions or in place, but it should be on there. Nurse A revealed the direct care staff was required to check on the resident every two hours and this was a standard of care. Review of the pressure ulcer policy dated 12/2005 revealed a stage 3 was defined as full thickness skin loss involving damage to, or necrosis (localized tissue death that occurs in a group of cells in response to disease or injury) of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. It also stated repositioning plans should be addressed in the comprehensive plan of care and the resident who can change positions independently may need supportive devices to facilitate position changes. When the resident was in a chair he/she were to be repositioned and check for reddened areas every hour. When the resident was in bed he/she was to be placed on a pressure-reducing mattress and turned every two hours. The facility failed to develop and implement interventions to promote healing for resident #19 after he/she admitted to the facility with a pressure ulcer.

The facility census totaled 22 residents with 12 included in the sample. The sample included the review of 1 resident for pressure ulcers. Based on observation, interview and record review, the facility failed to failed to develop and implement interventions to prevent the development of 3 facility acquired pressure ulcers for 1 of 1 sampled resident at risk for the development of pressure ulcers. (#1) Findings included: - Review of resident #1's physician orders, dated 7/5/13, revealed the resident had the following Diagnoses: [REDACTED]. Review of the annual MDS (Minimum Data Set) dated 12/26/12 revealed the resident had impaired cognition, poor memory recall and impaired decision making ability. The assessment also identified the resident as dependent on 2 staff members for all ADLs (Activities of Daily Living), had no teeth or eating problems, and at risk for the development of pressure ulcers, but did not have any pressure ulcers at that time. The assessment identified the resident had a pressure relieving device for the bed, chair, and staff provided the resident with a turning/repositioning program. Review of the quarterly MDS with a date of 7/24/13 identified the resident with cognitive impairment, dependent on 2 staff for ADLs, had no teeth or eating problems, and now had a stage 4 (full thickness tissue loss with exposed bone, tendon or muscle. Dead tissue ranging in color from creamy white to black may be present on some parts of the wound bed. Often includes undermining-destruction of tissue under the wound's edges and tunneling-a passageway of destruction of tissue under the skin's surface) pressure ulcer present. Review of the Pressure Ulcer CAA (Care Area Assessment) dated 12/26/12 identified the resident at risk for the development of pressure ulcers due to his/her urinary and bowel incontinence and decline in mobility. The assessment identified staff toileted the resident "per schedule" and provided peri-care after each episode of incontinence, and identified that staff repositioned by the resident. Review of the pressure ulcer risk assessment dated [DATE] identified the resident was at high risk for the development of pressure ulcers. Review of the pressure ulcer care plan, dated 9/13/11, identified the resident at risk for pressure ulcers "more now than in the past." The care plan identified the resident had pressure relieving devices in the resident's bed and wheelchair, but staff were to inspect the resident's skin daily with cares and notify the nurse of any red areas for further assessment, to ensure all the resident's extremities were in a safe position when transferring the resident or propelling the resident in the wheelchair. On 5/21/12 staff had written in "Please ensure that I have heel protectors on B (bilaterally-both) feet at all times." Staff then struck through this intervention, but did not date the change. The care plan lacked specific interventions for how often staff were to reposition the resident and lacked guidance on padding the surface of the wheelchair/Geri chair's foot rests. This care plan lacked individualized interventions regarding a turning/repositioning plan for this dependent resident. Review of the pressure ulcer care plan, dated 4/4/13, included all of the previous interventions, except for the heel protectors, which were not struck out on the care plan. It also had an undated entry that identified the resident developed a deep tissue injury pressure ulcer on the outer aspect of the left calf, and the area opened "despite treatment staff provided." The care plan identified (also undated) staff