Every finding on record at Lakeshore Post Acute and Rehabilitation Center

Based on observations and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure resident rooms, shower rooms and hallways received necessary maintenance and repairs. Findings include:I. Observations On 8/26/25 at 10:20 a.m., observations of the facility revealed the following:In the shower room on the A hall, it was revealed that there was a missing vent, leaving a hole in the ceiling.-The ventilation system in the A Hall shower room was not working The vents on the A hall and B hall were rusty with a brown colored substance around the surfaces, and the vents were missing paint.A hole was observed in the drywall of room F-4.On Hall C, room [ROOM NUMBER] had water leaking from the ventilation system located on the ceiling towards the window in the room.On 8/27/25 at 11:15 a.m., observations of the facility revealed the following:Near the door going into the main dining room, there was water leakage from the roof of the building.Resident #1 said there was a pool of water flowing out of the ceiling the night before, causing a puddle of water to settle on the ground at the entrance to the facility.At 11:20 a.m., there was a loose handrail, and there was a light hanging from the hallway ceiling. At 11:30 a.m., the following doors to resident rooms were difficult to open:Room #A2, room #C12, room #C13, room #C16, room # C18, room #D3, room #D5, room #D6, room #D7, room #E6, room #E10, room #F1 and room #F10.II. Resident interviewsThe resident who resided in room #D 6-2 was interviewed on 8/25/25 at 1:223 p.m. The resident said her door got stuck daily and she could not open it most of the time.The resident who resided in room [ROOM NUMBER] was interviewed on 8/25/25 at 3:22 p.m. She said the door to her room was difficult to open and close. The resident said she had spoken with several certified nurse aides CNAs to complete a maintenance work order, but no one had fixed the door.The residents who resided in room # D6 were interviewed together on 8/27/25 at 11:28 a.m. One of the residents said her door to her room had been difficult to open and close since he was admitted to the facility. The other resident said he stayed in his room most of the time. He said he would prefer to have the door shut when his roommate left the room, but his roommate could not open the door when he returned. III. Staff interviews and observationsAn environmental tour was conducted on 8/27/25 at 3:18 p.m. with the maintenance director (MTD), and the above concerns were observed. The MTD said all identified concerns would be addressed immediately. The MTD said staff should be putting in work orders when they notice something is broken. He said the facility utilized an electronic work system to track needed repairs. He said the facility staff also verbally let him know what needed to be repaired. He said the maintenance staff put the work orders into the electronic work system. He said all of the maintenance staff knew how to put a work order into the electronic work system.The MTD said he would take notes on what needed to be repaired. He said work orders were completed in order to be completed when it was received, except emergency work orders, which were completed immediately.The MTD said he completed weekly audits throughout the building once a week.The MTD said he completed maintenance work orders when he noticed any issues during his weekly audits and walk-throughs and ensured that they were completed.The MTD said that when it rained the previous night, the gutters became flooded, affecting the roof, causing leakages from several areas of the building. He said the facility was in the process of replacing the roof of the building.The nursing home administrator (NHA) said that staff could place work orders in the facility's computerized healthcare software system. The NHA said the computerized healthcare software system would then generate a work order in the facility's management computerized system.The NHA said the identified concerns would be immediately taken care of. She said she would review the maintenance work order system to identify where the issues were and provide education.

Based on record review and interviews, the facility failed to ensure one (#1) of two residents received treatment and care in accordance with professional standards of practice out of 55 sample residents. Specifically, the facility failed to ensure timely follow-up from a telehealth (virtual) pulmonology appointment to ensure Resident #1 was evaluated through a sleep study for a potential continuous positive airway pressure (CPAP) machine.Findings include:I. Resident #1A. Resident statusResident #1, age less than 65, was admitted on [DATE]. According to the August 2025 computerized physicians orders (CPO), diagnoses included chronic obstructive pulmonary disease, morbid obesity with alveolar hypoventilation (inability to breathe rapidly or deeply), acute and chronic respiratory failure with hypercapnia (too much carbon dioxide in the blood), acute and chronic respiratory failure with hypoxia (low levels of oxygen in the body tissues) and sleep apnea (sleep disorder in which breathing repeatedly stops and starts).The 7/30/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident was dependent on staff assistance for most of his mobility and toileting activities of daily living (ADL). The assessment documented the resident was on continuous oxygen. B. Resident interviewResident #1 was interviewed on 8/25/25 at 10:20 a.m. Resident #1 said he had not received his CPAP machine (a machine that delivers constant and steady air pressure to help with breathing while sleeping). He said he had had at least two appointments with his pulmonologist and still had not heard about his CPAP machine. He said his pulmonologist had filled out all of the paperwork and faxed it over to the facility. He said he had been waiting since March 2025 for his CPAP machine. Resident #1 was interviewed a second time on 8/28/25 at 12:34 p.m. Resident #1 said he was not given any paperwork after his appointments because they were telehealth appointments. He said that his pulmonologist told him that she had faxed over his paperwork for the CPAP machine to the facility. Resident #1 was interviewed a third time on 8/28/25 at 3:02 p.m. Resident #1 said he was supposed to have a sleep study, but one had not been scheduled yet. C. Record reviewThe respiratory care plan, revised 4/2/25, revealed Resident #1 had an altered respiratory status and difficulty breathing due to his diagnoses (see resident status above). Pertinent interventions included monitoring the resident for respiratory distress, shortness of breath, and maintaining a clear airway, providing oxygen and administering medications/puffers (inhalers) as ordered. -Review of Resident #1's comprehensive care plan did not reveal any care plan focus or interventions for a CPAP machine. -Review of Resident #1's physician's orders did not reveal a physician's order for a CPAP machineReview of two grievances made by Resident #1 since his March 2025 admission were reviewed and revealed the resident was concerned he had not gotten a CPAP machine yet and mentioned a sleep study and pulmonology appointments. -Review of Resident #1's electronic medical record (EMR) did not reveal any progress notes or records of his pulmonology appointments while at the facility. D. Staff interviews The regional clinical resource (RCR) was interviewed on 8/28/25 at 12:29 p.m. The RCR said she did not have any physician's orders or information from Resident #1's pulmonologist about a CPAP machine. She said she would contact the pulmonology office to get his records sent over. -However, the resident's pulmonology appointment records were not provided by the survey exit on 8/28/25.The health information manager (HIM) was interviewed on 8/28/25 at 1:09 p.m. The HIM said she did not believe Resident #1 had had any appointments with a pulmonologist while he was at the facility. She said if she did not know about the appointment, then she could not follow up to request the documentation from the appointment. The receptionist was interviewed on 8/28/25 at 1:13 p.m. The receptionist said Resident #1 had pre-existing appointments scheduled with his pulmonologist when he was first admitted to the facility. She said he had appointments scheduled on 4/15/25, 5/21/25 and 7/25/25 She said all of the appointments were telehealth appointments. She said when residents went out to appointments, they would let her know when they came back if there were follow-up appointments and the van driver would give the floor nurse the packet of paperwork. The director of nursing (DON) was interviewed on 8/28/25 at 1:38 p.m. The DON said normally when a resident went out for an appointment and then came back, they would come back with a packet and the packet would be given to the floor nurse. She said the floor nurse would open the packet and look to see if there were any changes that needed to be made. She said if the resident came back without any paperwork, then the appointment schedule would get pulled and the HIM would follow up with the physician's office the resident went to. She said telehealth appointments were harder to track, especially if the resident did not say anything to staff. She said she would expect the same follow-up practice to occur with telehealth appointments as it did with the other appointments. She said she was unsure if a sleep study was ever scheduled for Resident #1.

Based on record review and interviews, the facility failed to provide and document sufficient discharge preparation and documentation for one (#97) of two residents reviewed for a safe and orderly discharge out of 55 sample residents. Specifically, the facility failed to notify the ombudsman in writing regarding Resident #97's discharge. Findings include:I. Resident #97A. Resident statusResident #97, age less than 65, was admitted on [DATE] and discharged home on 6/18/25. According to the August 2025 computerized physician orders (CPO), diagnoses included fracture of right lower leg, asthma, type 2 diabetes mellitus and fibromyalgia (pain disorder).The 6/4/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She required set-up assistance with eating, substantial to maximum assistance from staff with personal hygiene, and toileting. The MDS assessment documented Resident #97 was discharged from the facility, as planned, on 6/18/25.B. Record reviewThe discharge summary nursing progress note, dated 6/17/25 at 3:22 p.m., revealed Resident #97 was admitted to the facility for post-acute care, skilled nursing and rehabilitation services following a hospitalization after a recent fall at home. The treatments provided during her stay were physical therapy, occupational therapy and skilled nursing orthopedic aftercare.The discharge social services summary note, dated 6/18/25 at 9:36 a.m., revealed Resident #97 received a notification on 6/17/25 from her commercial insurance plan that they had determined she was no longer appropriate or needing the services of an inpatient skilled stay, and they would no longer cover her skilled services at the facility starting on 6/17/25.The social services discharge summary documented Resident #97 was assisted by the admissions coordinator and the social services director (SSD) to file an appeal on behalf of the resident. The SSD and the admissions coordinator explained to the resident that she would be able to stay at the facility for 30 days of the appeal; however, if the appeal was denied, the resident would have to pay private pay to the facility.The discharge care plan, initiated 6/5/25 and revised 7/2/25, revealed Resident #97 wished to return to her home upon completion of skilled nursing services and once regaining weight-bearing status.The discharge planning note, dated 6/18/25 at 9:36 a.m., revealed that the SSD left a voicemail notifying the local long-term care ombudsman of the resident's discharge situation and requested a return call.-A review of Resident #97's electronic medical record (EMR) did not reveal documentation to indicate the ombudsman was notified of Resident #97's discharge in writing prior to the resident's discharge from the facility.II. Staff interviewsThe SSD, the regional clinical resource (RCR), the nursing home administrator (NHA) and the director of nursing (DON) were interviewed together on 8/28/25 at 10:30 a.m. The SSD said she sent a list of discharges to the ombudsman at the beginning of each month for the previous month's discharges. The RCR said that the SSD's process did not meet the regulatory requirements. She said the ombudsman should be notified in writing before the resident's discharge from the facility.The SSD was interviewed again on 8/28/25 at 2:35 p.m. The SSD said she was responsible for coordinating residents' discharges. She said Resident #97 was discharged before her care conference date, which was scheduled to be held on 6/20/25. The SSD said she left a voicemail for the local long-term care ombudsman about Resident #97's situation and discharge, but said she did not notify the ombudsman in writing of the resident's discharge. She said she was aware that notifying the ombudsman in writing was part of the regulatory compliance in relation to discharges. The SSD said she sent the ombudsman notification in writing at the end of the month (June 2025), after Resident #97's discharge from the facility.

Based on observations, record review and interviews, the facility failed to provide ongoing group activities designed to support the needs and preferences of the residents for two (#2 and #78) of five residents reviewed for activities out of 55 sample residents.Specifically, the facility failed to provide activities that met Resident #2 and Resident #78's preferences. Findings include:I. Facility policy and procedureThe Activity policy and procedure, revised September 2024, was received from the nursing home administrator (NHA) on 8/28/25 at 4:20 pm. It read in pertinent part, It is the policy of this facility to ensure that residents have the right to choose the types of activities and social events in which they wish to participate. Residents are encouraged to choose the types of activities and social events in which they prefer to participate. Residents who wish to meet with or participate in social or religious activities, or other community activities, at or away from the facility are encouraged to do so.II. Resident #2A. Resident statusResident #2, age less than 65, was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnosis included cerebral palsy (abnormal brain development), schizoaffective disorder (mental illness), bipolar disorder (mental illness) and muscle weakness.The 7/22/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She was dependent on staff for assistance with toileting, personal hygiene, and required set-up assistance with eating.The assessment documented the resident's activity preferences included listening to music, being around animals, keeping up with the news, doing activities with groups of other people and going outside when the weather was good for fresh air.B. Resident interviewResident #2 was interviewed on 8/25/25 at 3:20 p.m. Resident #2 said she had lived at the facility for over two years. She said the facility obtained a new bus for group activities, however the new bus had only one spot for residents in wheelchairs. Resident #2 said she had missed several group outings because other residents had already signed up. She said it was very stressful for her not to be able to participate with her friends in any group outings because she was unable to transfer to a seat and required her wheelchair at all times. She said she really enjoyed outings outside the facility. She said since there was only one spot for a wheelchair, she had just been spending time with her sister C. Record reviewThe activities care plan, initiated on 9/13/24 and revised on 7/23/25, documented that Resident #2 enjoyed group activities such as going outside when the weather was nice, Bingo, going to the movies, shopping, community outings, karaoke and music performers. Interventions included assisting with arranging community outings with transportation and introducing the resident to other residents with similar backgrounds and interests.Review of activity log from 11/1/24 to 8/28/25 revealed that Resident #2 participated in three (11/6/24, 12/12/24 and 4/3/25) outside group trip activities and refused to participate in one event (7/16/25).III. Resident #78A. Resident statusResident #78, age greater than 65, was admitted on [DATE]. According to the August 2025 CPO, diagnoses included post-traumatic stress disorder (PTSD), depression, anxiety disorder, multiple sclerosis (progressive disease that affects movement) and renal insufficiency. The 10/3/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required setup help with eating, maximum assistance with transfers, dependent with showers, and toileting. She utilized a motorized wheelchair for mobility.The10/3/24 MDS assessment for Resident #78 documented that Resident #78 enjoyed group activities and going out when the weather was nice.B. Resident interviewResident #78 was interviewed on 8/25/25 at 4:35 p.m. Resident #78 said she wished she could go out on a group activity with her friends, but the facility bus could only accommodate one wheelchair, and most of the time was left behind because she could not transfer to a seat. She said she went to dialysis a couple of times a week. When she was available to go on an outing, the staff told her there were no spots available , She said she enjoyed being outside but had never had the opportunity to go out on a trip into the community with her friends this year. The resident said it was very frustrating that she could not join her friends because she could not walk.C. Record reviewReview of activity log from 11/1/24 to 8/28/25 revealed that Resident #78 did not participate in two outside group trip activities (11/12/24 and 11/14/24).-Review of the activity log did not show any further documentation that indicated the resident participated in group outings. IV. Staff interviewsThe activity bus driver was interviewed on 8/28/25 at 8:40 a.m. The activity bus driver said the facility bus could only accommodate one resident in a wheelchair. He said most of the residents in wheelchairs who could not be transferred to a seat were often left behind. He said several residents had expressed their concerns about the bus situation.The activity director (AD) was interviewed on 8/28/25 at 9:00 a.m. The AD said the bus could only take one wheelchair, which made it extremely difficult to include residents who were in wheelchairs and could not be transferred onto a seat to go on outside group activities. The AD said she rotated the residents who required wheelchairs to take turns. She said that the facility bus had 12 seats and one wheelchair accessible spot. The AD said outside group activities were first-come first first-served for all residents who required wheelchairs. She said most residents in wheelchairs were left behind due to the bus limitations. The NHA was interviewed on 8/28/25 at 10:15 a.m. The NHA said each resident's participation in group activities was based on their physical and cognitive abilities. She said when outside group activities required additional transportation assistance, arrangements would be made to accommodate the event. She said the activity bus driver could also make multiple trips. She said it had not been brought to her attention that residents were concerned about their inability to participate in outside group activities with their peers.

Based on observations, record review and interviews, the facility failed to provide proper contracture management services, equipment, and assistance for two (#66 and #37) of three residents reviewed for restorative services out of 55 sample residents. Specifically the facility failed to:-Ensure staff consistently applied Resident #66's wrist splint to the resident's right hand, which had a contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff); and,-Ensure Resident #37 was provided with passive range of motion (PROM) to her bilateral ankles, which had contractures.Findings include: I. Facility policy and procedure The Contracture policy, dated 2022, was provided by the nursing home administrator (NHA) on 8/26/25 at 4:20 p.m. It revealed in pertinent part, A resident with a limited range of motion or contracture shall receive appropriate treatment and services, based on the comprehensive assessment of the resident, to increase range of motion and/or to prevent further decrease. II. Resident #66 A. Resident status Resident #66, age [AGE], was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included schizophrenia, contracture unspecified hand, unspecified injury of head subsequent encounter, age-related cognitive decline, unspecified lack of coordination, dependence of wheelchair, contracture right hand and abnormal posture. The 7/14/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. She depended on staff assistance with bathing, dressing, toileting and transferring. She depended on a wheelchair. The assessment indicated that the resident wore a splint on her right wrist. B. Observations On 8/25/25 at 5:29 p.m. Resident #66 was sitting in the hallway near the television (TV). Her right hand was contracted at the wrist and she was not wearing a splint or a palm protector. Her fingers looked as if they were clutching something but her hand was empty. On 8/26/25 at 1:30 p.m. Resident #66 was sitting in her room in her wheelchair. Her right hand was contracted and she was not wearing a splint or a palm protector. On 8/27/25 at 8:42 a.m. Resident #66 was sitting in the hallway near the TV. Her right hand was contracted and her fingers were curled inward toward her palm. She was not wearing a splint or a palm protector. On 8/27/25 at 10:40 a.m. Resident #66 was in the dining room with the activities group. She was sitting in her wheelchair. Her right hand was contracted at the wrist and her fingers looked like they were digging into her palm. She was not wearing a splint or a palm protector. C. Record review Review of Resident #66`s musculoskeletal care plan, initiated 5/6/25, revealed that the resident had an alteration in musculoskeletal status related to a contracture of her right hand. Interventions included anticipating and meeting the resident's needs and ensuring the call light was within reach and responding promptly to all requests for assistance. -The care plan did not include an intervention for the resident's right hand splint. Review of Resident #66's self care deficit care plan, initiated 10/28/24, revealed the resident had a care deficit related to schizophrenia and a history of elevated troponin. Pertinent interventions included ensuring the resident's right hand resting splint was on in the morning and off in the evening (initiated 5/6/25). Review of a Therapy for Skilled Nursing document, undated, revealed that Resident #66 had a right elbow and hand contracture. Review of Resident #66's August 2025 CPO revealed the following physician's order: Apply splint on the right hand in the morning and remove in the afternoon, two times a day, ordered 5/6/25. Review of Resident #66`s treatment administration record (TAR) revealed that the resident's splint was documented as being applied on 8/26/25 and 8/27/25. -However, Resident #66 was not observed wearing the splint on 8/26/25 and 8/27/25 (see observations above). Review of Resident #66`s progress notes did not reveal documentation to indicate whether or not the splint was applied or whether Resident #66 refused to wear the splint on 8/26/25 and 8/27/25. D. Staff interviews Certified nurse aide (CNA) #8 was interviewed on 8/27/25 at 9:50 a.m. CNA #8 said splints were necessary to keep resident's muscles relaxed which would stop Resident #66`s hands from contracting even more. She said Resident #66 often refused to wear the splint. She said the staff would attempt to apply the splint multiple times during the day if she refused. She said she would chart applying, removing, and refusal of the splint in the resident's electronic medical record (EMR). She said if Resident #66 refused the splint, CNAs were to report the refusal to the registered nurse (RN) and the RN would chart the splint refusal in the resident's progress notes. RN #4 was interviewed on 8/27/25 at 10:15 a.m. RN #4 said she would document Resident #66's right hand splint application, removal and resident refusals on the resident's treatment administration records (TAR). She said she would additionally document a progress note if the resident refused to wear the splint. The NHA was interviewed on 8/28/25 at 10:27 a.m. The NHA said that Resident #66's TAR documentation for 8/26/25 and 8/27/25 revealed that the splint was on the resident's right wrist. -However, observations on those dates revealed the resident did not have her splint on (see observations above). The NHA said if residents refused to let staff apply a splint, nurses should document a progress note regarding the refusal. CNA #8 was interviewed a second time on 8/28/25 at 10:34 a.m. CNA #8 said Resident #66 would let staff know at the beginning of the splint application process whether she was going to tolerate the splint or not. She said Resident #66 would not take the splint off on her own. The director of rehabilitation (DOR) was interviewed on 8/28/25 at 10:45 a.m. The DOR said hand splints were to prevent skin breakdown and to prevent contractures. She said Resident #66 would only allow certain staff members to put the splint on to her right hand. She said the splint did not have to stay on all day and it should be removed in the afternoon. She agreed that the CNAs should let the nurses know if the resident refused. She said the nurses should chart refusals of the splint in the progress notes. She said if the resident's refusal behavior continued for approximately for a week, the nurses should let her know that the therapy was not working. III. Resident #37 A. Resident status Resident #37, less than age [AGE], was admitted on [DATE]. According to the August 2025 CPO, diagnoses included chronic cystitis with hematuria (a condition where blood is present in the urine), multiple sclerosis, epilepsy, chronic obstructive pulmonary disease (COPD), chronic systolic and diastolic congestive heart failure, contractures of the left and right ankle, anxiety disorder and major depressive disorder. The 5/15/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident was impaired on both sides of her lower extremities. She required maximum assistance with transfers, bathing, and toileting, and set-up assistance with eating. The MDS assessment indicated Resident #37 was part of a restorative program, which included passive range of motion (PROM) and splint or brace assistance twice per week. B. Resident interview and observations Resident #37 was interviewed on 8/26/25 at 1:02 p.m. Resident #37 said her ankles were contracted due to her diagnosis of multiple sclerosis. She said the restorative program at the facility had been non-existent. Resident #37 said she was supposed to receive PROM two times a week; however, she barely received it two times a month. She said the restorative CNAs were often pulled to work on the floor and they did not have the time to complete their restorative duties. During a continuous observation on 8/26/25, beginning at 1:00 p.m. and ending at 4:00 p.m., the following was observed: At 1:00 p.m. Resident #37 was in bed in her room. CNA #3 went to the resident's room to assist with care. CNA #3 left the resident's room at 1:08 p.m. -CNA #3 did not provide PROM to the resident. At 2:00 p.m., CNA #3 engaged in a short conversation with Resident #37 in her room, picked up the trash from the resident's trash can and left the resident's room. -CNA #3 did not provide PROM to the resident. -No other staff members entered Resident #37's room after CNA #3 exited the resident's room shortly after 2:00 p.m. until the continuous observation ended at 4:00 p.m. Resident #37 was not provided with PROM during the three-hour continuous observation. C. Record review Review of Resident #37's August 2025 CPO revealed the following physician's order: The restorative care plan, revised 11/21/24, documented that Resident #37 had limited physical mobility related to contractures, multiple sclerosis and weakness. Interventions included PROM of the resident's bilateral ankles, providing supportive care, assisting with mobility as needed and documenting assistance provided and ensuring the resident was wearing Multi Podus boots on both feet when she was in her wheelchair, per physical therapy recommendations for her ankle contractures. -The care plan did not include how often the resident was to receive PROM. -A review of Resident #37's electronic medical records (EMR), from 5/1/25 to 8/27/25, did not reveal documentation to indicate that the resident had received PROM. D. Staff interviews CNA #3 was interviewed on 8/26/25 at 2:05 p.m. CNA #3 said Resident #37 had contractures in both of her ankles. She said Resident #37 was Multi Podus boots on her feet. CNA #3 said the restorative CNAs provided restorative care for residents, including PROM for Resident #37. The minimum data set coordinator (MDSC) was interviewed on 8/28/25 at 10:00 a.m. MDSC said she had just been assigned the role of managing the restorative team, and she intended to review the entire restorative program together with the restorative team. The MDSC said Resident #37 was on a restorative program to receive PROM. She said staff were expected to document all restorative sessions in the resident's EMR. The MDS coordinator said there were no documented sections in the resident's EMR. The MDSC said the facility currently had one restorative CNA but she said the facility was hiring more staff to revamp the restorative department. The DOR was interviewed on 8/28/25 at 10:30 a.m. The DOR said restorative staff were provided training for any ongoing restorative programs for contracture management after therapy had completed the residents' treatment plans. She said it was important that the therapists' recommendations were followed to ensure residents' contractures did not worsen. The DOR said the rehabilitation department recommended Resident #37 be provided a PROM restorative program to her bilateral ankles every day as tolerated by the resident. She said she was not sure if that recommendation was being followed by the restorative staff. She said staff should provide PROM to the resident's bilateral ankles for her ankle contractures and the resident should have Multi Podus boots on her feet when she was up in her wheelchair. The DOR said there were no documentation in Resident #37's EMR that indicated the resident was receiving PROM.