changed treatments as the physician ordered and staff were to off-load the heels (ensure the resident's heels were not lying directly on a surface) whenever the resident sat in a chair or lay in bed. The care plan failed to identify what interventions were developed after each pressure ulcer developed to prevent additional skin breakdown and promote healing. On 8/15/13, review of an undated form called Nurse Aide's Information Sheet instructed the direct care staff to reposition the resident every 2 hours. Review of a PUSH (Pressure Ulcer Healing Chart) revealed staff identified a pressure ulcer on the resident's left calf on 3/5/13. (Wound #1) Review of a nurse's note, dated 3/5/13, revealed the physician saw the resident that day. The physician measured an area on the resident's left leg at 1.7 cm (centimeters) x 2 cm, assessed the area had no odor, slight amount of drainage and was black in color. Review of a physician progress notes [REDACTED]. The note identified the resident had recently developed a sore on his/her left leg as a result of "what is believed to be inadequate padding on his/her chair. The resident was essentially immobile at that point." Review of a nurse's note, dated 3/19/13, identified the area measured 4 cm x 5 cm and had eschar (dead tissue that is black in color) tissue, the surrounding tissue measured 4.5cm x 7.5 cm. x 0.5 cm. The note identified the area had heavy, serosanguineous (wound drainage of a semi-thick reddish fluid) drainage with foul odor. Surrounding tissue is slough (dead tissue that is creamy white or yellow in color). The measurements showed the area's increase in size and development of signs/symptoms of infection. The staff still did not document new interventions to relieve pressure on the resident's left leg and assist the area to heal. Review of a physician's discharge note from a local hospital dated 5/7/13 revealed the physician admitted the resident to the hospital 3/26/13 for treatment of [REDACTED]. A [DEVICE] (mechanical equipment used to assist wounds in healing) was used for part of the hospitalization though the area failed to further progress (heal) and the [DEVICE] was then DC'd (discontinued).Cultures of the wound [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus-a type of bacteria) and treated with antibiotics. Review of a nurse's note, dated 5/7/13, identified the resident returned from a hospitalization with a wound identified as a stage 4 pressure ulcer that measured 6 cm x 4 cm x 2cm. The facility staff noted an odor with copious (a great deal) drainage. Review of a nurse's note, dated 5/14/13, staff documented the resident's pressure ulcer measured 6 cm x 3 cm x 1.5 cm, with light to moderate drainage with no odor. Staff documented they performed the physician-ordered treatment of [REDACTED]. The staff documented the staff floated the resident's left leg on pillows under his/her ankle and knee keeping pressure off affected area. Review of the nurse's notes revealed staff documented the following assessments on the pressure ulcer on the resident's left calf: 5/28/13--6cm x 1.5 cm less than 0.2 cm deep/Moderate drainage noted. 5/30/13--no measurements--purulent (containing pus) drainage noted to left calf. Culture sent to lab for sputum/wound culture. 6/3/13--no measurements--wound culture results Pseudomonas aeruginosa-(type of bacteria) moderate amount.[MEDICAL CONDITION] large amount. Awaiting physician orders. 6/4/13--6 cmx 2 cm x 0.6 cm--granulation (healing) tissue. Moderate amount purulent drainage. Received orders for [MEDICATION NAME](2 different antibiotics) x 10 days. 7/2/13--2 cm x 1/2 cm open with granulation tissue to wound bed. No drainage. 7/9/12--5 cm 2 cm x 0.7 cm with light drainage. 8/13/13--4 cm x 1.5 cm light amount of drainage. Review of a physician's progress note dated 7/5/13, revealed the resident had readmitted from an extended hospitalization related to a deep, infected ulceration. Wound infection (of the left leg) showed cultures that were susceptible to a combination of oral antibiotics and would be treated with a combination [MEDICATION NAME] for the next 12 days. The physician ordered staff to apply Santyl in wound on calf, cover with saline dampened 4x4, then wrap with gauze wrap daily. Review of a PUSH tool revealed on 5/23/13, staff identified a pressure ulcer to the resident's left interior heel. (Wound #2) Review of a physician order, dated 5/23/13, revealed the physician identified a blood blister measuring 2 cm x 2 cm on the resident's left interior heel. The physician documented the resident lays/sits with outward rotation of the left leg. The physician ordered staff to apply Petroleum gauze (gauze with petroleum jelly on it), 4x4 fluff (type of gauze padding) and gauze wrap placed. Continue till healed. The medical record lacked evidence the staff determined what caused the blister, and the staff failed to update the care plan to include interventions to help the area to heal and prevent new areas from developing. According to the PUSH tool, the area healed on 7/5/13. Review of a PUSH tool, dated 7/4/13, identified staff identified a pressure ulcer on the resident's coccyx. (Wound #3) Review of a physician's orders [REDACTED]. Area cleansed, petroleum gauze and Sursite (a clear dressing) applied. The order directed staff to pay attention to relieve pressure off bedding. May try a donut pillow. The medical record and care plan lacked the development and implementation of new interventions to assist the area to heal. According to the PUSH tool, the area healed on 7/14/13. Review of the monthly nutrition progress note, dated 7/17/13, revealed the resident received a regular blended diet, was dependent on staff for eating, and received protein supplement shakes. The note identified the resident's meal intake was greater than 75% and the resident consumed 100% of supplements. The resident had chewing problems due to being edentulous (had no teeth). Observation on 8/13/13 at 9:25 a.m. revealed Licensed nurse H prepared to dress the resident's wound on the outer left calf. Staff H measured the wound as 3.0 cm long x 1.0 cm wide with red granulation tissue in wound bed. After measuring the wound, Staff H cleaned the wound, applied [MEDICATION NAME] ointment and applied a 4x4 gauze folded in half for padding. The nurse then wrapped the leg with gauze cling dressing and secured with paper tape. Observation of the resident on 8/13/13 at 9:45 a.m. revealed the resident sat in a Geri chair (a reclining wheelchair that has a raised foot rest) at the dining table and drank from a large 16 oz. (ounce) protein shake assisted by direct care staff C. The resident also had a glass of water and a glass of cranberry juice. The resident consumed 100% of the fluids. Staff did not offer any food to the resident, even though the physician ordered staff to offer a pureed diet. Staff had positioned the resident in the Geri chair with a foam cushion under his/her knees to relieve pressure on the resident's left calf, and the resident wore heel protectors on both feet. Observation on 8/13/13 at 11:25 a.m. revealed direct care staff E assisted the resident to drink a 16 oz. protein shake along with 2 glasses of water and a glass of cranberry juice for lunch. The resident consumed 100% of the fluids. The staff offered no other food source. Observation on 8/13/13 at 11:40 a.m. revealed direct care staff E and M transferred the resident to bed with the use of a mechanical lift. The staff changed the resident's incontinent brief and provided peri care. Observation of the resident's buttocks, coccyx area revealed no broken skin. Staff E and M positioned the resident's legs with a wedge and pillows and the resident wore heel protectors on both feet. Observation on 8/14/13 at 9:00 a.m. revealed the resident sat at the dining table positioned in a Geri chair with a cushion under the legs to relieve pressure from his/her left calf, as well as heel protectors on both feet. On 8/13/13 at 12:39 p.m. interview with Direct care staff C revealed the direct care staff were expected to report any changes in the resident's condition to the charge nurses. He/she defined changes in conditions as a resident's decreased ability to take care of themselves, a change in the ability to eat, any skin issues, or mood and behavioral issues. He/she revealed "a lot of things get reported to the nurses around here that never get followed up on." He/she revealed the facility "used a lot of agency nurses and things just don't get followed up on like they should." Staff C revealed that he/she had reported to the nurses several times that the resident had a wound to the back of his/her leg and the next thing Staff C heard was that the resident had "a stage 4 or 5 whatever the worst wound is to his/her lower legs." Direct care staf C identified that staff were to reposition the resident every 2 hours. During an interview on 8/13/13 at 3:50 p.m. Direct care staff M reported the resident had the pressure area for a long time but did not remember when it appeared. Staff M stated that staff were to reposition the resident "every couple of hours." The staff member also reported the resident only drank protein shakes for meals cause that was all he/she liked. When asked, staff