Based on observations, record review and interviews, the facility failed to ensure an environment free from risk of accident hazards for one (#5) of two residents out of 55 sample residents.Specifically, the facility failed to provide adequate supervision for Resident #5, who had a history of elopement. Findings include:I. Facility policy and procedureThe Elopement policy and procedure, revised September 2024, was provided by the nursing home administrator (NHA) on 8/28/25 at 9:47 a.m. It read in pertinent part, It is the policy of this facility to ensure that the facility provides a safe and secure atmosphere for all residents in the facility while striving to maintain the highest practicable function and the least restrictive environment. To ensure that residents at risk for elopement are properly monitored. Residents who are at risk for elopement would have an appropriate plan of care developed to address the risk.II. Resident #5A. Resident statusResident #5, age greater than 65, was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure, major depressive disorder, anxiety disorder and dementia.The 7/22/25 minimum data set (MDS) assessment revealed Resident #5 had severe cognitive impairments with a brief interview for mental status (BIMS) score of seven out of 15. He was dependent on staff with toileting, required touch assistance with personal hygiene, and set-up assistance with eating. The assessment indicated he required a manual wheelchair for mobility and had a wander guard in place.B. ObservationsDuring a continuous observation on 8/25/25, beginning at 12:37 p.m. and ending at 2:05 p.m., the following was observed:At 12:37 p.m., Resident #5 was sitting in his wheelchair near the east side of the E-hall entrance to the smoking patio.At 12:40 p.m., Resident #5 self-propelled himself outside while other residents were entering the building from the smoking patio. He sat in his wheelchair waiting for the 1:00 p.m. supervised smoking break. There were no staff members in the smoking area.At 12:58 p.m., activity assistant (AA) #1 entered the smoking patio with a container of cigarettes and assisted the residents with smoking.At 2:05 p.m., AA #1 assisted Resident #5 back onto E-hall.On 8/26/25 at 2:33 p.m., Resident #5 self-propelled his wheelchair from the E-hall through the exit door when other residents, who smoked independently, were going out to the smoking patio to smoke. His wander guard alarm did not activate. There was no staff member in the area.At 2:55 p.m. Resident #5 sat in his wheelchair outside. An unidentified resident alerted a staff member that Resident #5 was outside at the smoking patio without staff.At 3:02 p.m. CNA #5 went out and stayed with the residents while AA #2 went to get the smoking container.On 8/27/25 at 2:15 p.m., a visual tour of the smoking area revealed there was a fence with an unsecured gate entrance leading directly to the street.C. Record reviewThe behavior and wandering care plan, revised 7/19/25, revealed Resident #5 was an elopement risk related to dementia with agitation and had a history of exit-seeking behaviors. Interventions included distracting the resident from wandering and exit seeking by offering smoke, pleasant diversions, structured activities, food, conversation, and television. The care plan indicated Resident #5 required supervision while smoking.A review of Resident #5's electronic medical record (EMR) from the admission date 7/9/25 until 8/27/25 did not reveal any episode of exit seeking.-However, interviews revealed Resident #5 had exit-seeking behaviors (see interviews below).Review of the August 2025 CPO revealed a physician's order that indicated to replace the wanderguard every 90 days, ordered 7/9/25. III. Staff interviewsCertified nurse aide (CNA) #6 was interviewed on 8/27/25 at 10:14 a.m. CNA #6 said Resident #5 had exit-seeking behaviors and required supervision at all times when he exited the building. She said the resident had a wanderguard, which was supposed to activate when Resident #5 entered the building. CNA #6 said she did not know how to ensure the wanderguard system was functioning currently.Registered nurse (RN) #5 was interviewed on 8/27/25 at 10:30 a.m. RN #5 said Resident #5 had wandering behaviors and had a wander on his ankle. RN #5 said the resident verbalized the desire to go home to live with his son. RN #5 said the staff were responsible for ensuring the resident was supervised when he was out of the building.The director of nursing (DON) was interviewed on 8/27/25 at 10:45 a.m. The DON said the facility staff were responsible for ensuring all unsafe smokers were adequately supervised. The DON said Resident #5 had exit-seeking behavior and had a wanderguard on his ankle. She said the staff were provided education on how to ensure residents with exit-seeking behaviors were monitored appropriately. The DON said she would immediately review the facility's smoking policy and provide education to all staff to ensure the safety of all residents.The NHA was interviewed on 8/28/25 at 11:30 a.m. The NHA said Resident #5 had a history of wandering and exit seeking. She said Resident #5 was admitted to the facility with the wander guard, and the facility had not completed its own assessment of the resident's wandering behavior. The NHA said the resident's wander guard program was immediately discontinued since an assessment of the resident's wandering behavior had not been completed, and there was no episode of exit seeking since admission. The NHA said Resident #5 expressed interest in living with his son; however, he had not left the building. The NHA said a physician's order was obtained to monitor for wandering and exit-seeking attempts for five days.

Based on observations, record review and interviews, the facility failed to ensure the medication error rate was not greater than five percent (%).Specifically, the facility's medication error rate was 10.3%, or three errors out of 29 opportunities for error.Findings include:I. Facility policy and procedureThe Subcutaneous Insulin Medication Administration policy, dated January 2022, was provided by the NHA on 8/28/25 at 9:47 a.m. It read in pertinent part, Prepare syringe/pen and safety needle. Line up the needle with the pen, and keep it straight as you attach it. Always perform the safety test before each injection. Performing the safety test ensures that you get an accurate dose by ensuring that pen and needle work properly and removing air bubbles. Select the priming dose by turning the dosage selector. Hold the pen with the needle pointing upwards. Tap the insulin reservoir so that any air bubbles rise up towards the needle. Press the injection button all the way in. Check if insulin comes out of the needle tip.The Medication Administration policy, revised August 2024, was provided by the nursing home administrator (NHA) on 8/28/25 at 4:00 p.m. It read in pertinent part, It is the policy of this facility that medications shall be administered as prescribed by the attending physician. Medications must be administered in accordance with the written orders of the attending physician.II. Resident #43A. ObservationsOn 8/26/25 at 3:25 p.m. licensed practical nurse (LPN) #3 prepared to administer medications to Resident #43, including a Symbicort 160-4.5 microgram per actuation (mcg/act) inhaler.At 3:28 p.m. Resident #43 self-administered the Symbicort inhaler with LPN #3's supervision.Resident #43 self-administered one puff of the Symbicort inhaler to herself.-LPN #3 failed to instruct the resident to take a second puff from the inhaler (see physician's orders below).-LPN #3 failed to instruct the resident to rinse her mouth with water and spit after Resident #43 used the inhaler (see physician's orders below).B. Record reviewReview of Resident #43's August 2025 computerized physician orders (CPO) revealed the following physician's order:Symbicort (budesonide-formoterol fumarate dihydrate) inhalation aerosol 160-4.5 mcg/act. Inhale two puffs orally two times a day for COPD (chronic obstructive pulmonary disease). Rinse and spit after inhaler use, ordered 3/18/25.C. Staff interviewLPN #3 was interviewed on 8/26/25 at 4:35 p.m. LPN #3 said she thought she saw Resident #43 administer a second puff from the inhaler to herself. After she looked up the physician's orders in Resident #43's electronic medical record (EMR), LPN #3 said the resident should have rinsed her mouth after she used the inhaler. LPN #3 said she was not positive, but she thought it was important for the resident to rinse her mouth after using the inhaler in order to prevent thrush.III. Resident #92A. ObservationsOn 8/27/25 at 3:11 p.m. registered nurse (RN) #2 prepared to administer medications to Resident #92, including a Dulera (mometasone furoate-formoterol fumarate dihydrate) inhalation aerosol 200-5 mcg/act inhaler.At 3:15 p.m. RN #2 allowed Resident #92 to self-administer the Dulera inhaler to himself.-RN #2 failed to instruct the resident to rinse his mouth with water and spit after Resident #92 used the inhaler (see physician's orders below).B. Record reviewReview of Resident #92's August 2025 CPO revealed the following physician's order:Dulera (mometasone furoate-formoterol fumarate dihydrate) inhalation aerosol 200-5 mcg/act. Inhale two puffs orally two times a day for COPD. Rinse mouth and spit after inhaler use, ordered 10/15/24.C. Staff interviewsRN #2 was interviewed on 8/27/25 at 3:35 p.m. RN #2 said Resident #92 usually self-administered the Dulera inhaler and he had been educated several times to rinse and spit after he used the inhaler. RN #2 said the resident just did what he wanted. She said she was unclear about why it was important for the resident to rinse and spit after he used the inhaler but she said she thought it prevented sores from the steroid medication in the resident's mouth.IV. Resident #99A. ObservationDuring a continuous observation on 8/27/25, beginning at 8:40 a.m. and ending at 9:10 a.m., the following was observed:At 8:40 a.m. RN #1 entered Resident #99's room to check his blood glucose level and administer medications, including insulin via the resident's insulin pen injector. The resident requested his brief be changed upon RN #1's arrival.After Resident #99's brief was changed, RN #1 administered the resident's oral medications, checked his blood glucose level and prepared to administer the insulin. RN #1 turned the dosage selector on the insulin pen to 13 units.-However, RN #1 failed to prime the insulin pen injector before she administered the insulin to Resident #99's right abdomen.-Additionally, the physician's order indicated the resident was to receive 15 units of insulin (see physician's order below).At the medication cart, RN #1 self-identified that the physician's order said she should have administered 15 units of insulin. RN #1 prepared to re-enter Resident #99's room to administer the final two units of insulin.Prior to entering Resident #99's room, RN #1 turned the dosage selector on the insulin pen to two units.-However, RN #1 again failed to prime the insulin pen injector before she administered the remaining insulin dose to Resident #99's left abdomen.At 9:10 a.m. RN #1 completed Resident #99's subcutaneous insulin administration via the insulin pen injector.Cross reference F760 for failure to ensure residents were free from significant medication errors.B. Record reviewReview of Resident #99's August 2025 CPO revealed the following physician's order:Lantus (insulin glargine-yfgn) subcutaneous solution 100 units per milliliter (unit/ml). Inject 15 units subcutaneously two times a day for diabetes mellitus. Call the provider (MD) if blood sugar (BS) is less than 60 milligrams per deciliter (mg/dl) or greater than 400 mg/dl, ordered 8/25/25.C. Staff interviewsRN #1 was interviewed on 8/28/25 at 9:40 a.m. RN #1 said the insulin pen should be primed prior to administration, but she was not clear on the correct process to do so. She said she primed the pen during the first administration of insulin. She said the needle did not need to be attached to prime the insulin. She said she did not prime the pen when she returned to Resident #99's room for the final administration of insulin. RN #1 said it was important to prime the insulin pen to remove the air so the resident would receive the full dose of insulin.V. Additional interviewsThe pharmacy consultant was interviewed by telephone on 8/28/25 at 10:37 a.m. She said LPN #3 should have followed the physician's order and instructed Resident #43 to take an additional puff from the inhaler. The pharmacy consultant said that standard practice when taking corticosteroids would be to have residents rinse and spit after using the inhaler in order to prevent thrush.The pharmacy consultant said the needle was required to be attached to the insulin pen in order to prime it prior to administration. She said the insulin pen was primed by pushing the insulin to the tip of the needle prior to drawing up the physician ordered dose of insulin in order to ensure the resident received the full dose of insulin.The director of nursing (DON) was interviewed on 8/28/25 at 5:04 p.m. The DON said LPN #3 should have followed the physician's order and instructed Resident #43 to take an additional puff from her inhaler. She said it was important that the resident received the full physician ordered dose of the inhaler to ensure she had received the full effect of the medication. The DON said Resident #43 and Resident #92 should have been instructed by LPN #3 and RN #2 to rinse and spit after they used an inhaled corticosteroid in order to prevent thrush.The DON said a needle must be attached to the insulin pen in order to prime the pen. She said priming was the first step of insulin administration. She said RN #1 should have primed Resident #99's insulin pen and made sure the insulin was visible at the end of the needle prior to administering the resident's insulin to her. The DON said it was important to prime the insulin pen prior to the administration of insulin to ensure the resident received the full dose of medication.

Based on observations, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards in two of three medication carts and one of one medication storage rooms.Specifically, the facility failed to:-Ensure medications for discharged residents were stored in a secure manner; and,-Ensure residents' medications were labeled and dated appropriately with the resident's name and the date the medication was opened.Findings include:I. ObservationsOn 8/28/25 at 3:15 p.m. the facility's one medication storage room was observed with the regional clinical resource (RCR) and registered nurse (RN) #1. There were multiple bubble packs of medications sitting out on the counter. The medications belonged to Resident #9 and Resident #31.On 8/28/25 at 3:25 p.m. the medication cart in hallway D was observed with licensed practical nurse (LPN) #3. The following items were found:-There were two fluticasone propionate 50 micrograms (mcg) nasal spray bottles stored in appropriately labeled medication boxes; however, the individual medication bottles inside were not labelled with the resident's name or the date the medications were opened for Resident #28 and Resident #52.On 8/28/25 at 3:34 p.m. the medication cart in hallway A was observed with RN #2. The following item was found:-There was a 3 milligram (mg) semaglutide (Rybelsus) oral tablet medication stored appropriately in a labeled medication box; however, the medication container inside was not labelled with the resident's name or the date the medication was opened for Resident #16.II. Staff interviewsThe RCR was interviewed on 8/28/25 at 3:15 p.m. The RCR said that Resident #9 and Resident #31 had been discharged , and their medications should have been brought to the director of nursing's (DON) office after a resident was discharged from the facility. The RCR removed the unsecured bubble packs of medications from the medication room at that time.The RCR was interviewed a second time on 8/28/25 at 3:25 p.m. The RCR said she did not know medication containers needed to be labelled when they were stored inside their respective medication boxes, which were labeled.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection on one of six units.Specifically, the facility failed to:-Ensure Resident #99's glucometer was cleaned according to manufacturer recommendations; and,-Ensure proper hand hygiene was conducted during medication administration. Findings include:I. Failure to clean the glucometer according to manufacturer recommendationsA. Cleaning and disinfecting guidelinesThe Assure glucometer manufacturer cleaning and disinfecting guidelines were provided by the nursing home administrator (NHA) on 8/28/25 at 9:47 a.m. It read in pertinent part, We suggest cleaning and disinfecting the meter between patient use. Cleaning and disinfecting can be completed by using a commercially-available EPA-registered (tested, approved and registered by the United States Environmental Protection Agency) disinfectant detergent or germicide wipe. To use a wipe, remove from the container and follow product label instructions to disinfect the meter.The Medline micro-kill germicidal-bleach wipes, which were EPA-registered, were utilized to clean a resident's glucometer. The Medline product label read in pertinent part, Contact time: allow surface(s) to remain visibly wet for 30-seconds to kill the bacteria and viruses on the label. A one minute contact time is required to kill Candida albicans and Trichophyton interdigitale. A two minute contact time is required to kill Candida auris. A three minute contact time is required to kill Clostridium difficile spores.B. ObservationsDuring the medication administration observation on 8/27/25 at 9:14 a.m. registered nurse (RN) #1 completed Resident #99's blood sugar check and medication administration. Before she exited the room, RN #1 pulled a cleaning wipe and wrapped it in a glove from her pocket. RN #1 spent less than ten seconds cleaning all surfaces of the glucometer. The surface of the glucometer did not become wet.-RN #1 failed to ensure the surface of the glucometer became and remained visibly wet for the minimum duration of 30-seconds to kill bacteria and viruses.C. Staff interviewsRN #1 was interviewed on 8/27/25 at 9:34 a.m. She said the facility used the Medline micro-kill germicidal-bleach wipes to clean and disinfect the glucometers. RN #1 said she was unclear on the manufacturer guidelines for cleaning the resident's glucometers. She said after she read the bleach wipes' product label, RN #1 said the cleaning time was three minutes. RN #1 said it was important to follow these instructions to kill the stuff on the glucometers.The infection preventionist (IP) was interviewed on 8/28/25 at 4:43 p.m. The IP said glucometers should be cleaned after every use with a wipe. She said the nurse should wrap the glucometer in the wipe for two minutes before letting it air dry. She said once the glucometer dried, it could be placed back into the resident's individual bag for storage inside the medication cart. The IP said it was important to ensure the glucometers were cleaned of any potential blood or bacteria. She said cleaning the glucometer prevented the spread of infection.The director of nursing (DON) was interviewed on 8/28/25 at 5:04 p.m. The DON said the glucometer must be saturated and the manufacturer's guidelines for cleaning must be followed. She said following the manufacturer's instructions to clean and disinfect the glucometer was important to ensure all potential pathogens were killed.II. Failure to ensure proper hand hygiene was conducted during medication administrationA. Facility policy and procedureThe Infection Control policy, dated October 2024, was provided by the NHA on 8/25/25 at 10:00 a.m. It read in pertinent part, Staff and patient education is done to focus on risk of infection and practices to decrease risk. Universal precautions, handwashing and aseptic practices arefollowed by personnel in performing procedures and in disinfection of equipment.B. ObservationsDuring the medication administration observation on 8/27/25 at 8:40 a.m. RN #1 started administering Resident #99's oral medications when the resident requested fresh ice water in his plastic cup. RN #1 did not remove the gloves or perform hand hygiene before leaving the resident's room. RN #1 walked down the hallway to the ice cooler. She lifted the lid, handled the scoop, filled the resident's cup with ice, returned to Resident #99's room and filled the cup with water from the faucet with the same gloved hands. -RN #1 failed to remove her gloves, perform hand hygiene and change her gloves before she continued to administer Resident #99's oral medications.C. Staff interviewsThe IP was interviewed on 8/28/25 at 4:43 p.m. The IP said hand hygiene during medication administration was important to help prevent the spread of potential infections and bacteria. She said she provided handwashing training monthly during the all staff meeting, as well as on an as needed basis. The IP said she last conducted hand washing training on 8/21/25.The DON was interviewed on 8/28/25 at 5:04 p.m. The DON said hand hygiene should be performed when the nurse left the resident's room during medication administration. She said gloves should not be worn in the hallway and the same gloves should not be used to touch multiple surfaces and then administer the resident medications.