confirmed he/she did not try to offer a pureed diet to the resident on this date. During an interview on 8/13/13 at 1:45 p.m. Licensed nurse H reported the resident had started with just a red area on his/her left calf where the leg turned in while in a Geri chair around March 2013. Staff continued to reposition the resident every 2 hours. Different treatments had been ordered by the physician and when one did not work, "the area developed into an open decubitus ulcer [MEDICAL CONDITION] when it was cultured." The physician then placed the resident in the hospital for antibiotics and a wound vac (vacuum). The resident was readmitted back to the facility in June 2013, and did better for a while then the area started getting bigger again so the treatment was changed. Nurse H identified the wound was beginning to get smaller again. The nurse also reported the staff were to offer the resident a pureed meal then the protein shake if the resident did not finish the meal. The protein shakes are only a supplement. The nurse stated he/she was not aware the staff were not offering a pureed meal first. During an interview on 8/15/13 at 11:45 a.m. Consultant O reported the resident had a deep tissue pressure ulcer prior to hospitalization . While in the hospital the wound was debrided (dead tissue surgically removed) and found to be a stage 4 pressure ulcer. The wound had a culture resulting in [MEDICAL CONDITION] infection. The resident was treated with antibiotics and a [DEVICE]. Review of the pressure ulcer policy with administrative nurses A and B on 8-15-13 at 10:30 a.m. revealed the nurses were unaware of the facility policy for repositioning the resident every hour. At that time, nurses A and B also stated they were unaware the resident had developed a blood blister on the heel or an open pressure ulcer on the coccyx. Review of the policy for Pressure Ulcers dated 12/2005 revealed: A purpose that included: To ensure that a resident who is admitted to the facility without a pressure ulcer does not develop a pressure ulcer unless clinically unavailable and that resident who has an ulcer received care and services to promote healing, prevent infection, and to prevent additional ulcers. Repositioning: Repositioning plans should be addressed in the comprehensive plan of care consistent with the resident's needs and goals. Wheelchairs should not be used for prolonged sitting. Reposition and check bony prominences for reddened areas every hour. The facility failed to provide sufficient repositioning/cushioning care for a resident at risk for the development of pressure ulcers. The resident developed a stage IV pressure ulcer to the outer left calf, a blood blister to the inner left heel, and a stage II to the coccyx and the staff failed to develop and implement new interventions after the development of each skin issue. The facility also failed to offer the resident sufficient protein intake through a failure to offer the ordered diet prior to providing supplemental drinks to the resident to ensure the resident's areas healed appropriately.

The facility census totaled 22 with 11 residents included in the sample. The sample included a review of 4 residents for weight loss. Based on observation, interview and record review the facility failed to serve the prescribed mechanically altered diet and identify weight loss for 2 of 4 sampled residents. Resident #23 had a severe weight loss of 11% of his/her body weight in 35 days. Resident #1 with a history of weight loss did not receive the diet as ordered. Findings included: - Review of resident #23's record revealed an admission date of [DATE]. The physician's orders [REDACTED]. or emotional reaction characterized by apprehension, uncertainty, and irrational fear). Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 4, which indicated the resident had severely impaired cognition, required set up help and supervision from staff with meals, had no swallowing disorders, and had a steady weight of 121 pounds. The assessment identified the resident had not lost 10% or more of weight in the last 6 months or 5% or more in the last 30 days. Review of the resident's significant change MDS dated [DATE] revealed the resident had short and long term memory loss with moderately impaired decision making skills, required extensive assistance of one staff member for eating. The assessment identified the resident had experienced weight loss that was not physician prescribed. The assessment also showed the resident received 60 minutes of speech therapy on 8/12/13. Review of the resident's Nutritional CAA (Care Area Assessment) dated 8/14/13 revealed the resident admitted to the hospital with [REDACTED]. The facility staff noted the resident had a weight loss and placed the resident on restorative dining on 8/1/13. The resident continued to refuse to eat or swallow. The physician ordered a [MEDICATION NAME] swallow test (a medical imaging procedure used to examine the upper GI (gastrointestinal) tract). The [MEDICATION NAME] swallow completed on 8/12/13 resulted in a recommendation for insertion of a feeding tube for the resident. The family refused the feeding tube per the resident's advanced directive and instead opted for hospice services. Review of the care plan dated 4/4/13 revealed the resident needed no assistance from staff with eating, but staff were to monitor the resident's eating ability. The care plan also identified the resident had lost most of his/her strength and did not want to get out of his/her chair. The care plan noted the physician and the family wanted the resident to have restorative therapy to gain strength and return home. The care plan also noted the resident frequently refused to go to the therapy room but allowed some exercises in his/her room. Review of the care plan update on 7/30/13 revealed the resident lost weight in July and staff put the resident on a restorative dining program. Staff updated the care plan on 8/5/13 to include the swallow study evaluation that revealed the resident needed nectar thick liquids and mechanical moist foods. Staff discontinued the care plan intervention to monitor eating ability on 8/13/13 and added a new intervention for honey thickened liquids and pureed solid foods. The care plan noted the resident could order the food he/she wanted to eat, and the spouse encouraged the resident to eat well. The care plan also noted the resident ate all of his/her meals in his/her room. Review of Initial Nutritional history assessment dated [DATE] revealed the resident consumed a regular diet, weight was 121.8 pounds, the resident was alert and confused, had his/her own teeth that were in fair condition. It also identified the resident as independent in eating, had no swallowing problems, with [DIAGNOSES REDACTED]. Review of the resident's meal intake tracking form for June 2013 identified that the resident ate poorly (less than 50% of the meal) or refused to eat for 3 different meals for the entire month. The Meal Intake tracking form for July 2013 identified the resident ate poorly or refused meals 26 times in the month, almost 1/3 of the meals offered to the resident. This indicated a significant decline in the resident's intake. Review of resident #23's weight monitoring sheet revealed the following: 4/09/13 - 121.8 pounds 4/16/13 - 121.8 pounds 4/23/13 - 121 pounds 4/30/13 - 121.8 pounds 5/07/13 - 122 pounds 5/14/13 - 121 pounds 5/28/13 - 121.1 pounds 6/25/13 - 121.6 pounds 7/30/13 - 108.1 pounds 8/07/13 - 106.8 pounds Review of the monthly nutritional notes, dated 7/17/13, identified the resident's current weight as 121.6 pounds, the resident's oral meal intake was good, had no chewing or swallowing problems, and included a notation for staff to encourage good intake of food and fluids. Review of the record revealed on 7/30/13 the resident's weight was recorded as 108.1 pounds. Staff notified the physician of the 13.5 pound weight loss. Staff documented on the weight flow record "No new orders". On 8/1/13, the staff faxed the physician and identified the resident had trouble swallowing and was choking on food, liquids, and medication. The staff asked for an order to obtain a swallow evaluation, and the physician responded on 8/1/13 that ordered staff to obtain a swallow study. On 8/2/13, the staff faxed the physician notification of changes in the resident's weight. The note identified the resident had a weight loss of 13.5 pounds in the past 30 days (or 12.49% in 30 days or 11.93% in 90 days. Staff had documented on the form the resident had no current supplement orders, required assistance from staff with meals, and had refused to eat in the last week. The resident had exhibited difficulty with swallowing and a swallow evaluation was scheduled. The physician noted the information by signing the form on 8/2/13. Results of the speech therapist's swallow study on 8/5/13 revealed the resident required assistance to eat from staff, directed staff to check the resident's mouth for pocketing after meals. The therapist also recommended mechanically altered foods, nectar thickened fluids, encourage the resident to keep his/her chin neutral (at 90 degrees), do not lie the resident flat after meals, encourage the resident to complete a double swallow with each