Based on observation and interviews, the facility failed to ensure one (#99) of six residents out of 55 sample residents were free from significant medication errors.Specifically, the facility failed to ensure the insulin pen was primed in a manner consistent with professional standards of practice prior to medication administration for Resident #99. Findings include:I. Facility policy and procedureThe Subcutaneous Insulin Medication Administration policy, dated January 2022, was provided by the nursing home administrator (NHA) on 8/28/25 at 9:47 a.m. It read in pertinent part, Prepare syringe/pen and safety needle. Line up the needle with the pen, and keep it straight as you attach it. Always perform the safety test before each injection. Performing the safety test ensures that you get an accurate dose by ensuring that pen and needle work properly and removing air bubbles. Select the priming dose by turning the dosage selector. Hold the pen with the needle pointing upwards. Tap the insulin reservoir so that any air bubbles rise up towards the needle. Press the injection button all the way in. Check if insulin comes out of the needle tip.II. Resident #99A. Resident statusResident #99, age less than 65, was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus, local infection of the skin and subcutaneous tissue, and infective myositis (an inflammation of the muscles caused by bacteria, parasites, fungi or viruses).The 8/26/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident was dependent on staff for activities of daily living (ADLs), including bathing, toileting, dressing and repositioning. B. ObservationsDuring a continuous observation on 8/27/25, beginning at 8:40 a.m. and ending at 9:10 a.m., the following was observed:At 8:40 a.m. registered nurse (RN) #1 entered Resident #99's room to check his blood glucose level and administer medications, including insulin via the insulin pen injector. The resident requested his brief be changed upon RN #1's arrival.After Resident #99's brief was changed, RN #1 administered the resident's oral medications, checked his blood glucose level and prepared to administer the insulin. RN #1 turned the dosage selector on the insulin pen to 13 units.-RN #1 failed to prime the insulin pen injector before she administered the insulin to Resident #99's right abdomen.At the medication cart, RN #1 self-identified that the physician's order said she should have administered 15 units of insulin. RN #1 prepared to re-enter Resident #99's room to administer the final two units of insulin.Prior to entering Resident #99's room, RN #1 turned the dosage selector on the insulin pen to two units.-RN #1 failed to prime the insulin pen injector before she administered the remaining insulin dose to Resident #99's left abdomen.At 9:10 a.m. RN #1 completed Resident #99's subcutaneous insulin administration via the insulin pen injector.Cross reference F759: the facility failed to ensure the medication administration error rate was less than 5% (percent).C. Staff interviewsRN #1 was interviewed on 8/28/25 at 9:40 a.m. RN #1 said the insulin pen should be primed prior to administration, but she was not clear on the correct process to do so. She said she primed the pen during the first administration of insulin. She said the needle did not need to be attached to prime the insulin. She said she did not prime the pen when she returned to Resident #99's room for the final administration of insulin. RN #1 said it was important to prime the insulin pen to remove the air so the resident would receive the full dose of insulin. The pharmacy consultant was interviewed on 8/28/25 at 10:37 a.m. The pharmacy consultant said the needle was required to be attached to the insulin pen in order to prime it prior to administration. She said the insulin pen was primed by pushing the insulin to the tip of the needle to ensure the resident received the full dose of insulin.The director of nursing (DON) was interviewed on 8/28/25 at 5:04 p.m. The DON said a needle must be attached to the insulin pen in order to prime the pen. She said priming was the first step of insulin administration. She said the nurse should make sure the insulin at the end of the needle was visible. The DON said it was important to prime the insulin pen prior to the administration of insulin to ensure the resident received the full dose of medication.

Based on record review and interviews the facility failed to develop and implement a baseline care plan that included the instructions needed to provide effective and person-centered care for three (#3, #11 and #14) of four residents reviewed for baseline care plans out of 22 sample residents. Specifically, the facility failed to ensure pertinent medical information was included on Resident #3, Resident #11 and Resident #14's baseline care plans within 48 hours of admission. Findings include: I. Facility policy and procedure The Comprehensive Person-Centered Care Planning, revised January 2022, was received from the nursing home administrator (NHA) on 2/26/25 at 5:08 p.m. It read in pertinent part, The interdisciplinary team (IDT) will develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care. The baseline care plan will include minimum healthcare information necessary to properly care for a resident including, but not limited to: physician orders, dietary orders, social services and PASRR recommendations. II. Resident #3 A. Resident status Resident #3, age less than 65, was admitted on [DATE]. According to the February 2025 computerized physician orders (CPO), diagnoses included encephalopathy (brain disorder), schizoaffective disorder bipolar type (mental illness that causes unusual shifts in a person's mood and behavior), borderline personality disorder and violent behavior. The 1/9/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. B. Record review Review of Resident #3's electronic medical record (EMR) revealed the resident was admitted with a pre-admission screening and resident review (PASRR) Level II evaluation, dated 12/17/24. The PASRR Level II findings revealed the resident had diagnoses of schizophrenia and bipolar I disorder with psychotic features. Pertinent information included Resident #3 experienced auditory and visual hallucinations, impulsive behavior, irrational thought content with aggressive behavior (yelling, cussing, throwing medication and food) in the hospital and at her previous assisted living facility (ALF). Specialized services required included psychiatry case consultation, case management, behavior management/therapy and neurocognitive evaluation. -Review of the baseline care plan, dated 12/27/24, did not include the level II PASRR findings or the specialized services that were required. III. Resident #11 A. Resident status Resident #11, age less than 65, was admitted [DATE]. According to the February 2025 CPO, diagnoses included metabolic encephalopathy, end stage renal failure, major depressive disorder and generalized anxiety. The 1/7/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. B. Record review The discharging hospital's transition report, dated 1/31/25, revealed the resident was on a end-stage renal diet and was receiving hemodialysis (medical procedure that filters waste out of the blood). The report indicated to limit the resident's sodium, potassium and phosphorus intake.It also indicated the resident was on a 1200 milliliter (mL) daily fluid restriction, and was receiving oxygen 3 liters per minute (LPM) by nasal cannula. Review of Resident #11's EMR revealed the resident was admitted with a PASRR Level II evaluation, dated 1/29/25. The PASRR indicated the resident had diagnoses of major depressive disorder, unspecified bipolar and generalized anxiety disorder. The recommendations included, in pertinent parts, psychiatric consultations to evaluate her medications and to rule out bipolar diagnosis and continued individual therapy. Specialized services required included psychiatry case consultation and individual therapy. -Review of the baseline care plan, dated 2/1/25, did not specify the resident was prescribed an end-stage renal diet, fluid restriction, or oxygen. The baseline care plan did not indicate the resident was receiving hemodialysis and did not include PASRR findings or requirements. IV. Resident #14 A. Resident status Resident #14, age 88, was admitted on [DATE] and readmitted on [DATE]. According to the February 2025 CPO, the diagnoses included sepsis (infection of the blood), type 2 diabetes, depression and generalized anxiety. The 1/28/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. B. Record review The discharging hospital's transition report, dated 1/27/25, revealed in pertinent part, that the resident was prescribed a diabetic diet and oxygen at 2 LPM by nasal cannula. The report indicated the resident had diagnoses of depression and generalized anxiety disorder. -Review of the baseline care plan, dated 1/27/25, did not include the resident's need for a diabetic diet, or the resident's oxygen use. V. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 2/26/25 at 2:35 p.m. LPN #1 said when a new resident was admitted to the facility, the staff looked through the admission paperwork, CPOs and miscellaneous information to find the information on how to care for the resident. She said the admitting nurse initiated the baseline care plan. The NHA, the director of nursing (DON) and the social services corporate consultant (SSCC) were interviewed together on 2/26/25 at 4:40 p.m. The DON stated the baseline care plan needed to be completed within 48 hours of admission with the pertinent information to be able to provide appropriate care. The DON said the admitting nurse initiated the baseline care plan. The DON and the SSCC said the baseline care plans needed to include specific information such as diet specifications and PASRR information.

Based on observations, record review and staff interviews, the facility failed to provide an ongoing program to support residents in their choice activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for three (#10, #6, and #4) of three residents reviewed for activities programming out of 22 sample residents. Specifically, the facility failed to offer and provide personalized activity programs for Resident #10, #6 and #4. Findings include: I. Activity calendar The February 2025 activity calendar for the week of 2/23/25 through 2/28/25 revealed there were seven to eight activities scheduled per day. The activity calendar had mind-stimulating activities scheduled on four of seven days for the week (2/23/25, 2/24/25, 2/25/25 and 2/26/25) in the form of Bingo. There was only one activity scheduled for the week for non-social dementia residents in the form of Puppy Friday (2/28/25). II. Resident #10 A. Resident status Resident #10, age 78, was admitted on [DATE]. According to the February 2025 computerized physician orders (CPO), diagnoses included Alzheimer's disease and dementia. The 2/14/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments. Per staff assessment, the resident had both short-term and long-term memory problems, the resident's cognitive skills for daily decision-making were severely impaired and the resident exhibited inattention. The resident required extensive assistance from one staff member for activities of daily living (ADL). The 9/16/24 MDS assessment revealed it was very important for the resident to be around animals, music, keep up on the news, attend religious services and go outside for fresh air. B. Observations During a continuous observation of the resident in the activities room on 2/25/25, beginning at 10:45 a.m. and ending at 11:44 a.m., the following was observed: At 10:45 a.m. the resident was sitting in her wheelchair but was not participating in the arts and crafts activity. The activity staff did not engage with her or encourage her to take part in any activity. At 11:09 a.m. the activity director (AD) asked Resident #10 if she wanted hot cocoa. At 11:10 a.m. the AD moved the resident to a nearby table. At 11:13 a.m. the AD brought Resident #10 a cup of hot cocoa with a straw and asked her if she wanted to drink, as the resident required hands-on assistance. The AD held the cup and guided the straw to the resident's mouth and she took a sip. At 11:16 a.m. the AD asked the resident if she wanted her nails painted pink. However, after asking the resident the question, the AD did not paint the resident's nails. At 11:40 a.m. an unidentified staff member assisted Resident #10 from the activity room to the community room for lunch. On 2/25/25 at 1:25 p.m. Resident #10 was in the common area at the end of hallway F, watching television (TV). At 1:34 p.m. an unidentified staff member assisted the resident to the activities room where she sat idle with no participation in any activities. At 2:03 p.m. Resident #10 was again in the common area and had no meaningful activity provided. The resident was staring downward. On 2/26/25 at 10:00 a.m. residents from around the facility were gathered in the activity room for the scheduled Catholic communion service. At 10:05 a.m. Resident #10 was sitting in the common area. The TV was on, however, there were no active meaningful activities provided to the resident. -The Catholic communion service concluded at approximately 10:25 a.m. -The facility failed to ensure Resident #10, whose religion had been identified as being very important to her, was assisted to the Catholic communion service. At 10:32 a.m. the resident was assisted to the activity room by an unidentified certified nurse aide (CNA). The unidentified CNA backed Resident #10 up against the wall near the door in the activity room and left. The resident sat alone while others were at nearby tables coloring. C. Resident #10's representative interview Resident #10's representative was interviewed on 2/26/25 at 10:06 a.m. The representative said staff tended to put Resident #10 down for a nap, rather than engaging her in activities. The representative said Resident #10 enjoyed listening to music and being part of a group. The representative said when she visited the facility, she had observed Resident #10 sitting in the common area at the end of Hall F, watching TV. The representative said the facility could encourage Resident #10 to participate in more activities. D. Record review Review of Resident #10's activity care plan, revised on 2/6/25, identified the resident's activity preferences included enjoying snacks between meals, eating sweets such as ice cream, listening to music, especially oldies and Mexican music, animals and participating in group activities, such as community parties, music performances, movies, puppy visits, going outside for fresh air, food socials and spending time with family and friends. The care plan documented that the resident was passive and required assistance during all group activities. Pertinent interventions included all staff conversing with the resident while providing care, assisting her with ADLs as needed during activities, encouraging ongoing family involvement, inviting family to attend special events, engaging her in group activities such as food socials, music performances, and crafts, playing oldies on her Bluetooth speaker, providing an activities calendar and notifying her of any calendar changes. The February 2025 activity participation documentation received from the AD on 2/26/25 documented Resident #10 was active with the independent activity of watching TV daily. The social activity section of the participation records was also marked as TV daily from 2/11/25 to 2/26/25. The record documented the resident attended group activities less than daily. The activity participation records documented Resident #10 had not attended any of the creative activities. Further review of Resident #10's activity participation records revealed the resident was offered a one-on-one activity daily from 2/11/25 to 2/26/25 for an unknown amount of time. -The resident was documented as receiving one-on-one activity visits daily, however, the one-on-one activity visits consisted of the activity staff meeting with the resident daily to bring the daily activities calendar, pages to color and, if able, bringing the resident beads to make bracelets (see AD interview below). The activity participation record for 2/26/25 for spiritual activities such as church services, documented Resident #10 attended a spiritual activity on 2/26/25. -However, the church service was over by the time staff brought the resident to the service (see observations above). III. Resident #6 A. Resident status Resident #6, age greater than 65, was admitted on [DATE]. According to the February 2025 CPO, diagnoses included cognitive communication deficit, unspecified dementia, psychotic disturbance, and mood disturbance. The resident required step-by-step instructions as needed, a consistent routine, and structured activities to support cognitive function and maximize involvement in daily decision-making. The 12/20/24 minimum data set (MDS) assessment revealed the resident had intact cognition with a BIMS score of 15 out of 15. The 10/3/24 MDS assessment revealed it was very important for the resident to keep up with the news, go outside and somewhat important to have music, to be around groups of people and to do activities of choice. B. Observations On 2/25/25 at 10:05 a.m. Resident #6 was sitting in the lounge in a recliner. The TV was on but there was no meaningful activity going on in the lounge area. On 2/25/25 at 1:25 p.m. Resident #6 was transferred to her recliner in the common area at the end of hallway F and was given a cookie. On 2/25/25 at 2:22 p.m. Resident #6 was sitting in her recliner in the common area, sleeping, with the TV on. On 2/26/25 at 9:17 a.m. Resident #6 was sleeping in a recliner in the common area at the end of hallway F. On 2/26/25 at 1:22 p.m. the resident was in the common area, watching T.V. On 2/26/25 at 2:13 p.m. Resident #6 was sleeping in her recliner in the common area while other residents participated in a bingo activity. C. Resident #6's representative interview Resident #6's representative was interviewed on 2/26/25 at 10:20 a.m. The representative said Resident #6 enjoyed activities, such as bingo and cornhole. He said the facility could better accommodate her by slowing down the pace of calling numbers during bingo to make it easier for her to follow along, as her vision was not great. He said Resident #6 enjoyed activities, participating in them and being part of a group. D. Record review Review of Resident #6's activity care plan, updated 2/26/25 (during the survey), identified the resident had impaired cognitive function, thought processes, and decision-making due to dementia and outlined goals to support her lifelong interests, including family visits, phone calls, holiday parties, coffee, bingo and shopping. Interventions included providing individual activities to the resident, necessary activity supplies, daily social contact and respecting the resident's right to refuse group activities. The February 2025 participation documentation received from the AD on 2/26/25 revealed Resident #6 was active with the independent activity of watching TV daily. Resident #6 was documented as receiving one-on-one activity visits daily, however, the one-on-one activity visits consisted of the activity staff meeting with the resident daily to bring the daily activities, pages to color and, if able, bringing the resident beads to make bracelets (see AD interview below). IV. Resident #4 A. Resident status Resident #4, age 81, was admitted on [DATE]. According to the February 2025 CPO, diagnoses included schizophrenia. The 12/23/24 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of zero out of 15. The resident required extensive assistance with ADLs. The 7/25/24 MDS assessment revealed it was very important for Resident #4 to do activities she liked, go outside to get fresh air and somewhat important to have books to read and listen to music. The assessment indicated it was not very important for the resident to be around animals, such as pets. B. Observations On 2/25/25, the following observations were made: At 10:00 a.m Resident #4 was sitting in the common lounge in front of the television (TV). She was not paying attention to the TV. Staff did not interact with her. At 10:30 a.m., the resident continued to sit in her wheelchair in the common area lounge. The TV continued to be on, however, Resident #4 was not watching it. At 2:00 p.m Resident #4 continued to sit in the common area lounge in front of the TV. There were no meaningful activities provided to the resident and staff did not interact with her. At 3:36 p.m. the resident was in bed and awake. There was no music playing in her room and no touch stimulation or books in her bed. At 3:57 p.m Resident #4 was sitting in the common area lounge again. There were no meaningful activities provided to the resident. On 2/26/25 at 3:30 p.m. Resident #4 was sitting in the common area lounge. The TV was on, however, the resident was not watching it. The AD asked the resident if she wanted to go to an activity and the resident said no. -The AD did not provide further encouragement to the resident to attend the activity and did not offer the resident a meaningful activity to do instead. -The AD did not offer hot chocolate or coke to the resident, which the resident enjoyed, to encourage the resident to attend the activity (see AD interview below). C. Resident representative interview Resident #4's representative was interviewed on 2/26/25 at 2:18 p.m. The representative said Resident #4's social activity levels had decreased through the years. She said the facility informed her that Resident #4 was put on a one-on-one activity program. She said she was not aware that the resident was no longer on the one-on-one activity program. She said Resident #4 liked to listen to music, however, she said she got overstimulated easily. The representative said Resident #4 liked to fidget with her hands and enjoyed the teddy bears she used to receive from staff. D. Record review Review of Resident #4's activity care plan, updated 10/4/24, revealed the resident said she only wanted to be in her room and left alone and not bothered and staff would provide independent leisure activities upon request. Pertinent interventions included providing one-on-one activities, staff would respect her right to limit or decline activities, inviting the resident to scheduled activities so she knew she was welcome to join organized group activities and activities staff would provide independent leisure activities upon request. -The care plan documented the Resident #4 would refuse to attend activities, however, there were no special instructions on how to invite the resident to activities. Review of Resident #4's electronic medical record (EMR) revealed the following progress notes related to activities: The 10/4/24 progress note documented a puppy activity was completed. -However, the 7/25/24 MDS assessment revealed it was not very important for the resident to be around animals (see resident status above). The 11/8/24 progress note revealed Resident #4 refused a one-on-one activity visit. The progress note further documented the resident liked coffee socials and music. There was no documentation of the resident enjoying music in the note. -There were no further progress notes documented in Resident #4's EMR to indicate one-on-one activity visits were offered to the resident following the resident's refusal of the one-on-one activity visit on 11/8/24. -Review of the resident's EMR did not reveal documentation to indicate Resident #4 was assisted to go outside per her preference. Review of Resident #4's EMR activity participation record for the past 30 days revealed the resident had attended one entertainment activity on 2/24/25. Independent activities were documented on the record, however, the record did not indicate what independent activities Resident #4 participated in. V. Staff interviews The AD was interviewed on 2/26/25 at 3:14 p.m. The AD said she recently became the AD at the facility. She said she previously worked as an activity assistant in another building prior to her current job. The AD said she was currently working on her activity certification. She said the facility had two full-time employees, one part-time employee, and one as needed (PRN) staff member who covered activities seven days a week. The AD said the activities staff offered one-on-one activities three times a week. She said either she or another activity staff member provided the sessions, which could include nail care, listening to music, watching a movie, sitting outside, participating in Puppy Fridays or bird watching, depending on the resident's cognitive awareness. She said residents who scored between eight to 15 on the BIMS assessment could participate in group activities and did not qualify for a one-on-one program. The AD said Resident #10 participated in one-on-one activities because she was unable to communicate verbally. She said activity staff engaged her by tracking her eye movements and if the resident did not attend group activities, the resident was provided with one-on-one activities. She said Resident #10 participated in Puppy Fridays and the resident enjoyed attending Catholic church services. She said if Resident #10 did not attend those activities, she ensured that the resident received one-on-one activity engagement three times a week. The AD said Resident #6 came to the morning coffee, enjoyed holiday parties and puppy parties and participated in activities.She said the resident did not stay in one place and came and went to the activities. She said the facility had Resident #6 participate in activities and took her on daily walks around the facility. The AD said that a box with knitting and crocheting supplies, including a magnifying glass, was in the resident's room for her to use. She said Resident #6 enjoyed bingo, especially with her son. The AD said the resident did not like to participate in activities much. The AD said staff did not wake Resident #6 up to play bingo unless the resident requested it. The AD said the activities staff documented if the resident refused activities. The AD said sitting in the lounge area in front of the TV accounted for independent activity for Resident #4. She said the resident liked to drink coke and hot chocolate. She said the resident would refuse activities, but if she was offered coke or hot chocolate, she would attend. She said Resident #4 used to be on a one-on-one activity program but was taken off the program on 11/13/24 because she was refusing. The AD said she had not reattempted to provide Resident #4 with one-on-one activities since she was taken off the one-on-one activity program. The social services corporate consultant (SSCC) was interviewed on 2/26/25 at 3:40 p.m. The SSCC said all residents should be invited to attend the activities. She said she had informed the activity staff that each resident needed to be charted on each day with each activity. She said when a resident refused activities, they should be re-approached in a different way, such as offering hot chocolate to Resident #4, in order to encourage them to attend. 52094

Based on observations, record review and staff interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in one kitchen. Specifically, the facility failed to ensure: -Foods of modified consistency were reheated to safe temperatures following the use of a multi-step preparation process; -Cutting boards were free from deep scratches and stains; and, -Beard restraints were worn in kitchen areas while serving food. Findings include: I. Food temperatures A. Professional reference According to the United States Public Health Service Food and Drug Administration (FDA) 2022 Food Code 3-403.11 (A) pg. 36 Time/Temperature Control for Safety Food (TCS) that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the food reach a temperature of at least 74 degrees C (165 degrees F) for 15 seconds. B. Observations and staff interview On 10/25/23 at 9:55 a.m. the cook (CK) had prepared the pork that was from the oven and placed it in a large metal container. The CK poured a large bottle of barbeque into the pan of pork and started mixing in the barbeque sauce and pork. The CK did not take the temperature of the pork prior to mixing in the barbeque sauce. The CK placed 11 scoops of the barbequed pork into the food processor and proceeded to puree the pork. The CK poured hot water into the barbequed pork until the puree reached the right consistency. The CK placed the pureed barbequed pork into a metal pan and proceeded to wrap it with aluminum foil. The CK was asked what the temperature of the pureed pork and the CK stated the temperature of the pureed chicken was 111 degrees F. He then wrapped the metal container and placed it into the warming oven. The CK pureed the green beans in the same process. With the temperature of the green beans being 121 degrees F after being prompted to take the temperature. He then wrapped the metal container and placed it into the warming oven. The CK proceeded to complete the same process for the minced meat mechanical soft barbequed pork. He then placed 11 scoops of the barbequed pork into the blender and proceeded to finish the minced meat mechanical soft pork. After getting it to the correct consistency he grabbed another metal pan and poured the barbequed pork into the pan. He placed it on the counter and took the temperature after being prompted, which was 111 degrees F. He wrapped it with aluminum foil and placed it into the oven. -At 10:13 a.m., the CK was asked if he checked the temperature of the minced moist foods and pureed food after pureeing them. The CK said, No, I do not, but I would take the temperatures before serving them and they should be at 160 degrees F. -At 11:04 a.m. the dietary manager (DM) again took the temperature of all items listed above. The barbequed pork minced meat mechanical soft was at 163 degrees F, the pureed barbequed pork was at 162 degrees F and the pureed green beans was at 163 degrees F. The regular barbequed pork was at 113 degrees F which was on the hold line. C. Additional interview The DM was interviewed on 10/26/23 at 8:41 a.m. She said she was aware the temperatures of the modified food dropped at times. She said the food was okay as long as it reached 165 degrees F before serving. She said dietary staff would be educated immediately to ensure the modified consistency of food reached proper temperatures and time frames. II. Cutting Boards A. Professional reference According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (updated 1/1/19), page 132, and Cutting surfaces that are scratched and scored must be resurfaced so as to be easily cleaned, or be discarded when these surfaces can no longer be effectively cleaned and sanitized. B. Observation The initial kitchen tour conducted on 10/23/23 at 8:45 a.m. revealed four large cutting boards. There were green, blue, red and brown cutting boards. All cutting boards were heavily scored and stained. On 10/25/23 at 9:47 a.m., the CK was cutting the pork on a red cutting board. C. Staff Interview The DM was interviewed on 10/26/23 at 8:44 a.m. The DM was told of the observations of the cutting boards in the kitchen. She said the cutting boards were visibly stained and scored. She said he would replace them immediately. She said the deep scratches could be a potential for bacteria to grow. III. Beard restraints A. Professional reference According to the Colorado Retail Food Establishment Rules and Regulations (updated 1/1/19) pg. 51, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single service and single-use articles. B. Observations and interviews On 10/25/23 at 8:32 a.m. the CK was observed in the kitchen area without wearing a beard restraint. The CK's beard was approximately two inches long. The CK was preparing meals and was standing over the oven stirring various foods. -At 9:49 a.m. the CK was observed in the kitchen area not wearing a beard restraint. The CK was observed preparing lunch meals. The DM was interviewed on 10/26/23 at 8:44 a.m. She stated all kitchen staff were required to wear hair restraints and should have all hair covered. The DM said staff who had facial hair should be wearing a mask or a beard guard while preparing or serving meals. She said all male staff who had facial hair should be wearing proper beard restraints while in food preparation areas to ensure hair did not fall into any food.

Based on record review and interviews, the facility failed to provide response, action and rationale to residents involved in group grievances. Specifically, the facility failed to effectively address, resolve and demonstrate the facility's response to grievances concerning resident care and dignity. Findings include: I. Facility policy and procedure The Resident Council policy, revised February 2021, was provided by the corporate nurse consultant (CN) on 10/25/23. It read in pertinent part, The purpose of the resident council is to provide a forum for discussion of concerns and suggestions for improvement. A resident council response form will be utilized to track issues and their resolutions. The facility department related to any issues will be responsible to address the item(s) of concern. II. Resident interview The resident council president, Resident #23, was interviewed on 10/26/23 at 10:19 a.m. She stated she did not know who was supposed to handle the grievances brought up in the council meeting. The council did not receive a resolution for grievances brought up in prior council meetings. III. Record review A review of the resident council meeting minutes dated 9/20/23 revealed group grievances concerning clothes not being returned timely and an insufficient amount of towels and washcloths. A review of the resident council meeting minutes dated 10/11/23 revealed group grievances concerning not being able to receive money timely, rooms not being mopped, unsatisfactory water pressure, noise levels due to residents who scream and staff not providing assistance with meals. A review of a resident council response form dated 9/20/23 revealed there had been training with the laundry staff concerning no washcloths, towels and linens. The resolution was dated 9/28/23. The nursing home administrator (NHA) signed off on the concern form 10/2/23. -No manager was listed as conducting the training and no training was attached. -There was no mention of discussing the resolutions with the resident council. A review of a resident council response form dated 10/11/23 revealed medications were not being given on time. The NHA signed off on the concern form 10/17/23. -No manager was listed as responding to the concerns, no resolution was documented and there was no mention of discussing resolutions with the resident council. A review of a resident council response form dated 10/11/23 revealed medications were being left on food trays and being taken to the kitchen. The NHA signed off on the concern form 10/17/23. -No manager was listed as responding to the concerns, no resolution was documented and there was no mention of discussing resolutions with the resident council. An in-service training form was included pertaining to medication administration being given on time and not being left at the bedside dated 10/12/23. Five nurses attended out of the twelve nurses employed. A review of a resident council response form dated 10/11/23 revealed there had been training with the housekeeping staff concerning mopping rooms properly. The resolution was dated 10/12/23.The NHA signed off on the concern form 10/16/23. -It was not documented that the resolution was discussed with the resident council. IV. Staff interviews The social services director (SSD) was interviewed on 10/25/23 at 2:27 p.m. She said she handled individual grievances and not the resident council grievances. The activities department ran the resident council meeting and wrote up the grievances. The grievances were given to the NHA who was the grievance official. The SSD did not know where the grievance forms went after it was resolved or who was responsible for following up with the residents. The activities assistant (ACT) was interviewed on 10/26/23 at 10:10 a.m. She said the activities director was currently out of the facility. The activity assistants helped the activities director with documentation during the resident council meetings. If a concern was brought up in the meeting and was isolated to one resident, the concern form was written as an individual grievance. If the concern brought up pertained to more than one resident, it would be written as a group concern. Group concern forms were given to the department responsible for the concern. The ACT did not know what happened to the concern forms after being given to the department manager. The NHA was interviewed on 10/26/23 at 11:36 a.m. The NHA stated not until October 2023, the facility had not been writing group grievances generated by resident council. The NHA had started a log to track the group grievances and responses. She was still evaluating the process and considering adjustments to ensure all grievances were being included in a group grievance form and followed up on with the council.

Based on observations and staff interviews, the facility failed to maintain a sanitary, orderly and comfortable environment for residents in 14 of 60 resident rooms in six hallways. Specifically, the facility failed to ensure walls, baseboards and doors were properly maintained. Findings include: I. Initial observations Observations of the resident living environment were conducted on 10/24/23 at 1:24 p.m. revealed: Room #C-21: The resident's sink had a one inch ring of rust around the drain. The wall next to the resident's bed had deep scratches from the bed being lifted and lowered. The vent on the ceiling had peeling and chipped sheetrock approximately two inches around the whole vent. The wood railing outside of C hall had chipped and splintering corners approximately three inches long and a half inch wide. The sheet rock was chipped and peeling with metal corners exposed. The nursing station had swinging doors that were removed. The area where the door hinges were located had chipped and damaged sheet rock approximately five inches long by four inch wide. The corner had chipped and peeling sheetrock. The wood railing outside of B hall had chipped and splintering wood approximately six feet long by one inch wide. Room #B-10: The telephone jack box had been removed next to the resident's bed with the outline visible. Room #B-1: The wall next to the resident's bed had deep scratches from the bed being lifted and lowered. Room #B-9: The toilet does not always flush. The floor around the toilet had water damage and black stained caulking around the whole base of the toilet. The laminate above the sink had an area approximately 14 inches long by one wide which was lifting and peeling. The wall next to the resident's bed had deep scratches from the bed being lifted and lowered. Room #B-7: The restroom had no call light. The wall next to the door had several dime sized holes where the television bracket had been removed. The restroom had two dime sized holes on the wall above the toilet paper. The wall in the bathroom behind the toilet had an area approximately five feet long by two feet wide which had rough and unfinished plaster. Room #B-5: The baseboard cove next to the restroom had a section approximately 10 inches long peeling away from the wall. There were four dime sized holes in the restroom where a soap dispenser had been removed. The wall in the bathroom behind the toilet had an area approximately five feet long by four feet wide which had rough and unfinished plaster. Room #A-2: The baseboard cove next to the sink had a section approximately five inches long by four inches high missing. Room #A-3: The wiring conduit behind the resident's bed had an area approximately six feet long which was damaged from the bed being lifted and lowered. Room #A-4: The wall next to the resident's bed had deep scratches from the bed being lifted and lowered. Room #A-7: the wall underneath the resident's window had water damaged approximately 10 feet long by two feet wide. The laminate next to the sink had an area approximately five feet long by two inches wide with damaged and peeling laminate. Room #A-6: The baseboard cove in the restroom had an area approximately 15 feet in length which was peeling away from the wall. The wood railing on hall A next to room A-9 was loose and could be physically moved when grabbed. Room #D-5: the entrance door had peeling and rusted paint chips approximately 14 inches high. Room #D-4: the baseboard cove had an area approximately 12 inches long by four inches wide which was peeling away from the wall. The wood rails next to the social workers office on D hall were loose and could be moved when they were grabbed. The baseboard cove by the secured unit entrance door had an area approximately six feet long which was lying on the ground. The baseboard past the entrance door to the secured unit had a section approximately seven feet long peeling away from the wall. Room #F-4: the wall next to the resident's bed had three large four inch screws sticking out of the wall and had seven dime sized holes. The baseboard cove next to the restroom had an area approximately four feet long peeling away from the wall. Two of the dresser drawers were broken and hanging off the dresser. II. Environmental tour and staff interview The environmental tour was conducted with the maintenance supervisor (MS) on 10/26/23 at 9:30 a.m. The above detailed observations were reviewed. The MS documented the environmental concerns. The MS said the facility utilized work orders as well as a computer system to identify environmental issues. The MS said he did not have work orders for the damage identified during the environmental tour. The MS said the above-mentioned damage should have been repaired and addressed in a timely manner.