bite, assist the resident to eat at a slow rate, may have small sips from cup and glass, one sip then swallow, crush all medicines and give with food/pudding. On 8/6/13, the staff sent the physician a faxed request to obtain a modified [MEDICATION NAME] swallow as recommended from the speech therapist. On 8/7/13, the physician returned the fax agreeing to the study. Review of the nutritional assessment, dated 8/10/13 revealed the resident's current weight as 108 pounds and admission weight of 120 pounds. The assessment identified the resident had swallowing and chewing problems and identified the resident took "super shake" (brand of supplements) supplements 3 times a day. Review of the record revealed a fax to the physician dated 8/13/13 that identified the resident had the [MEDICATION NAME] swallow study completed, and staff asked the physician to review the recommendations made and advise the staff regarding diet suggestions. The results of the swallow study suggested honey thick liquids and pureed solids. On 8/13/13, the physician returned the fax and changed the diet to the suggested diet that the recommendations after the [MEDICATION NAME] swallow study. Observation on 8/12/13 at 2:21 p.m. revealed Direct care staff D brought the resident to the dining room after the resident returned from his/her doctor's appointment. Staff D gave the resident a honey thickened liquid protein shake. The resident took 10 bites of the shake, and then put the shake down to rest. Staff failed to offer the resident the pureed diet prior to offering the dietary supplement. Observation on 8/13/13 at 8:51 a.m. revealed direct care staff D talked to the resident about what he/she would like to eat for breakfast, Staff D offered the resident a chocolate or strawberry shake. The resident agreed to the strawberry shake. The staff member spoon fed the resident a thickened strawberry protein shake with much encouragement and praise when the resident opened his/her mouth and swallowed. The resident did not have any choking or difficulty swallowing, no noted facial grimacing, or straining noted. The resident consumed approximately 10% of the health shake and staff then removed him/her and placed him/her back in a recliner in his/her room. Staff failed to offer the resident a breakfast meal. On 8/13/13 at 10:55 revealed Direct care staff D gave the resident a honey thickened protein shake and a honey thickened glass of water and grape juice. The resident took 3-5 bites of the protein shake from the spoon and refused to eat anymore. The staff took the resident back down the hall to his/her room and the resident began coughing and choking and had to remove excessive phlegm from his/her mouth. On 8/13/13 at 10:10 a.m. interview with direct care staff D revealed he/she had gotten the resident up and gotten him/her around and dressed this am and put him/her in the recliner and gave the resident a glass of thickened water. Staff D stated the resident had anxiety and the staff found that the resident dealt with it better if he/she did not go into the dining until everyone else had gone as it upset him/her too much. Staff D stated staff assist the resident to eat in the dining room when everyone is gone. On 8/13/13 at 11:45 a.m. Direct care staff D revealed the resident had problems swallowing and he/she refused to eat most of the time. Staff D stated the resident got a protein shake for meals. Staff D identified the resident would take the shakes, but he/she had to go to the dining room when it was not busy related to his/her increased anxiety level. Staff D said the resident used to eat in his/her room independently, then staff changed that so he/she went to restorative nursing. Staff D stated that staff either assist the residents to eat or are cued to eat and the residents sit in the dining room. Staff D identified the direct care staff were expected to document the percentage of the resident's meal consumed in the ADL (Activities of Daily Living) book. Staff D, while looking at the ADL sheets stated according to the sheets the staff offered the resident a snack. Staff D said everyone was offered a snack; it was not a high protein snack or supplement. Staff D stated the resident did not get a health shake between meals. On 8/13/13 at 2:12 p.m. interview with direct care staff C revealed that the resident always ate in the room with the family and the aides reported the family stopped assisting the resident like they said they were and we moved the resident into the restorative dining program which meant the residents have to come out to the dining room to be assisted and monitored. The direct