Based on record review and interviews, the facility failed to ensure five (#13, #38, #3, #23 and #52) of eight residents were free from unnecessary psychotropic medications out of 32 sample residents. Specifically, the facility failed to: -Monitor targeted behaviors and individualized non-pharmacological approaches for psychotropic medications for Residents #13, #38 and #3; -Follow pharmacist recommendations for gradual dose reductions of psychoactive medications for Resident #3 and #23; -Ensure risks were reviewed for an antipsychotic medication prior to administration for Resident #3; and, -Ensure as-needed (PRN) orders for psychotropic/antipsychotic medication did not extend 14 days without documented clinical rationale from the physician or a physician evaluation of the resident for Residents #52 and #23. Findings include: I. Facility policy The Behavior Monitoring policy dated 3/10/23, was provided by the corporate nurse consultant (CN) on 10/25/23 at 3:36 p.m. It read in pertinent part: The purpose of behavior monitoring is to establish an accurate pattern of resident target behaviors determined by the resident's history, evaluation, assessment. If a psychoactive medication is needed, use the lowest possible dose and document the outcome. Initiate behavior tracking for the specific psychoactive medication-list the target behaviors identified. II. Resident #13 A. Resident status Resident #13, age under 65, was admitted on [DATE]. According to the October 2023 computerized physician orders (CPO), diagnoses included schizoaffective disorder bipolar type and unspecified intellectual disabilities. The 9/5/23 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview of mental status (BIMS) score of 15 out of 15. No behaviors were indicated. B. Record review The comprehensive care plan, revised 9/5/23, revealed the resident had poor boundaries with staff, primarily male staff members. She made sexually inappropriate comments and had delusional beliefs she was in romantic relationships with male staff. Interventions included to monitor, report and document sexually inappropriate behaviors. The resident had a history of sexual trauma and when feeling triggered, she would display sleep disturbances, increased irritation, and make false allegations. Staff were to provide the resident care with another staff member present. The resident had a history of physical aggression such as throwing items or self harm. Triggers included others' public display of affection and being called by her legal name not her preferred name. Interventions included being aware of triggers, monitoring for signs and symptoms of depression, anxiety, difficulty sleeping, irritability, anger and sadness. The October 2023 CPO revealed the following physician orders: Sertraline 100 milligram (MG)- give one time a day for depression-ordered on 8/30/23. Observe for general behaviors related to schizoaffective disorder: itching, picking at the skin, restlessness, agitation, hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, and refusing care- ordered on 8/30/23. -A review of the resident's medication administration records (MAR) and treatment administration records (TAR) from 8/1/23 to 10/24/23 failed to reveal any behavior tracking. III. Resident #38 A. Resident status Resident #38, age under 65, was admitted on [DATE]. According to the October 2023 CPO, diagnoses included bipolar disorder. The 8/31/23 MDS assessment documented the resident was cognitively intact with a BIMS score of 15 out of 15. No behaviors were indicated. B. Record review The comprehensive care plan, indicated on 7/28/23, revealed the resident received antidepressant, antianxiety, and antipsychotic medications related to bipolar disorder. Symptoms included insomnia, auditory hallucinations, perseveration of stressful events and expressions of sadness. Interventions included monitoring for behaviors of sadness, loss of pleasure or interest in activities, feelings of worthlessness and mania or hypomania. The October 2023 CPO revealed the following physician orders: Aripiprazole (antipsychotic) 5 MG- give one time a day for bipolar disorder-ordered on 7/28/23, Clonazepam (anticonvulsant) 2 MG- give one time a day for bipolar disorder-ordered on 7/28/23; and, Mirtazapine (antidepressant) 15 MG- give one time a day for insomnia-ordered on 9/7/23. -A review of the resident's MAR and TAR from 8/1/23 to 10/24/23 failed to reveal any behavior or hours of sleep tracking. IV. Resident #3 A. Resident status Resident #3, age under 65, was admitted on ,d+[DATE]. According to the October 2023 CPO, diagnoses included borderline personality disorder and major depressive disorder. The 9/25/23 MDS assessment documented the resident was cognitively intact with a BIMS score of 15 out of 15. No behaviors were indicated. B. Record review The comprehensive care plan, revised 6/22/23, revealed the resident had a history of trauma and difficulty trusting male staff members. When feeling triggered, she would become resistant to personal care, have difficulty managing her anger, engage in self-harm, or punch walls. Non-pharmacological interventions such as audio books, arts/crafts, taking her to smoke and socializing with other residents were to be encouraged. Staff were to monitor for signs and symptoms of depression, anxiety and substance abuse issues. The resident had a history of becoming verbally aggressive with other residents, teasing other residents and making false allegations towards staff. Interventions include to assess the residents' understanding of the situation and document observed behaviors, potential causes and interventions tried. The resident had a history of cutting (self-mutilation) and expressions of suicidal ideations. Staff were to observe and monitor for indicators such as verbal expressions of suicidal ideations, stock pilling pills, saying goodbye to family, refusing to eat or refusing medications or therapies. Interventions include offering games to play on a tablet, coloring, talking when she had calmed down, providing a physically based pillow for anger moments and praising the resident for improvement in behaviors. The October 2023 CPO revealed the following physician orders: Paroxetine (antidepressant) 30 MG-give two tablets a day for major depressive disorder-ordered on 9/17/22; and, Lamotrigine (anticonvulsant) 200 MG-two times a day for major depressive disorder-ordered on 5/16/22. Observe behaviors related to antipsychotic medication. Offer to express feelings, positive reinforcement, redirection, food/fluid offered, activity/distraction offered, medication ordered or other-ordered on 1/18/23. Abilify (antipsychotic) 5 MG-give one time a day for major depressive disorder-ordered on 5/22/23. Observe behaviors of sad affect and labile mood related to antidepressant medication. Offer to express feelings, positive reinforcement, redirection, food/fluid offered, activity/distraction offered, medication ordered, or other-ordered on 6/7/23; Observe behaviors of anger and thoughts of self-harm related to antidepressant medication. Offer to express feelings, positive reinforcement, redirection, food/fluid offered, activity/distraction offered, medication ordered, or other- ordered on 7/28/22; and, Observe behaviors of increased aggression related to antidepressant medication. Offer to express feelings, positive reinforcement, redirection, food/fluid offered, activity/distraction offered, medication ordered, or other- ordered on 7/28/22; Latuda (antipsychotic) 20 MG-give one time a day for major depressive disorder-ordered on 8/3/23. The 8/4/23 medication regimen review from the pharmacist documented a recommendation to review the Lamotrigine 200 MG two times a day and the Paroxetine 30 MG two tablets a day for a gradual dose reduction. -As of time of survey on 10/23/23, the gradual dose reduction had not been reviewed. -A review of the resident's medical record failed to reveal consent that reviewed the risks associated with the medication had been obtained for the administration of the Abilify. -Behavior tracking was initiated in the orders however, the non-pharmacological interventions were not individualized. Behavior tracking for the antipsychotics had no target behaviors listed. V. Resident #23 A. Resident status Resident #23, age 80, was admitted on [DATE]. According to the October 2023 CPO, diagnoses included bipolar disorder and post traumatic stress disorder. The 8/7/23 MDS assessment documented the resident was cognitively intact with a BIMS score of 14 out of 15. No behaviors were indicated. B. Record review The comprehensive care plan, revised 3/16/22, revealed the resident had a diagnosis of gastroesophageal reflux disease (GERD) and experienced nausea. The resident took PRN Prochlorperazine for her nausea. Interventions include to observe and document side effects and effectiveness. The October 2023 CPO revealed the following physician orders: Prochlorperazine (antipsychotic) 10 MG-give one tablet every six hours as needed for nausea- ordered on 6/19/23; and, Alprazolam (antianxiety) 0.5 MG- give one tablet every six hours PRN for anxiety-ordered on 10/12/23. The October MAR reviewed from 10/1/23 to 10/26/23 revealed: Prochlorperazine 10 MG was administered 20 days out of the month. Alprazolam 0.5 MG was administered 11 days out of the month. The 8/4/23 medication regimen review from the pharmacist dated 8/4/23 documented regulations limit the PRN use of any psychoactive medications to 14 days. Antipsychotic medications must have a 14 day stop date. There is no exception for psychotropic medications being used for nausea. Please add a 14 day stop date to the order for prochlorperazine. -As of 10/25/23, the time of the survey, the medication remained as a PRN administration. VI. Staff interviews Certified nurse aide (CNA) #3 was interviewed on 10/25/23 at 11:10 a.m. She stated Resident #13 had no behaviors other than becoming upset when she did not get her way. There were no concerns with male caregivers taking care of her and CNA #3 was unaware of any incidents with male caregivers. The resident had no history of harming herself or others. She knew the resident required care in pairs, meaning more than one caregiver present during care, but she did not know why. She was not aware of specific behaviors to monitor or individualized interventions for the resident. CNA #3 stated Resident #38 had no behaviors towards staff or other residents. She had no behaviors of self-harm or harming others. She was not aware of specific behaviors to monitor or individualized interventions for the resident. Resident #3 had no behaviors toward staff or other residents. She had no behaviors of self-harm or harming others. CNA #3 was not aware of specific behaviors to monitor or individualized interventions for the resident. If a new behavior was noticed, the CNA would report the behavior to the nurse. She was not sure where the nurse documented behaviors. CNAs documented in a different system than the nurses and the behaviors and interventions for each resident were the same. Behaviors and interventions were not personalized. She did not have access to look at resident care plans. Licensed practical nurse (LPN) #1 was interviewed on 10/25/23 at 11:28 a.m. She stated Resident #13 was manipulative towards the staff, pitting staff against each other. If the resident could get one-on-one attention from the staff for 10 minutes, her behaviors improved. The resident had no history of harming herself or others. LPN #1 knew the resident required care in pairs, and said it was because of the resident's physical condition. She was unaware of any inappropriate behaviors or behaviors directed towards male staff. She was not aware of specific behaviors to monitor or individualized interventions for the resident. LPN #1 said Resident #38 did not have behaviors. There were no specific interventions for her. Staff would offer her food or drinks or take her to activities. There were no hours of sleep tracked because the resident was on an antidepressant for insomnia not a sleep aid. She stated Resident #3 suffered from depression and had a history of making suicidal statements. The interventions were to provide her with one-on-one attention and take her out for a cigarette break. She was not aware of any other specific behaviors to monitor or individualized interventions for the resident. LPN #1 said the nurses have to track the resident's behaviors, interventions and outcome on the TAR. If a resident had specific interventions other than the generic ones listed on the TAR, it would be communicated verbally to the nurses by management. She was not sure what was done if a staff member who provided care for a resident was not present when management discussed new interventions. LPN #4 was interviewed on 10/25/23 at 12:37 p.m. She stated Resident #13 had behaviors of making false allegations toward staff but did not know specifically what the allegations had been. She was not aware of inappropriate behaviors toward males or why the resident required care in pairs. She was not aware of any other specific behaviors to monitor or individualized interventions for the resident. LPN #4 stated Resident #3 had behaviors of making suicidal comments. There were no other behaviors she was aware of or specific interventions to use with the resident. The social services director (SSD) was interviewed on 10/25/23 at 2:27 p.m. She stated behavior tracking showed up on the nurse's TAR for documentation. The nurse entered the order and triggered it to show up on the TAR. Behaviors documented were used in the facility's drug committee meeting to determine if medications were effective or not. Resident specific target behaviors and interventions came from the resident's admission information, evaluations from the state mental health agency, the resident or the family. The behaviors listed on the trackers were personalized but the interventions were generic for each resident.A behavior tracker was put into effect when a psychoactive medication was started and should be initiated for all psychoactive medications. Tracking behaviors were important to ensure a resident's needs are met and the care provided is effective. The CNAs had only recently started documenting resident behaviors in the CNA tasks and had not received any education on monitoring or documenting behaviors. The behaviors and interventions on the tasks were not personalized for each resident. Resident #13 had behaviors of being sexually inappropriate with male staff. The nurses and CNAs should be looking in the resident's care plan for specific behaviors and interventions. The SSD was not aware the staff were not looking in the care plans. Resident #13 displayed behaviors of throwing items at staff and residents. Resident #3 had behaviors of expression of suicidal ideations, manipulation of staff and providers and verbal aggression. She said the behavior tracking for the antipsychotic medication was missed. Resident #38 experienced auditory hallucinations and would perseverate on stressful life events. She said the behavior tracking for the antipsychotic and anticonvulsant medications were missed. Anticonvulsant medications used to treat mental illness needed to have behavior tracking in order to monitor effectiveness. The resident was taking an antidepressant for insomnia and hours of sleep should be tracked. She said she was not aware hours of sleep were not being tracked. She said PRN antipsychotic medications must have a 14-day stop date included in the order when started. She was not aware Resident #23 had been on a PRN antipsychotic since June 2023 without a stop date and that a stop date was requested in a pharmacy review in August 2023. The director of nursing (DON) was interviewed on 10/25/23 at 4:39 p.m. The facility's policy on PRN antipsychotic medications was a 14-day stop date to be included in the initial order. When a resident was admitted on psychoactive medications, the admission nurse would obtain consent from the resident or responsible party. When a resident was started on a psychoactive medication, consent was needed before the medication could be started. She was not aware Resident #3 did not have a consent in place for Abilify. A consent should have been obtained before the medication was ordered to ensure the resident or responsible party were in agreement. She said to track behaviors, CNAs utilize the kardex (CNA tasks system) for behavior interventions. The kardex were linked to the resident's care plan. Behaviors observed and interventions tried generated in the CNA documentation system but the behaviors and interventions were not personalized. The facility provided training to nurses on how to document behaviors but no specific training for the CNAs. Generic interventions that were not person centered were not helpful for the staff when managing behaviors because each resident was different. The DON was not aware the trackers non-pharmacological interventions for suicidal ideations were the same as the interventions for aggression. During the survey, the DON identified the pharmacy recommendations were not being sent to the residents attending physicians and the system was broken. She would be working on developing a new system for pharmacy recommendations to ensure better communication with the physicians. VII. Facility follow-up On 10/26/23 at 10:39 a.m. the DON provided consent for Resident #3's Abilify. The consent was obtained on 10/26/23 at 10:15 a.m. On 10/27/23 at 1:28 p.m an email was received from the DON. It revealed education had been provided to the hospice provider for Resident #23 and #52 regarding including a 14-day stop date on all PRN orders. Documentation included in the email was a stop date order for Resident #52 Lorazepam dated 10/27/23 and Resident #23 Alprazolam dated 10/27/23. -However, there was no stop date on Resident #23's Prochlorperazine, which was an antipsychotic medication that could not be renewed past 14 days unless the attending physician evaluated the resident for the appropriateness of the medication. 31820 VIII. Resident #52 A. Resident status Resident #52, age over 65, was admitted on [DATE]. According to the October 2023 computerized physicians orders (CPO), diagnoses included degeneration of the brain, dementia and abnormalities of gait. The 8/6/23 minimum data set (MDS) assessment revealed the resident's cognitive status was severely impaired and unable to complete a brief interview for mental status (BIMS). The assessment did not identify the resident had any behaviors during the assessment period. The assessment identified the resident was taking an anti-anxiety medication. B. Record review The care plan, initiated on 6/29/23 and revised on 10/9/23, identified the resident had physical aggression related to dementia and poor impulse control. Interventions included: -Administer medications as ordered. Monitor/document for side effects and effectiveness. -Monitor/Document observed behaviors and attempted interventions in behavior log every shift. The care plan, initiated on 10/16/2020 and revised on 10/6/23, identified the use of antianxiety medication for a diagnosis of dementia with behavioral disturbance. Interventions included: -Administer anxiolytic (antianxiety) medications as ordered by the physician. Observe for side effects and effectiveness. -Observe/document/report as needed medications show any adverse reactions to anxiolytic therapy. The October 2023 CPO included Lorazepam 0.5 milligrams (mg), Give one tablet by mouth three times a day and every six hours as needed (PRN) for agitation. The order was written on 9/18/23. She received one PRN dose on 10/11/23. The medication regimen review dated 7/5/23 identified the medication Lorazepam 0.5 mg as needed. The review included, Can you please indicate an anticipated duration of use and document continued use and rationale for the medication. C. Staff interviews Registered nurse (RN) #1 was interviewed on 10/25/23 at 12:45 p.m. She reviewed the order for Lorazepam in the resident's electronic chart. She identified the standing order for three times a day was written with the as needed order. She said the orders should have been written separately. The DON was interviewed on 10/25/23 at 4:35 p.m. She said she was not aware how the order was written. She said the order should have been written separately and the as needed order should have been reviewed if used after 14 days by the physician for indication and duration.

Based on observations, record review and interviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections such as COVID-19 for three of six units Specifically, the facility failed to ensure: -Staff performed hand hygiene between glove use; -Staff wore personal protective equipment (PPE) when entering COVID positive rooms; -Staff doffed (removed) gowns prior to exiting a COVID positive room; and, -A COVID positive resident did not occupy areas frequented by COVID negative residents. Findings include: I Professional reference According to the Centers for Disease Control (CDC) guidance, Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19, dated 6/3/2020, retrieved on 11/2/23 from https://www.cdc.gov/coronavirus/2019-ncov/downloads/A_FS_HCP_COVID19_PPE.pdf. It read in pertinent part, -PPE must be donned correctly before entering the patient area. -PPE must remain in place and be worn correctly for the duration of work in potentially contaminated areas. PPE should not be adjusted. -Both your mouth and nose should be protected. II. Facility policy The COVID-19 Prevention, Response, and Testing policy, dated 6/26/23, was provided by the corporate nurse consultant (CN) on 10/24/23 at 1:39 p.m. It read in pertinent part: Procedure when COVID-19 is suspected or confirmed: Place the resident in isolation with droplet transmission-based precautions with the door closed. Wear gloves, gowns, goggles/face shields, and N95 masks upon entering the room and when caring for the resident. Evaluate the need for hospitalization . Restrict the resident to his/her room. Ask the resident to cover their nose/mouth prior to entering the room. Place facemask on resident if leaving the room for medically necessary activities. III. Failures with PPE Signage on the COVID-19 rooms on isolation read: Enhanced droplet precautions, perform hand hygiene, N95 mask, eye protection, gown when entering room, gloves when entering the room. Observations on 10/24/23 The nurse practitioner (NP) was observed at 10:09 a.m. donning (putting on) personal protective equipment (PPE) prior to entering Resident #53's room, who was COVID-19 positive. The NP wore the same N95 mask he came into the hallway wearing. He did not perform hand hygiene prior to putting on gloves or put on eye protection before entering Resident #53's room. The NP exited Resident #53's room at 10:14 a.m. He doffed all of his PPE outside of the residents room. He rolled up his gloves in the gown, entered Resident #53's room again and discarded the PPE inside the room. He did perform hand hygiene after doffing his PPE. The NP proceed with same process as he had done with Resident #53's room when entering Resident #19 and Resident #66's rooms at 10:20 a.m. who were COVID-19 positive. He did not change his N95, he did not perform hand hygiene before or after entering the residents' rooms. He doffed his PPE outside of the resident's room and then reentered the room to dispose of the PPE. The NP entered the room of a resident who was not COVID positive on a different unit at 10:25 a.m He did perform hand hygiene prior to entering or exiting the room. An unidentified resident aide (RA) and RA #1 were observed going into Resident #19's room at 10:53 a.m to change the resident's linen. During this process neither of the RAs were wearing PPE when changing the residents linens. RA #1 was then asked to assist with another resident who was not COVID positive. RA #1 entered the resident's room to assist. IV. COVID-19 positive resident Resident #35 was observed on 10/24/23 at 2:45 p.m. exiting a quarantined unit. The resident was COVID-19 positive and not wearing a mask. An unidentified certified nurse aide (CNA) offered him a mask but he ignored her. He left the unit and went into the main lobby coughing several times. There were no other residents in the lobby. An unidentified nurse passing by was able to encourage the resident to put a mask on at 2:46 p.m. Resident #35 was observed again in the front lobby at 3:35 p.m. He had left through the smoking area, came around the building and entered. He was sitting in the front lobby without a mask. He then returned to his quarantined unit at 3:39 p.m. No residents had been in the lobby with him. V. Staff interviews CNA #11 was interviewed on 10/24/23 at 10:05 a.m. CNA #11 said she was informed that morning Resident #53, Resident #19 and Resident #66 were all positive for COVID-19. She said the residents had been feeling bad for some time and were tested that morning. The results showed all three residents were COVID-19 positive. The NP declined to be interviewed on 10/24/23 at 10:30 a.m. Registered nurse (RN) #4 was interviewed on 10/24/23 at 2:50 p.m. RN #4 worked in the quarantined unit. She stated residents were to keep the room doors closed and wear a mask if they left the rooms. The staff encouraged the residents to stay on the unit but if the residents wanted to leave the unit, staff were to encourage the resident to wear a N95 mask or at least a surgical mask. The infection preventionist (IP) was interviewed on 10/24/23 at 4:20 p.m. She stated Resident #35 often refused care and redirection. If the staff persisted to attempt to redirect a behavior, he would become angry and agitated. The staff would have to walk away and return. The staff tried to encourage him to wear a mask when he left his room and if he left the quarantined unit. The staff tried to keep other residents away from him when he sat in the front lobby. The director of nursing (DON) was interviewed on 10/24/23 at 5:07 p.m. The facility had assigned a designated sitter to accompany Resident #35 when he left his unit. This was to ensure if he refused to wear a mask, he could be redirected from other residents and areas he occupied would be disinfected. The staff would utilize some of the resident's favorite snacks to provide incentive for him to wear a mask. VI. Facility COVID-19 status The IP was interviewed on 10/24/23 at 4:20 p.m. She said the facility had 11 COVID-19 positive residents.

Based on record review and interviews, the facility failed to ensure in-service training for certified nurse aides (CNAs) consisted of annual training for dementia management for six of six CNAs reviewed. Specifically, the facility failed to ensure CNAs #3, #4, #5 #6, #1 and #2 received annual dementia management training. I. Training review Six nurse aides were reviewed for the annual required dementia management training. Training records revealed six of the six did not have the required annual training: CNA #3 was hired on 7/7/22. She had not had annual dementia management training. CNA #4 was hired on 1/21/21. She had not had annual dementia management training. CNA #5 was hired on 10/27/22. She had not had annual dementia management training. CNA #6 was hired on 8/31/21. She had not had annual dementia management training. CNA #1 was hired on 8/23/22. She had not had annual dementia management training. CNA #2 was hired on 1/12/22. She had not had annual dementia management training. II. Interview The director of nursing (DON) was interviewed 10/25/23 at 4:35 p.m.She said the facility had not provided dementia management training to any CNAs in the past 12 months. She said all aides providing care should be trained on dementia management due to the population the facility serves.

Based on observations, record review and interviews, the facility failed to ensure residents were free from physical restraints imposed for purposes of convenience, and the least restrictive alternatives were used for two (#52 and #11) of three residents reviewed for restraints out of 32 sample residents. Specifically, the facility failed to: -Obtain a physician's order for a lap buddy for Resident #52 and #11; -Obtain consent before the use of a lap buddy for Resident #52 and #11; and, -Evaluate the ongoing use of a lap buddy for Resident #52 and #11. Findings include: I. Facility policy and procedure The Restraint Free Environment policy, implemented 12/1/22, was provided by the director of nursing (DON) on 10/25/23 at 3:10 p.m. included: Policy: It is the policy of this facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. Policy: It is the policy of this facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. Using devices in conjunction with a chair, such as trays, tables, cushions, bars or belts, that the resident cannot remove and prevents the resident from rising. A physician's order alone is not sufficient to warrant the use of a physical restraint. The facility is responsible for the appropriateness of the determination to use a restraint. Before a resident is restrained, the facility will determine the presence of a specific medical symptom that would require the use of restraints, and determine: -How the use of restraints would treat the medical symptom. -The length of time the restraint is anticipated to be used to treat the medical symptom, who may apply the restraint, and the time and frequency that the restraint will be released. -The type of direct monitoring and supervision that will be provided during use of the restraint. -How the resident will request staff assistance and how his/her needs will be met while the restraint is in place. -How to assist the resident in attaining or maintaining his or her highest practicable level of physical and psychosocial well-being. II. Resident #52 A. Resident status Resident #52, age over 65, was admitted on [DATE]. According to the October 2023 computerized physicians orders (CPO), diagnoses included degeneration of the brain, dementia and abnormalities of gait. The 8/6/23 minimum data set (MDS) assessment revealed the resident's cognitive status was severely impaired and unable to complete a brief interview for mental status (BIMS). The assessment identified the resident had two or more falls during the look back period. No restraints were identified in the assessment. B. Observations A lap buddy can be used as a positioning device when the resident is unable to maintain upright position in the chair and is used to provide trunk and upper arm/body support for wheelchair mobility or self-feeding. It can be used as a restraint to prevent a resident from rising from the wheelchair. Resident #52 was in the television room on 10/23/23 at 3:00 p.m. with a lap buddy on. Resident #52 was in the dining room on 10/24/23 at 10:40 a.m. with a lap buddy on. Resident #52 was in the television room on 10/25/23 at 11:00 a.m. with a lap buddy on. C. Record review The care plan, initiated on 4/28/2020 and revised 8/1/23, included a history of falls. Interventions included, lap buddy to wheelchair, check function and placement every shift. Resident able to remove independently. -The October 2023 CPO did not include an order for the lap buddy. -There was evidence of the facility checking function and placement of the lap buddy every shift. -The resident did not have a signed consent to review the risks of the lap buddy. The 7/24/23 quarterly device evaluation identified Resident #52 had a lap buddy positioning device for the medical reasons of cognitive impairment, behavior and mobility impairment. The evaluation documented there had not been a risk versus benefits reviewed with the resident or the responsible party. -The evaluation did not review whether the resident could remove it or not. The lap buddy was not reviewed with resident/responsible party to review the risks of it restricting the resident's movement. D. Staff interviews Certified nurse aide (CNA) #7 was interviewed 10/25/23 at 12:40 p.m. She said Resident #52 needed a lap buddy because Resident #52 had a history of falling. She said she did not know if Resident #52 could remove the lap buddy on her own. Registered nurse (RN) #1 was interviewed on 10/25/23 at 12:45 p.m. She said she could not locate a physician's order for the lap buddy in the October 2023 CPO. She said Resident #52 was a fall risk and the lap buddy was in place to help prevent falls. She said she did not know if Resident #52 could remove the lap buddy or not. The social services director (SSD) was interviewed on 10/25/23 at 2:30 p.m. She said a restraint was a mechanism that restricted movement. She said Resident #52 had a lap buddy, however, she could not locate a consent or a current order for the lap buddy. She said a lap buddy restricted the movement of Resident #52. The DON was interviewed on 10/25/23 at 4:35 p.m. She said Resident #52 had a history of falling and the lap buddy was in place to help prevent the falls. She said she thought Resident #52 could remove the lap buddy on her own. E. Facility follow-up The facility provided a restraining evaluation dated 10/26/23. The evaluation identified the resident had impaired cognition, was mobility impaired with the use of a wheelchair and had muscle weakness. The evaluation identified the resident would benefit from the use of a restraint or assistive device for positioning in the wheelchair. -The evaluation did not review whether or not the resident could remove the device. It did not document the benefit was reviewed with the responsible party. 31821 III. Resident #11 A. Resident status Resident #11, age 66, was admitted on [DATE]. According to the October 2023 computerized physician orders (CPO), diagnoses included bipolar, schizoaffective, catatonic disorder and chronic obstructive pulmonary disease. According to the 10/5/23 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The resident had verbal behaviors directed toward others. She required extensive assistance for bed mobility, transfers, grooming and toilet use. The restraint assessment did not document use of a lap buddy. B. Observation Resident #11 was sitting in the common area on 10/24/23 at 8:50 a.m. Resident #11 was leaning forward with her arms extended to the floor and her upper torso was lying on the lap buddy. The resident's feet were behind the double footrest on her wheelchair. Resident #11 was sitting in her wheelchair in the common area on 10/25/23 at 12:40 p.m. Resident #11 was trying to lift her left leg back over the double footrest. Resident #11 was having difficulty moving her foot back in front of the double foot support on her wheelchair. C. Record review The care plan, initiated 4/26/23 and revised 10/5/23, identified the resident had a history of falls related to poor balance, poor safety awareness. She often removes lap buddy and attempts to self-ambulate. She will often scoot on her bottom in her room. She has a soft helmet for safety that she wears intermittently. She will often lower herself to the floor related to the history of sitting on the floor per her culture norms. Interventions include a fall mat placed next to bed. Check cushion and lap buddy for proper placement. Floor of the room was padded with foam squares for safety while moving about when not in a wheelchair. Hipsters at all times to reduce risk for major injuries as resident tolerates. Mattress on floor for safety. -The resident did not have a physician's order for the lap buddy. -An evaluation/assessment, interdisciplinary notes and risk-benefit statement were requested during the survey. They were not provided at time of exit on 10/26/23. -In addition, there was no evaluation/assessment of the footrest that could inhibited her movement (see observations above). D. Staff interviews CNA #2 was interviewed on 10/24/23 at 12:55 p.m. CNA #2 said the resident had a lap buddy as the resident would lean forward in her wheelchair because of lack of core support. Licensed practical nurse (LPN) #2 was interviewed on 10/25/23 at 11:31 a.m. She said the resident had a history of falls. She said the lap buddy was to keep the resident in her wheelchair and from falling forward. She said she did not know if the resident could take the lap buddy off on her own. IV. Administrative interview The DON was interviewed on 10/25/23 at 4:35 p.m. She said a restraint was a device that confined a resident or did not allow them to move freely. She said all restraints needed to have a consent and an order. The resident should have an assessment, should be updated and reviewed by the interdisciplinary team.

Based on interviews and record review, the facility failed to ensure two (#31 and #55) out of four residents reviewed for abuse were kept free from abuse out of 32 sample residents. Specifically, the facility failed to: -Prevent a resident-to-resident altercations between Resident #58 and #55; and. -Prevent a resident-to-resident altercation between Resident #58 and #31. Findings include: I. Facility policy and procedure The Abuse policy, dated 5/3/23, was provided by the director of nursing (DON) on 10/23/23 at 4:28 p.m., included in part, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, mental anguish, deprivation of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. II. Resident #58 A. Resident status Resident #58, age 82, was admitted on [DATE]. According to the October 2023 computerized physicians orders (CPO), diagnoses included dementia, cognitive deficit and muscle weakness. The 7/28/23 minimum data set (MDS) assessment revealed the resident's cognitive status was severely impaired with a brief interview for mental status (BIMS) score of one out of 15. No behaviors were identified on the assessment. B. Record review The care plan, dated 7/31/23 and revised on 8/21/23, identified aggressive behaviors that appear to be unprovoked. Interventions included: -Monitor for signs and symptoms of aggression. -One-to-one for safety. -The care plan did not include interventions for Resident #58 when she would become aggressive (cross-reference F744 for dementia care). A progress note from Resident #31's record dated 7/17/23 at 5:00 p.m. included, The aide informed this writer at 4:50 p.m. that Resident #58 smacked Resident #31 on their head. Aide stated that she was assisting another resident with dinner when she heard Resident #31 yell, 'Leave me alone.' When aide went to see what was wrong, Resident #58 was standing near Resident #31 who was sitting in her wheelchair next to the dining room door in the hall. Resident #31 was holding her head. Another resident's family member who was sitting with her mom at a table next to the dining room door told the aide that Resident #58 was attempting to push Resident #31 in her wheelchair and when Resident #31 did not allow her to do so, Resident #58 smacked Resident #31 in the head. A progress note dated 7/31/23 at 2:30 p.m. included, Resident #55 was getting up from (the) sofa and Resident #58 was coming into the common area/television area. Resident #58 slapped Resident #55 in the face, and hit her again in the head. The CNA (certified nurse aide) got between the two residents so Resident #58 would not hit again, Resident #55 was redirected to her room. The aide told Resident #58 to sit down on the couch. III. Resident #55 A. Resident status Resident #55, age 83, was admitted on [DATE]. According to the October 2023 CPO, diagnoses included Alzheimer's disease and dementia. The 10/5/23 minimum data set (MDS) assessment revealed the resident's cognitive status was severely impaired with a brief interview for mental status (BIMS) score of one out of 15. The assessment identified verbal behaviors towards others and other behavioral symptoms toward others. IV. Resident #31 A. Resident status Resident #31, age over 65, was admitted on [DATE] and readmitted [DATE]. According to the October 2023 CPO, diagnoses included neurocognitive disorder and psychosis. The 10/4/23 minimum data set (MDS) assessment revealed the resident's cognitive status was severely impaired with a brief interview for mental status (BIMS) score of two out of 15. No behaviors were identified on the assessment. V. Altercation on 7/17/23 A. Investigation Resident #58 was attempting to push Resident #31 down the hallway in her wheelchair. Resident #31 was telling Resident #58 to stop and Resident #58 slapped Resident #31 in the head. The residents were immediately separated and Resident #58 was placed on a one-to-one monitoring until she went to bed. The altercation was witnessed by a visitor. Resident #31 did not have noted injuries. The facility substantiated the assault. VI. Altercation on 7/31/23 A. Investigation Resident #55 had just gotten up from the couch when Resident #58 walked into the television room, passing each other when Resident #58 started hitting Resident #55 in the face and right arm. Resident #55 did not have noted injuries. The facility substantiated the assault. VII. Interview The nursing home administrator (NHA) was interviewed on 10/26/23 at 12:00 p.m. She said she was the abuse coordinator. She said the facility was every resident's home and they have the right to live and not be afraid and not be harmed by anyone. She said the facility had implemented the one-to-one staff supervision originally on 7/17/23 and discontinued it on 7/31/23 and within 15 minutes the second altercation had happened. She said the facility had implemented one-to-one staff supervision again after the second altercation which had been effective since the 7/31/23 altercation. She said since then there have not been any altercations since the one-to-one staff supervision.

Based on observations, record review and interviews, the facility failed to ensure interventions were carried out or offered to prevent pressure injury from occurring for two (#1and #2) of four out of 10 residents. Specifically, -Resident #1 was at high risk for pressure injury when she entered the facility. The facility failed to encourage the resident to reposition, As a result the resident developed an unstageable pressure injury to her right heel. The facility failed to ensure treatments were provided as ordered by the physician and develop a person-centered care plan for the resident's pressure injury to the right heel. Additionally the facility failed to ensure: -Resident #2 was not repositioned timely and physician orders were not followed. Findings include: I. Professional reference The National Pressure Ulcer Advisory Panel, https://npiap.com/page/PressureInjuryStages accessed on 3/8/23 read in pertinent part: Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. The National Pressure Ulcer Advisory Panel (NPUAP), Prevention and Treatment of Pressure Ulcers reads that steps to prevent the emergence of pressure ulcers in individuals identified as being at high risk include scheduled repositioning to avoid individuals being in a position that places pressure on a vulnerable area for a long period of time. The following steps should be taken to prevent the worsening of existing pressure ulcers and promote healing: -Positioning that places pressure on the pressure ulcer should be avoided. -The pressure ulcer should be assessed upon development and reassessed at least weekly. The results of assessments should be documented. -The ulcer should be observed with each dressing change for signs of infection, improvement, deterioration, or other complications. -Signs of deterioration in the wound should be addressed immediately. -The assessment should include: location, category/stage, size, tissue type, color, peri-wound (skin around the wound) condition, wound edges, exudate, undermining/tunneling, order. II. Facility policy and procedure The Skin Management policy, revised 10/21/2021, was provided by the director of nursing (DON) on 3/9/23. It read in pertinent part: Residents receive care to aid in the prevention or worsening of wounds and/or pressure ulcers. Individuals at risk for skin compromise are identified, assessed and provided treatment to promote healing, prevent infection, and prevent new ulcers from developing. Ongoing monitoring and evaluation are provided for optimal resident outcomes.Residents admitted with skin impairments will have: Interventions implemented to promote healing;A physician's order for treatment; Wound location and characteristics documented. A Care Plan is developed upon admission, and reviewed upon readmission, identifying the contributing risks for breakdown, including history of skin impairment or the actual impairment, and the interventions implemented to promote healing and prevent further breakdown. The Care Plan should address, but is not limited to the following: Hydration; Nutrition;Preventive device;physical activity; Pain management; Positioning requirements; Proper body alignment; and Psychosocial adjustment to skin impairment. III. Resident #1 A. Resident status Resident #1 age 86, was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO) diagnoses included, vascular dementia, chronic pain syndrome, type II diabetes mellitus and cognitive communication deficit. The 1/23/23 minimum data set (MDS) assessment, revealed the resident had severe cognitive impairment and was unable to participate in the brief interview for mental status (BIMS). No behaviors or refusals of care were noted. The resident required total assistance with activities of daily living. The resident was incontinent of bladder and frequently incontinent of bowel. The MDS revealed the resident was at risk for pressure ulcers and indicated the resident had a pressure injury. B. Observations On 3/7/23 Resident #1 was observed continuously from 8:59 a.m. until 1:07 p.m. -At 8:59 a.m., Resident #1 was in the dining area in her wheelchair. The resident had socks on her feet. -At 9:00 a.m., the resident propelled herself to the common area. -At 9:10 a.m., the resident was assisted to her room by certified nursing aide (CNA) #8. -At 9:14 a.m., the resident was assisted by CNA #8 to lay in bed, heel pressure relief boots were not offered. Foot elevation not offered. The resident's bilateral heels were directly on the mattress. -At 9:30 a.m., the resident continued to lay in bed on her right side. Her heels continued to not be offloaded. -At 9:44 a.m., the resident continued laying in bed, registered nurse (RN) #3 took resident ' s vitals. Heel pressure relief boots not offered. Foot elevation not offered. -At 9:48 a.m., the resident was offered water by CNA #8 but declined and remained on her right side in bed. Heel pressure relief boots not offered. Foot elevation not offered. -At 9:59 a.m., the resident remained asleep on her right side. -At 10:58 a.m., the resident remained on her right side in bed. -At 12:30 p.m., the resident remained in bed. -At 12:31 p.m., the resident was assisted out of bed by CNA #8. -At 12:37 p.m., the resident was assisted back to lay down in bed by CNA #8. The resident was not offered or provided the heel pressure relief boots. Foot elevation not offered. -At 1:07 p.m., the resident was still in bed laying on her right side. On 3/8/23 the resident was observed continuously from 8:33 a.m. until 12:03 p.m. -At 8:33 a.m. the resident was in bed, on her back, foot not elevated, pressure relief boots not observed. -At 8:55 a.m., the resident remained at the same position. -At 9:21 a.m. CNA #8 entered the resident ' s room, replaced water in cup beside the bed. CNA #8 did not wake, reposition or encourage hydration. Resident was not offered pressure relief boots or foot elevation. -At 10:13 a.m., the resident was observed in the room asleep on her back. The resident was observed without pressure relief boots and without her foot elevated. -At 10:21 a.m., the resident observed on the floor, she had experienced a fall. CNA #8 and CNA #9 entered the room to assist the resident. -At 10:30 a.m., the resident was assisted into wheelchair. CNA#9 failed to offer the pressure relief boots. -At 10:56 a.m., CNA #9 assisted the resident back into bed. Pressure relief boots and or foot elevation were not offered. -At 11:03 a.m., RN #3 attempted to administer her medications. Pressure relief boots were not offered. -At 11:41 a.m., RN #3 and DON completed wound dressing change. After the dressing change, the resident was not offered the pressure relief boots. Dressing change The March 2023 CPO showed a physician order for the pressure injury: wound care; right heel eschar (dead tissue that falls off (sheds) from healthy skin.), cleanse with NS (normal saline), apply layer of Santyl, cover with xeroform, abdominal pad (ABD, an abdominal pad is an extra thick primary or secondary dressing designed to care for moderate to heavily draining wounds), and wrap with kerlix. Notify the medical doctor (MD) with concerns. Do not use wound cleanser. Additionally, a treatment order for the pressure injury: Skin: green heel protector boots to both feet when in bed. On 3/8/23 at 11:34 a.m. a dressing change performed by the director of nursing (DON) was observed. The resident was lying in bed and did not have green heel protector boots on as ordered when the resident was in bed. The soiled dressing was removed and consisted of xeroform and kerlix, an abd pad was not used although it was ordered. The wound was located on the right posterior heel. There was pink tissue with white exudate, the wound was oozing serous fluid and no odor was noted. The DON rubbed the wound bed in an upward and downward motion using the same 2x2 gauze saturated in normal saline, although debridement was not part of the dressing change order. Next, a layer of Santyl was applied followed by xeroform, an abd pad, and wrapped with kerlix. Visibly dirty socks were placed back on the residents feet and the resident was assisted into her wheelchair. C. Record review The 11/15/22 initial skin documented the resident had no pressure injuries. The progress note dated 12/13/22 documented, the resident was found to have a blister on the right heel during shower skin assessment by CNA and was reported to the nurse. The nurse contacted wound nurse to assess. The progress note documented open blistered area, and the resident ' s name was added to the wound care list for the provider to see on next visit. The note documented heel protector boots were initiated and encouraged, however the resident often kicks them off. Treatment orders were in place. The wound measurements were 4 cm length x 3 cm width with no measurable depth, with an area of 12 sq cm. The wound care physician ' s assistant (WCPA) note dated 12/12/22 documented, the blister was a pressure injury, unstageable, stable eschar, will continue to be followed by the wound team. Encourage turn and repositioning, footrests only to be on during transporting. Wound care physician assistant (WCPA) assessed the resident on 12/19/22. Heel eschar stable. Right heel was an unstageable pressure injury, obscured full-thickness skin and tissue loss pressure ulcer and has received a status of not healed. Wound encounter measurements are 4 cm length x 3 cm width with no measurable depth, with an area of 12 sq cm. There was no drainage. Wound bed has 100% eschar. The wound was stable. The Kardex for skin integrity and skin protection identified the resident: have an air mattress in place to promote skin integrity. Monitor pain level during wound care, encourage use of pain medication before/during/after wound care as indicated; cease wound care performance if indicated by my verbalization. Need pressure relieving /reducing cushion to protect the skin while up in chair. Need pressure relieving /reducing mattress and position pillows to protect the skin while in bed. Monitor right second finger skin tear. The Kardex failed to address the physician's order for the pressure relieving boots. The Braden scale completed on 2/27/23 showed the resident was at high risk for pressure ulcers with a score of 17. The care plan last revised on 12/29/22 identified the resident was at high risk for potential and or actual impairment to skin integrity related to fragile skin. Pertinent interventions included: pressure relieving/reducing mattress and positioning pillows to protect the skin while in bed. The care plan did not identify the pressure areas, and also failed to include the interventions to provide the pressure relieving boots. D. Interviews RN #3 was interviewed on 3/9/23 at 9:47 a.m. The RN said the resident developed the pressure ulcer from not being mobile and from being in bed all the time and will only get up to use the toilet. In order to treat the pressure injury residents should be repositioned, offered pressure relief boots or elevation and wound care. Any staff member can offer the resident the pressure relief boots and they should be offered every time she was in bed. Wound care team assessed the resident on Monday. The dressing change was ordered for every other day. RN #3 confirmed the resident was not offered the pressure relief boots by her or the staff present on 3/9/23 during continuous observation. The director of nursing (DON) was interviewed on 3/9/23 at 10:57 a.m. The DON said the resident was at high risk for pressure ulcers due to limited mobility, high fall risk, and she enjoyed to be in bed a lot, sometimes she liked to sleep in bed all day. Initially the ulcer started on 12/7/22 as a blister, which is when the resident was we referred the resident to the wound care doctor. Interventions put in place were: elevating heels and pressure relief boots anytime she is in bed, which should be offered every time she is in bed. The pressure ulcer that developed on her right heel was avoidable. DON confirmed she did receive training by the physician'ss assistant on how to do the dressing change. DON confirmed the antibiotic pad was not in place per the March 2023 CPO. DON said the WCPA applied lidocaine prior to debridement of the wound bed and then continued with the dressing change. The wound care physician ' s assistant (WCPA) was interviewed on 3/9/23 at 10:17 a.m. The WCPA said the dressing change was always demonstrated because he expects staff to perform the dressing changes exactly how he demonstrated. The WCPA also said when he gave an order it was a verbal order and he also writes the order in his wound care visit note, his note is then uploaded into the residents chart. He also notifies the primary doctor at the facility if the order was complex. Then he logs into the residents chart and signs the order to confirm it was entered correctly. The WCPA also said turning and repositioning is very important and an air mattress is not a substitute. The WCPA said Resident #1 pressure injury on her heel was avoidable. 48114 III. Failure to follow physician orders 2. Resident #2 A. Resident status Resident #2, age less than 65, was admitted on [DATE]. According to the October 2022 computerized physician orders (CPO), diagnoses included, osteomyelitis, unspecified, pressure ulcer of other site, stage 3, pressure ulcer of other site, stage 1, pressure ulcer of sacral region, stage 2, pressure ulcer of right buttock, stage 4, pressure ulcer of left buttock, stage 4, pressure ulcer of sacral region, unstageable, pressure ulcer of unspecified part of back, stage 3, and pressure ulcer of left heel, unstageable. The minimum data set (MDS) dated [DATE], showed the resident had no cognitive impairment with a score of 15 out of 15 on the brief interview for mental status (BIMS). The resident required extensive assistance with bed mobility, transfer, locomotion on and off unit, dressing, and toilet use. The MDS coded that the resident had two stage 3 pressure injuries, three stage 4 pressure injuries, and two unstageable deep tissue injury. The MDS coded the resident as at risk for pressure injuries and had unhealed pressure injuries. B. Resident interview Resident #2 interviewed on 3/6/23 at 5:30 p.m. Resident #2 said she had two pressure injuries on her buttock area. C. Physician ' s orders for the pressure injury treatment The March 2023 CPO documented the following: -Use two green wedges for side to side positioning due to stage IV left and right ischial tuberosity wounds. They are to be used at every shift related to pressure ulcers with a start date of 10/27/22. -Wound care for left ischial tuberosity: Cleanse wound bed, apply collagen, cover with ABD pad, cover with Hydralock super absorbent dressing, do not use tape. Start date/revision date 1/3/23. -Wound care for right sacrum: cleanse wound bed, apply collagen, cover with ABD pad, cover with HudraLock super absorbent dressing, do not use tape. Start date/revision date 1/3/23. -Wound care for right ischial tuberosity: cleanse wound bed, pack 12 o ' clock tunnel with 1/4 inch iodoform packing with Mupirocin 2% ointment, apply collagen, cover with ABD pad, cover with HydraLock super absorbent dressing, do not use tape. Start date/revision date 1/3/23. C. Observations During the dressing change which was performed by the DON on 3/8/23 at 1:06 p.m., the physician was not followed. The physician order was for a HydraLock dressing, however were not present on the soiled dressing and not available for the new dressing. The resident ' s leg was also wrapped in Kerlix which the DON failed to adhere to the physician ' s order. On 3/8/23 at 1:06 p.m. a dressing change was observed for resident #2 performed by the director of nursing (DON). Staff turned the resident on her side from lying on her back and the DON removed the soiled dressing from the residents sacral, left ischial tuberosity and right ischial tuberosity regions. The soiled dressings consisted of three pieces of collagen from each wound, one ABD pad across the sacrum (the ordered HydraLock dressing was not present), one ABD pad from the left ischial tuberosity (the ordered HydraLock dressing was not present), one HydraLock pad from the right ischial tuberosity and one small piece of packing from the tunneling present in the right ischial tuberosity. The wound on the right ischial tuberosity had both red and pink tissue, significant tunneling, serous/serosanguinous fluid, and no odor was present. The wound on the left ischial tuberosity had bright red tissue with a small amount of white exudate, serous fluid, and no odor was present. The wound on the sacral area was a circular area with depth, serous fluid, and no odor present. The DON sprayed each area with wound cleanser, packed the tunneling in the right ischial tuberosity with 1/4 inch iodoform with 2% mupirocin, covered each of the three wounds with collagen, and placed an ABD pad over each wound. The ordered HydraLock dressing was not used on any of the wounds. The resident was then placed on her back in the same position as she was prior to the dressing change. A soiled dressing from a fourth wound on the residents right posterior calf consisted of xeroform, ABD pad, and kerlix. The wound had red and pink tissue with white exudate, serous fluid, and no odor present. The DON sprayed wound cleanser on the wound, applied xeroform, covered with an ABD pad and wrapped with kerlix. The orders stated not to wrap this wound. The dressing change was complete at 1:31 p.m. and the resident remained on her back without green wedges or pillows for offloading. Record Review The 10/5/22 admission assessment documented the resident was admitted to the facility with a stage 4 pressure injury to the left and right ischial tuberosities, stage 2 pressure injury to sacral region stage 2, pressure injury unspecified part of back stage 3, pressure injury left heel unstageable, and pressure injury to sacral region unstageable. The 10/5/22 admission Braden scale for predicting pressure injuries revealed the resident was at a high risk for developing pressure sores. The assessment revealed the resident had slightly limited sensory perception, her skin was rarely moist, she was bedfast, very limited mobility, had adequate nutrition, and had a problem for friction or shear which indicated she required moderate to maximum assistance in moving. The care plan, last updated on 1/9/23, revealed the resident had actual skin breakdown. Interventions included: -elevate head of bed (HOB) no more than 30 degrees; -implement turning schedule if resident is unable to turn and reposition self; -observe and assess weekly (sensory, activity, and, mobility risk); and -use pressure redistribution surface to bed and wheelchair if indicated. Wound care note dated 2/27/23 by wound care physician assistant (WCPA) noted that Wounds worse on today ' s visit. Although unable to probe to bone, recommending XR (x-ray) of right calf, pelvis, and lumbar spine to evaluate for osteomyelitis as the larger wounds are stagnant or worsening. Right 2nd toe wound has resolved and the left 2nd toe wound showing significant improvement. Pending XR results, will also consider VAC (vacuum-assisted closure) therapy on sacral wound as this wound has been stagnant for several weeks. Wound assessment(s) dated 2/27/23: Wound #1 left ischial tuberosity, stage 4 pressure injury pressure ulcer, subsequent wound encounter measurements are 8.5cm length x 7.5cm width x 0.6cm depth, with an area of 63.75 sq cm and a volume of 38.25 cubic cm. Wound #2 right calf, stage 3 pressure injury pressure ulcer, subsequent wound encounter measurements are 9cm length x 2cm width with no measurable depth, with an area of 18 sq cm. Wound #4 right sacrum, stage 4 pressure injury pressure ulcer, subsequent wound encounter measurements are 2.5cm length x 2.5cm width x 2cm depth, with an area of 6.25 sq cm and a volume of 12.5 cubic cm. Wound #5 right ischial tuberosity, stage 4 pressure injury pressure ulcer, subsequent wound encounter measurements are 6.5cm length x 6cm width x 1cm depth, with an area of 39 sq cm and a volume of 39 cubic cm. Interviews The director of nurses (DON) was interviewed on 3/7/23 at 4:19 p.m. The DON stated that Resident #2 often refused to be turned side to side, however, the resident needed to be educated and offered with each care. The DON was interviewed a second time on 3/8/23 at 1:56 p.m. The DON said staff were to follow the physician orders which included both the dressing changes and the positioning devices. She said the order not to wrap Resident #2 lower extremity wound was a new order placed last week and had not been updated in the EMR. She also said the facility was out of the HydraLock dressing and she needed to order more. She said orders are typically entered into the EMR as soon as they are received but the wound care nurse is new and still learning. The registered dietician (RD) was interviewed on 3/9/23 at 10:04 a.m. The dietician reviewed the record and said he was familiar with the resident. The RD said the resident had multiple pressure injuries and was prescribed two health shakes a day for added nutrition and in addition was to receive double protein at all meals and a multivitamin. The wound care physicians assistant (WCPA) was interviewed on 3/9/23 at 10:17 a.m. The WCPA said the dressing change is always demonstrated because he expects staff to do exactly what he demonstrated exactly how he demonstrated. The WCPA also said when he gives an order it is a verbal order and he also writes the order in his wound care visit note, his note is then uploaded into the residents chart. He also notifies the primary doctor at the facility if the order is complex. Then he logs into the residents chart and signs the order to confirm it was entered correctly. The WPCA also said turning and repositioning is very important and an air mattress was not a substitute. Additional interviews The wound care physician ' s assistant (WCPA) was interviewed on 3/9/23 at 10:17 a.m. The WCPA said pressure injuries were avoidable unless there were outstanding circumstances or comorbidities like diabetic ulcers. He went on to say turning and repositioning were very important and an air mattress did not substitute a turning and repositioning schedule.