care staff are expected to notify the charge nurses when we notice changes in the residents, including a change in the ability to eat, feed themselves, or swallow. The aides are responsible for documenting the meals in the ADL book. On 8/13/13 at 1:41 p.m. interview with Licensed nurse H revealed the resident received orders for a speech evaluation after staff notified the physician of the resident's significant weight loss in one month. Staff H revealed the direct care staff failed to report changes in the resident's ability to eat and swallow to the charge nurses. Staff H stated the resident was eating really well and all of a sudden he/she just stopped. On 8/13/13 at 1:59 p.m. interview with Administrative nurse A revealed the resident had been able to eat independently and did so in his/her room per the request of the family. Nurse A stated the resident had been doing well. Staff A revealed the staff notified the physician and placed the resident on the restorative dining program at the end of July when the resident had a significant weight loss. Staff A confirmed that he/she was unaware that the resident was losing weight or having any kind of difficulty with eating or swallowing until he/she saw the resident's weights on 7/30/13. Staff A revealed the staff did not mention changes in the resident's intake, he/she always wore gender specific loose clothing and staff did not suspect a change in weight. Staff A stated the Certified Nurse's Aides (CNAs) were expected to notify the charge nurse of any changes in resident conditions. Staff A stated Administrative Nurse B monitored the ADL sheets and staff A was unsure why staff B did not recognize the resident had a significant decline in his/her nutritional intake. Staff A confirmed the resident's care plan lacked the update to include the health shakes, and staff were to offer the resident a pureed diet and if they will not eat the offered food, then the staff were to offer the shakes. Staff A said staff were to provide the health shakes as a supplement to the meals. Staff A confirmed the health shakes the resident received were to be given for extra nutrition and not given as the meal. On 8/15/13 at 1:39 p.m. interview with Consultant P revealed staff were to give the resident the health shakes three times daily in addition to the physician prescribed pureed diet. Staff P stated the shakes were ordered to increase the resident's caloric intake related to his/her recent weight loss. Staff P revealed his/her expectations for the facility included staff to follow the prescribed physician's orders [REDACTED]. Staff P stated he/she expected the facility to provide him/her with current, accurate weights of the residents to use for review. Review of the facility's Weight Monitoring and Reporting policy, last revised on 3/2011, revealed all residents shall be weighed on admission, then weekly for 4 weeks or until stable. Residents will be weighed monthly unless otherwise ordered by the physician. Weight changes will be calculated at time of weight. If the resident has a change of 3 pounds or more the resident will be reweighed the following day for accuracy. The physician notification will be done for any resident with a significant weight change. Significant weight change is indicated by any of the following: 3 pound weight gain or loss in 7 days, 5% weight loss in 30 day, 7.5% in 90 days, 10% in 180 days, and the registered dietician will review the resident's weights and intakes and make recommendations as needed. The facility failed to monitor and respond to changes in a resident's meal intake. The resident experienced a significant weight loss of 13.5 pounds in one month, or 11.1%, a severe weight loss. The facility also failed to follow the physician's orders [REDACTED]. - Review of resident # 1's signed physician orders [REDACTED]. Review of the annual MDS (Minimum Data Set) dated 12/26/12 revealed the resident had cognitive impairment with poor memory recall and impaired decision making ability. The assessment identified the resident as dependent on 2 staff members for ADLs (Activities of Daily Living), had no teeth, no eating problems, received a mechanically altered diet and was on a physician-ordered diet to gain weight. The assessment identified the resident's weight as 177 pounds. Review of the quarterly MDS with a date of 7/24/13 revealed the resident had cognitive impairment and was dependent on staff for ADLs, had no teeth, no eating problems, received a mechanically altered diet and was on a physician-ordered diet to gain weight. The assessment identified the resident had not lost 5% or more of weight