Based on observations, record review and interviews, the facility failed to ensure residents were offered sufficient fluid intake to maintain proper hydration and health for four (#1, #3, #5 and #9) of four out of ten residents. Specifically, the facility failed to: -Ensure Resident #1 was offered hydration on a consistent basis or encouraged to accept hydration per assessed daily minimum recommendation (see nutrition assessment below). Although Resident #1'ss risk for dehydration was identified upon admission, the facility failed to implement measures to ensure the resident received sufficient fluids to maintain hydration needs. As a result, of the resident poor fluid intake Resident #1 had a change of condition prompted by lack of hydration. The resident was diagnosed with dehydration and was ordered intravenous (IV) fluid therapy. The facility's failure to provide Resident #1 with adequate hydration led to the resident needing IV therapy. Upon the completion of the prescribed IV therapy, the facility failed to ensure the resident consumed sufficient amounts of fluids; failed to monitor the resident ' s fluid intakes to ensure fluid intake meet the resident ' s identified hydration needs; and failed to update the care plan with a care focus that identified the resident was at risk for dehydration; and failed to identify and implement appropriate interventions to prevent repeated episodes of dehydration. The facility's failure left Resident #1 at a high risk for repeated occurrences of dehydration. In addition the facility failed to: -Ensure Residents (#5, #3 and #9) were offered and encouraged hydration per daily minimum recommendations based on the facilities nutrition evaluation. Findings include: I. Professional reference According to Beck AM, Seemer J, [NAME] AW, [NAME] T. Narrative Review of Low-Intake Dehydration in Older Adults. Nutrients. 2021 Sep 9; retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8470893/ accessed on 3/15/23. Low-intake dehydration is a common and often chronic condition in older adults. Adverse health outcomes associated with low-intake dehydration in older adults are multifaceted, ranging from poorer cognitive performance, reduced quality of life, delirium, falls, fractures, worsened course of illness and recovery to heart disease, heat stress, kidney failure, unplanned hospital admissions, and increased mortality. II. Facility policy and procedure The Hydration policy, revised 10/1/2021, was provided by the director of nursing (DON) on 3/9/23. It read in pertinent part: The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health. Care plan implementation: The resident's goals and preferences regarding hydration will be reflected in the resident's plan of care. Interventions will be individualized to address the specific needs of the resident. Examples include, but are not limited to: Offer the resident a variety of fluids during and between meals; provide assistance with drinking; ensure beverages are available and within reach; evaluate resident's medications that may place the resident at risk for dehydration; offer alternative fluids such as broths, popsicles, gelatin, and ice cream; address underlying causes of dehydration or fluid imbalance; provide thickened liquids after underlying causes of symptoms are addressed; real food and beverages will be offered first before adding supplements or assisted hydration (unless clinically indicated); tube feeding or parenteral fluids will be provided in the context of the resident's overall clinical condition and resident goals/preferences. Monitoring of the resident's condition and care plan interventions will occur on an ongoing basis. III. Failure to ensure Resident #1 was offered and encouraged adequate hydration per daily minimum recommendation based on the facilities nutrition evaluation. 1. Resident #1 A. Resident status Resident #1, age 86, was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO) diagnoses included, vascular dementia, chronic pain syndrome, type II diabetes and cognitive communication deficit. According to the 1/23/22 minimum data set (MDS) assessment, the resident had severe cognitive impairment and was unable to participate in the brief interview for mental status (BIMS). The resident required total assistance with activities of daily living (ADLs) and staff supervision with encouragement and cuing (throughout the meal) while eating. The resident was incontinent of bladder and frequently incontinent of bowel. The MDS documented the resident was at risk for pressure ulcers and had developed a pressure injury that has not healed since 12/12/23. The MDS documented the resident was not having any behaviors or refusal of care. B. Observations The resident was observed continuously on 3/6/23 from 3:54 p.m. until 6:00 p.m. -At 3:54 p.m. the resident was observed sleeping, with a full bottle of water on the bedside table, but the water bottle was not within reach of the resident. -At 4:14 p.m., the resident was observed sleeping, staff had not entered the resident ' s room. -At 4:22 p.m., the resident was assisted out of her bed to the wheelchair in preparation for dinner time. The resident was not offered hydration. -At 4:26 p.m., the resident was observed out in the hallway and encouraged to dine in the dining room on the unit. -At 4:27 p.m., the resident was served dinner with 240 cubic centimeters (cc) of water, 240 cc of milk, 240 cc of juice, and 240 cc of hot chocolate. -At 4:33 p.m., the resident was observed not eating and or drinking. Certified nurse aide (CNA) #9 encouraged the resident to eat by saying eat your food. The resident did not eat or drink any of the food or drinks offered. -At 4:45 p.m., the resident was not eating the served meal; staff approached and offered the resident an alternative meal. -At 4:47 p.m., the resident had not consumed any of the meal and pushed away from the table. When the resident pushed the meal away from the table, none of the staff present encouraged the resident to return to the table to eat or drink any of her fluids. -At 4:55 p.m., the resident was transported and transferred to bed by CNA #9. No hydration was offered and or encouraged during this care. -At 5:20 p.m., the resident remained in bed. The water bottle beside the bed was untouched and remained full. -At 6:00 p.m., the resident remained in bed. The water bottle was untouched and remained full. No staff provided encouragement, or physical assistance for the resident to accept any amount of hydration during this observation. The resident was observed continuously on 3/7/23 from 8:45 a.m. until 1:07 p.m. -At 8:45 a.m., Resident #1 was observed in the unit ' s dining room, food and drinks were untouched. -At 8:59 a.m., the resident remained in the dining area in her wheelchair, food and drinks untouched. Staff were observed providing assistance to other residents but not with Resident #1. -At 9:00 a.m., the resident propelled herself to the common area. -At 9:10 a.m., the resident was assisted to her room by CNA #8. The CNA proceeded to assist the resident to lay down. No hydration was offered or encouraged. Resident #1 ' s water bottle was observed to be full and not within reach of the resident. -At 9:30 a.m., the resident continued to lay in bed on her right side. Staff had not entered the room since 9:10 a.m. A full water bottle was available by bedside, however, it was not within the resident ' s -At 9:44 a.m., the resident continued laying in bed. RN #3 took the resident's vital signs. The RNa did not offer or encourage the resident to accept hydration. The water bottle at the resident ' s bedside remained full and out of reach. -At 9:48 a.m., the resident was offered water by CNA #8 stating Do you want something to drink? The resident did not respond and remained on her right side asleep. The CNA did not make any other attempt to wake the resident or encourage the resident to drink. -At 9:59 a.m., the resident remained asleep on her right side. Water bottle was untouched and remained full by the bedside. -At 10:58 a.m., the resident remained on her right side in bed. The water bottle at the bedside remained full and untouched. -At 12:00 p.m., the resident was assisted to the dining room. The resident was served lunch, however, she was not served anything to drink. -At approximately 12:15 p.m., RN #3 provided the resident a glass with approximately 90 cc of water. RN #3 placed the water on the table; however, RN #3 did not encourage the resident to drink. The resident did not drink on her own. -At 12:20 p.m., the resident was assisted to bed. No fluids offered/ encouraged. -At 12:30 p.m., the resident was assisted by CNA #8 to sit up in bed. CNA #8 asked the resident Would you like some food? The water bottle at bedside remained full and out of reach. -At 12:34 p.m., the resident was assisted by CNA #8 to the unit ' s dining room. The resident was offered 240 cc of juice, a grilled cheese and meal assistance. The resident did not respond to meal assistance and propelled herself away from the table. Food and drink untouched. CNA #8 asked the resident Do you want to lay down? -At 12:35 p.m., the resident was assisted to her room by CNA #8. The resident was not offered hydration. -At 12:37 p.m., the resident was assisted to sit up in bed by CNA #8. The resident was prompted to eat a snack by CNA #8 Do you want a snack?, no hydration offered. The CNA #8 exited the room. -At 1:07 p.m., the resident was still in bed laying on her right side. The water bottle remained full and untouched. The resident was observed continously on 3/8/23 from 8:33 a.m. to 12:17 p.m. -At 8:33 a.m., the resident was in bed, on her back. The resident's water bottle was full by the bedside but not within reach of the resident. -At 8:55 a.m., the resident remained at the same position. The water bottle remained untouched. -At 9:21 a.m., CNA #8 entered the residents room, and provided fresh water but did not wake or encourage hydration. -At 10:13 a.m., the resident was observed in the room asleep on her back. The water bottle remained full. -At 10:21 a.m., the resident was observed on the floor mat beside the resident's bed, calling out help me, it was unclear if the resident climbed or rolled out of her low bed, as the angle of view did not allow for full view of the resident's bed; but of the resident ' s and the bedside table. CNA #8 and CNA #9 entered the room to assist the resident. The unit RN entered to assess the resident for injury. -At 10:30 a.m., the resident was assisted into a wheelchair, and transported to the common area. CNA #9 poured water in a 90 cc cup and offered it to the resident. The resident refused. -At 10:36 a.m., nursing staff offered the resident 30 cc of Ensure (protein supplement), but did not get the resident to drink any of the supplement.The 90 cc of water remained in front of the resident. -At 10:39 a.m., the resident took a sip of water. CNA #8 entered the secure unit ' s dining room and sat beside the resident to document the resident ' s meal choice. CNA #8 did not encourage the resident to drink. -At 10:50 a.m., the resident's water and Ensure remained untouched. -At 10:57 a.m., the resident's water and Ensure remained untouched. CNA #9 assisted the resident to her room; the resident was not offered hydration. -At 11:05 a.m., the resident was in bed, still the resident was not assisted or encouraged to accept hydration. -At 11:41 a.m., the director of nursing (DON) offered the resident a snack and drinks. DON stated Do you want some Sprite, a Twinkie or 7 up? The resident did not respond to the DON. The DON did not attempt to re-engage the resident and did not provide the resident with a snack or drink. C. Record review 1. Nutritional and fluid needs. The comprehensive care plan, last revised on 12/18/22, identified the resident required supervision with eating and drinking. The resident was to use a two handled cup with lid and built-up utensils at all meals. Pertinent interventions included: -Staff to sit with the resident and share a meal to attempt to increase meal intake; -Staff to observe document/report any signs and symptoms of diminished appetite and intake; -Offer preferred foods, meal alternates, as needed. Offer snack, as needed; -Encourage fluids with and between meals; and -Health shake everyday at lunch and observe intake and record after every meal. 2. Change of condition Nursing progress note dated 1/22/23, revealed in pertinent part: the resident was not acting like herself so CNA took vital signs. All vital signs were within normal limits except for the resident ' s blood pressure which was 97/61. The resident ' s physician was notified and an order for intravenous fluid (IVF) of normal saline (NS) at 100 cc per hour was provided. The physician also ordered lab orders for blood work. The resident's legal representative was notified that the resident had a change of condition, due to not eating or drinking much and dehydration was suspected. The legal representative suggested giving the resident 7up. According to the January 2023 computerized physician orders (CPO) the resident was ordered Normal Saline 0.9 percent via IV every shift for hydration on 1/22/23 and 1/23/23. The nutrition evaluation dated 3/6/23, revealed Resident #1 had been experiencing weight loss since admission. Resident ' s body weight prior to admission was approximately 150 pounds (lbs) and as of the assessment weighted 122 lbs, related to poor intake. The resident's nutrition needs indicate the resident ' s minimum recommended fluid intake should be 1,375 cc per day. -Resident #1 required feeding supervision and encouragement for intake to meet assessed nutrition needs. The resident was at risk for malnutrition due to dementia and diabetes. Nursing and CNA reports the resident had increased refusal of meals and supplements. -Recommendation by registered dietician (RD): included to continue with snacks twice a day, protein liquid twice a day, and continue with house shake once per day. Review of the resident's fluid intake tracing document revealed facility staff failed to document the resident's daily fluid intake to demonstrate whether the resident was meeting the daily minimum fluid intake recommendation. The facility DON was unable to provide any additional documents that tracked the resident's daily fluid intake/. The comprehensive care plan last updated 12/18/22 indicated the resident should be offered 7 up as that is her preferred choice of hydration, furthermore the care plan was not updated after the resident documented change of condition with a care focus to adder the resident's actual and risk of repeated episodes of dehydration. D. Interviews CNA #8 was interviewed on 3/9/23 at 9:10 a.m. The CNA said Resident #1 was able to feed herself, but required encouragement to eat and drink. The resident did refuse care, however staff were expected to re-approached at a later time when she refused care assistance. CNA #8 said that the amount of the food and fluids the resident consumed were supposed to be documented in the resident record. Registered nurse (RN) #3 was interviewed on 3/9/23 at 9:17 a.m. RN #3 said the resident feeds herself but required encouragement which included reminding the resident to eat, and offering the resident different things to eat and drink. The resident was always very picky when it came to eating and drinking; therefore staff should offer the resident multiple food and drink options based on the resident's choice. The resident's daughter also brought snacks and drinks the resident enjoys to eat. Staff should also provide positive reinforcement. RN #3 said Resident #1 received intravenous (IV) hydration by infusion into the resident's vein (refers to a way of giving a drug or other substance through a needle or tube inserted into a vein.) this past December 2022 because the resident was severely dehydrated and needed to be hydrated with fluid. RN #3 said she only tracked fluids if it was ordered by the physician. Otherwise the CNAs were to document the fluids consumed by the resident during meals and snack time. The RD was interviewed on 3/9/23 at 10:04 a.m. The RD was in the facility weekly to assess residents who were on the high risk list for pressure ulcer, dialysis, enteral nutrition (nutrition by gastric tube into the gastric intestinal tract) or hospice care. Otherwise residents were reviewed every three months. The RD said he did evaluate residents for hydration needs. Residents in general at meal times should receive 237 cc to 356 cc of fluids. Additionally, residents should also be offered hydration at medication pass times and additionally provided the facility house shakes if at risk for dehydration. The RD reviewed resident #1's medical record. The RD said Resident #1 had experienced a change of condition due to dehydration and required an IV for fluid hydration. The resident had been assessed to require as minimum daily fluid intake need to be between 1350 cc to1650 cc and that recommendation should be followed. The RD said 1375 cc daily at minimum would be his recommendations.The RD confirmed the care plan did not include a hydration focus or care after the resident December 2022 change of condition. The RD's expectation was to offer the resident drinks that the resident preferred such as 7up. The director of nurses (DON) and the regional nurse consultant (RNC) were interviewed on 3/9/23 at 10:57 a.m. The DON said residents should be offered something to drink at meals; in between meals;, when they wake up from sleeping; and at just before going to bed. The minimum hydration recommendation identified by the RD should be followed. The DON said the resident fluid intake at meals were tracked, but facility staff missed documenting the additional fluids provided to the residents. The RNC confirmed that they were unable to find the fluid intake tracker for Resident #1. The DON said the Resident #1 should have a specific care plan for hydration which included the resident's hydration needs with an intervention that included a need to track the resident's fluid intake. The RNC said the resident's fluid consumption needed to be watched more closely. IV. Other failures to maintain resident hydration 1. Resident #5 A. Resident status Resident #5, age older than 80, was admitted on [DATE] and readmitted on [DATE]. According to the March 2023 CP) diagnoses included dementia, overactive bladder, mild cognitive impairment, and abnormalities of gait and mobility. According to the 3/17/22 MDS assessment, the resident had severely impaired cognition as evidenced by a BIMS score of four out of 15. The resident required extensive assistance with activities of daily living, including supervision for eating. The resident was frequently incontinent of bladder and bowel. The MDS coded the resident as an individual that sustained 5% -10% weight loss in the last 6 months. The MDS coded the resident as not having any behaviors or refusal of care. B. Observations The resident was observed continuously on 3/6/23 from 3:54 p.m. to 6:03 p.m. -At 4:01 p.m., Resident #5 was in the secure unit ' s dining area in her wheelchair. -At 4:23 p.m., kitchen staff provided meals to the secure unit. -At 4:47 p.m.,the resident started to eat her dinner. -At 5:49 p.m., the resident finished her meal. The resident drank: 100 % of a 240cc cup of water and 50% of a 240cc cup of hot chocolate (120cc). The resident was observed continuously on 3/7/23 from 8:59 a.m. to 1:03 p.m. Throughout the observations, the resident was not offered anything to drink until the meal time. Observations were as follows -At 8:59 a.m., Resident #5 was in the dining area in her wheelchair. -At 9:08 a.m.,the resident was propelled to the common area by CNA #8. -At 9:20 a.m., the resident was asleep in her wheelchair in the common area. -At 9:59 a.m., the resident remained asleep in her wheelchair in the common area. -At 10:58 a.m., the resident remained asleep in her wheelchair in the common area. -At 11:08 a.m., CNA #8 escorted the resident to the dining area. -At 11:23 a.m., the resident received her meal. She received 240 cc of milk, 240 cc of coffee. -At 11:25 a.m., the resident began to eat.The resident drank: approximately 180 cc of milk, and 120 cc of coffee but not all of the hydration provided. -At 12:27 p.m., the resident was no longer eating her meal and was not being prompted to eat or drink. Staff approached and the resident was taken back to the secure unit by CNA #8 to sit in the common area. C. Record review The nutrition evaluation was completed on 3/6/23. The evaluation showed the resident's minimum recommended fluid intake should be 1590 cc per day. The evaluation documented the resident required supervision and encouragement with eating and drinking. Resident #5 was at risk for malnutrition due to dementia. The comprehensive care plan, last revised on 11/10/22, identified the resident required supervision with eating and drinking. Pertinent interventions included: -Encourage juice and milk with meals for added calories. -Observe intake and record every meal. -Encourage good nutrition and hydration in order to promote healthier skin. The nutrition-amount eaten task records (records daily fluid intake), dated 2/21/23 through 3/8/23, that were completed by the CNA staff were reviewed. The documentation revealed the Resident #5 averaged a fluid intake of approximately 777 cc of fluid per day in contrast with the RD recommended minimum of 1590 cc based on the nutrition evaluation. D. Interviews The RD was interviewed on 3/9/23 at 10:04 a.m. The RD said Resident #5 ' s recommended minimum daily fluid intake for the resident to consume 1500 cc of fluid per day. The RD reviewed resident #5 ' s record and confirmed the care plan did not include hydration care focus. The RD ' s expectation would be for the resident to have a care focus for hydration, based on the documentation showing an inadequate fluid intake where the resident averaged a fluid intake of 583cc per day in comparison with the daily recommended minimum fluid intake of 1500cc. CNA #8 was interviewed on 3/9/23 at 9:10 a.m. The CNA said Resident #5 was able to feed herself, but required to be reminded to eat and drink. The resident had refused care, especially being fed, as she is very independent and attempts to maintain her independence. CNA #8 said that the amount of the food and fluids the resident consumed were supposed to be documented in the resident record. Registered nurse (RN) #3 was interviewed on 3/9/23 at 9:17 a.m. RN #3 said the resident feeds herself but required encouragement which included reminding the resident to eat, and offering the resident different things to eat and drink. RN #3 said she only tracked fluids if it was ordered by the physician. Otherwise the CNA ' s were to document the fluids consumed by the resident during meals and snack time. 47960 2. Resident #9 A. Resident status Resident #9 was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO) diagnoses included nontraumatic intracranial hemorrhage, cerebral infarction, and anxiety. According to the 1/18/23 minimum data set (MDS) assessment, the resident had a brief interview for mental status (BIMS) score of 5 out of 15. The resident required total assistance with activities of daily living. The resident was incontinent of both bowel and bladder. The MDS coded the resident as not having any behaviors or refusal of care. B. Observations Observations revealed the resident did not receive the minimum amount of fluid as assessed. Observations were as follows: On 3/7/22 at 8:38 a.m. continuous observation began. Resident #9 was observed in the main dining room eating breakfast. The resident was served 240 cc of red drink. -9:07 a.m. Resident #9 finished 240 cc of a red drink. -9:35 a.m. Resident #9 was laying in bed. The 240 cc of protein drink was on the table in front of her but no one offered any encouragement for her to consume it. -10:37 a.m. Resident #9 was provided incontinence care and placed in her wheelchair. The meal replacement drink was in the same location and the volume had not changed. -10:38 a.m. Resident #9 was assisted into the dining room for lunch and a 240 cc regular cup of water was placed in front of her. -10:48 a.m. Resident #9 took two small sips of water. -11:07 a.m. Resident #9 was served lunch which included 240 cc of a red drink. -12:48 p.m. Resident #9 returned to her room after drinking approximately 120 cc of a red drink, 120 ml of a meal replacement drink, and 4 small sips of water. -2:01 p.m. CNA #3 went into Resident #9 ' s room and said goodbye. There was a container of water in front of the resident within her reach but the CNA did not offer or encourage the resident to drink it. -2:29 p.m. CNA #5 entered Resident #9 room and asked about dinner choices, however a drink was not offered. -2:53 p.m. Resident #9 remained in the same position in her wheelchair in her room. -3:08 p.m. LPN #1 and CNA #5 entered Resident #9 ' s room for incontinence care and did not offer any drinks. -4:10 p.m. Resident #9 was assisted to the dining room for dinner. -5:53 p.m. Resident #9 was assisted back to her room after she finished eating dinner and approximately 120 ml of the red drink. Observations ended and the total amount of fluid consumed was 600 cc. C. Record Review The 3/1/23 physician diet order read, HSG (name of kitchen contract) regular diet, HSG dysphagia advanced texture, regular/thin consistency, two-handed cup, scoop plate, built-up handle utensils, and red lap tray for all meals. The nutritional assessment dated [DATE] documented the resident required 1022 cc to 1200 cc fluid per day. The care plan also directed staff to offer water in conjunction with turning/care schedules. The Nutrition tracking chart for 3/7/23 for Resident #9 documented Resident #9 consumed 270 cc at 1:38 p.m., 270 cc at 1:39 p.m. and 800 cc at 9:48 p.m. for a total of 1340 cc. Continuous observations directly contradicted that amount. 48114 3. Resident #3 A. Resident status Resident #3, age 66, was admitted on [DATE] and discharged on [DATE]. According to the October 2022 computerized physician orders, diagnoses included, pressure ulcer of left hip, stage 3, and chronic respiratory failure with hypoxia. According to the minimum data set (MDS) dated [DATE], the resident had no cognitive impairment as she scored a 15 on the brief interview for mental status (BIMS). The resident required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Resident #3 did not have any complaints of difficulty or pain when swallowing and loss of liquids/solids from mouth when eating or drinking. Record Review The 10/18/22 nutrition evaluation showed Resident #3's estimated amount of fluid intake was 1500-1900 cc a day. The evaluation stated that resident #3 required limited assistance during meals. The hydration tracking task flow sheet record showed Resident #3's average amount of fluid intake ranged between 480 cc to 1200 cc of fluid intake daily. The nursing daily skilled charting dated 10/20/22 showed, the resident required extensive assist for self-feeding and had weakness in right and left hand. Interviews The registered dietician (RD) was interviewed by phone on 3/9/23 at 10:04 a.m. The RD reviewed the medical record and said the resident ' s hydration needs were estimated at 1500cc to 1900cc's a day. The RD did not know how much Resident #3 was drinking per day. The RD reported that he was involved in Resident #3 ' s care upon admit and after that he reported that he did not see her again. Additional interviews The director of nurses (DON) and the regional nurse consultant were interviewed on 3/9/23 at 10:54 a.m. The DON said that residents should be getting fluids between meals, when they were awake and throughout the day. The DON said that they follow the recommendations of the dietician regarding how much fluid each resident should consume. The DON said that they track fluid amounts on tasks which only tracked fluid intake during meals. The DON said that an additional fluid task has been asked to be put in, so that it showed residents were not just getting fluids at meal times but at other times during the day.