in the last month or 10% or more in the last 6 months and identified the resident's weight as 158 pounds. Review of the Nutritional CAA (Care Area Assessments) dated 12/26/12 revealed the resident drank his/her meals. The resident pocketed food (stored food in his/her cheeks rather than swallowing) and "had to go to liquids." Review of the care plan, dated 4/4/13, revealed the resident had no teeth or dentures and ate a pureed diet. The resident liked to make choices, at times, of the food served to him/her. The clinical record included 3 different meal consistencies that the resident received. Review of the resident's weight flow record revealed the staff monitored the resident's weights weekly. The resident's weights revealed the following: 01/29/13: 164.6 02/07/13: 164.8 02/12/13: 165 02/19/13: 165.1 02/27/13: 165.8 03/06/13: 163 03/12/13: 164.8 hospitalized 05/07/13: 157.8 (return from hospital) 05/14/13: 157.8 05/22/13: 158 06/05/13: 158 06/11/13: 159.8 06/18/13: 158 06/25/13: 164 06/28/13: 162 07/04/13: 157.2 07/08/13: 158 07/15/13: 158.1 07/30/13: 160.8 08/11/13: 164.7 Review of laboratory blood test drawn on 4/29/13 revealed an [MEDICATION NAME] level (a blood test used to measure the amount of protein in the blood and is used in part to determine a person ' s nutritional status) of 3.1 g/dl (grams per deciliter)--normal range 3.4 to 5 g/dl, Hemoglobin (a complex protein-iron compound in the blood that carries oxygen to the cells from the lungs and carbon [MEDICATION NAME] away from the cells to the lungs) 12.5 g/dl--normal range 14.0 to 18.0 g/dl, hematocrit (a measure of the packed cell volume of red cells, expressed a s a percentage of the total blood volume) 38.2%--normal range 40.0 to 54.0%. Review of the monthly nutrition progress note, dated 7/17/13, revealed the resident received a regular blended diet, was dependent on staff for eating, and received protein supplement shakes. The note identified the resident's meal intake was greater than 75% and the resident consumed 100% of supplements. The resident had chewing problems due to being edentulous (had no teeth). Observation of the resident on 8/13/13 at 9:45 a.m. revealed the resident sat in a Geri chair (a reclining wheelchair that has a raised foot rest) at the dining table and drank from a large 16 oz. (ounce) protein shake assisted by direct care staff C. The resident also had a glass of water and a glass of cranberry juice. The resident consumed 100% of the fluids. Staff did not offer any food to the resident, even though the physician ordered staff to offer a regular diet, texture as tolerated. Observation on 8/13/13 at 11:25 a.m. revealed direct care staff E assisted the resident to drink a 16 oz. protein shake along with 2 glasses of water and a glass of cranberry juice for lunch. The resident consumed 100% of the fluids. The staff offered no other food source. Observation on 8/13/13 at 3:50 p.m. revealed the resident sat in semi fowlers position (a person who lays in bed on their back with the head of the bed at approximately 30 degrees) drinking a protein shake with assistance from direct care staff M. On 8/13/13 at 12:39 p.m. interview with Direct care staff C revealed the direct care staff are supposed to report any changes in the resident's condition to the charge nurses. Staff C defined changes in conditions as decrease ability to take care of themselves, changes in the ability to eat, skin issues, mood and behavioral issues. Staff C revealed a lot of things get reported to the nurses around here that never get followed up on. During an interview on 8/13/13 at 3:50 p.m. direct care staff M reported the resident only drank protein shakes for meals because that was all he/she liked. When asked, staff confirmed he/she did not try to offer a pureed diet to the resident that day. Staff M stated the resident would just refuse the food, anyway. During an interview on 8/13/13 at 1:45 p.m. licensed nurse H reported the staff were to offer the resident a pureed meal then the protein shake if the resident did not finish the meal. Staff were to use the protein shakes as a supplement to the resident's diet. The nurse stated he/she was not aware the staff were not offering a pureed meal first. During a meeting on 8/15/13 at 6:00 p.m., Administrative Nurses A and B failed to provide further explanation when told staff failed to offer food to the resident before offering a supplemental drink. The facility failed to ensure a resident maintained acceptable protein levels and weight range by not offering the resident food at each meal before assisting the resident to drink a supplemental protein drink.