Based on record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for one (#2) resident out of four sample residents. The facility failed to ensure mechanical lift equipment, which included slings, were in proper working order to ensure the safety of all residents, who required the use of mechanical lifts. Resident #2, who required a mechanical lift and two staff assistance for transfers, was placed in a sling that was in disrepair and fell four feet from the mechanical lift to the floor. Due to the facility failures to identify and replace slings and keep them in good working order, Resident #2 was sent to the emergency room for complaints of pain. Resident #2 sustained acute nondisplaced fractures to the left lumbar four and five spinous and the left lateral part of the sacrum (see radiology results-section record review). Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 12/28/2020 to 12/30/2020, resulting in the deficiency being cited as past noncompliance with a correction date of 11/9/2020. I. Facility immediate action As a result of the accident and through the investigation which was conducted from 10/30/2020 through 11/4/2020, the facility audited all of the mechanical lift slings and lift equipment on 10/30/2020 which identified 41 slings that were old or damaged out of a total 47 facility slings. The facility destroyed the damaged slings and ten new slings were ordered on [DATE] and arrived on 11/11/2020. On 10/30/2020 the restorative manager educated facility staff members present in the building to inspect mechanical lift slings prior to using them for a transfer. This education continued to ensure all staff members were educated prior to their next shift with all staff completing education by 11/9/2020. On 11/4/2020 the housekeeping supervisor educated the housekeeping and laundry staff on proper care of the slings related to laundry chemicals, water temperature, the need to air dry the slings, and to inspect the slings for damage prior to returning them to the floor for use. A reminder sign for these procedures was posted in the laundry room. Weekly audits of mechanical lift equipment and slings were performed by the DON, Assistant director of nursing (ADON) and staff development coordinator (SDC) on 11/2/2020, 11/10/2020, 11/19/2020, 11/23/2020, 12/3/2020, 12/10/2020, 12/17/2020, 12/24/2020, 12/30/2020 and would continue for at least 90 days. The Quality Assurance and Performance Improvement (QAPI) meetings were held on 11/2/2020, 11/18/2020, 12/16/2020, and would continue for at least three months. Observations conducted during the onsite investigation between 12/28/2020 through 12/30/2020 confirmed mechanical lift slings were in operable condition and signage was present in the laundry room. II. Resident #2's interview regarding the poor condition of the sling Resident #2 was interviewed on 12/29/2020 at 2:06 p.m. She stated a lot of the slings the facility used prior to her fall were in bad condition. She stated she had told the care staff many times about the condition of the slings, though nothing was done until after she fell . She stated she did not tell any management staff and was unsure if the care staff she told had told anyone else. She stated the staff took good care of her and followed procedures, and she fell due to the sling being in poor condition, not because staff did anything against procedure III. Facility policy and procedure The Fall Management policy, dated July 2017, was provided by the nursing home administrator (NHA) on 12/30/2020 at 11:25 a.m. It read: in pertinent part: The facility assists each resident in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices and/or functional programs, as appropriate, to minimize the risk for falls. The Lift and Transfer Guide, dated 2010, was provided by the NHA electronically on 12/31/2020. It read, in pertinent part: The director of maintenance will be to ensure that all lifting devices are clean and are maintained in accordance with all manufacturers instructions. Direct care staff will be responsible for the following: -Using mechanical lifting devices in accordance with manufacturer recommendations and instructions -Notifying the Administrator, Director of Nursing, Safety Champion, and/or Maintenance Director immediately of mechanical lifting devices which are broken or inoperable. IV. Resident #2 A. Resident status Resident #2, age under [AGE] years, was admitted on [DATE]. According to the December 2020 computerized physician orders [REDACTED]. The 11/8/2020 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required extensive assistance of one to two staff members with her mobility and activities of daily living (ADLs) with the exception of transfers and bathing for which she was totally dependent on staff. B. Record review The ADL care plan, dated 11/9/17 and revised on 11/11/2020, revealed the resident required a full body mechanical lift with an extra large sling and extensive assistance of two staff members for transfers. On 10/30/2020 a progress note revealed, when transferring resident from bed to the shower chair using the mechanical lift the left lower sling strap broke dropping the resident to the ground. When the nurse entered the room, the resident was laying across the mechanical lift with a certified nurse aide (CNA) standing next to the resident holding her upper body to keep her head from laying on the floor. The resident did not hit her head but was complaining of back pain. Upon assessment, the nurse found red marks to the resident's mid back, right hip, and left heel. The resident also had bruising starting to appear to the back of left ankle, left buttock, and left hip. The director of nursing (DON) notified the physician and received orders to x-ray the resident's back. The resident then requested to be sent to the emergency room , the physician was contacted again and an order was received to send the resident to the emergency room for evaluation and treatment. The emergency room records for the resident from 10/30/2020 revealed the resident stated she landed on her tailbone and the middle of her back onto the legs of the mechanical lift when she fell . She was feeling pain in the center of her back that radiated down to her lower back. Radiology results revealed acute nondisplaced fractures to the left lumbar four and five spinous and the left sacral ala (lateral part of the sacrum). The injuries were non-operative, so pain control was the only action. The resident was given pain medication and returned to the facility. The facility investigation revealed the staff performing the transfer followed procedure of placement of the sling and hooking the sling to the lift, though did not inspect the sling for integrity prior to the transfer. Upon inspection of the sling after the fall, the sling was worn around the hooks. An interview with the resident documented in the investigation revealed she had told staff on prior occasions that she did not like the way the sling was looking. Review of concern and maintenance forms revealed no formal concern was ever filed related to the condition of the slings. V. Additional resident interview Resident #4 was interviewed on 12/29/2020 at 1:50 p.m. She stated she used to be transferred with a mechanical lift but currently transferred with a slide board. She stated when she was previously transferred by mechanical lift, she noticed the slings were old and was often uneasy about transfers because of the condition of the slings. She stated she did tell the staff about the slings, though was not sure if a formal complaint was ever filed. VI. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 12/29/2020 at 1:56 p.m. She stated all of the slings were recently replaced and she received training to monitor and inspect the slings for any damage before using them. She stated if she were to find a sling that was damaged, she would bring it to the DON and obtain a different one to use. The DON, NHA, and district clinical director (DCD) were interviewed on 12/30/2020 at 11:30 a.m. They stated there had been no reports of slings in disrepair prior to the fall with Resident #2. They stated all of the slings in the facility were inspected, compromised or damaged slings were removed and destroyed and all new slings were ordered. They stated this incident caused a company wide action related to mechanical lift equipment and slings. They stated audits were continuing weekly.

Based on observations, record review, and interviews, the facility failed to provide the necessary treatment and services to promote pressure injury healing, prevent pressure injuries from worsening, and maintain accurate skin assessments for two (#78 and #38) of five residents reviewed for pressure injury out of 41 sample residents. The facility failed to ensure Resident #78, who had a history of [REDACTED]. Multiple failures contributed to this outcome as evidenced by the facility failing to accurately and timely complete the Braden Scale for Predicting Pressure Sore Risk assessment upon readmission resulting in a delay in implementing preventive measures. Resident #78 pressure ulcers were not comprehensively assessed by staff upon admission and consistently thereafter. Moreover, the staff did not notify the physician to obtain treatment orders timely, complete the treatments for the pressure injuries according to the physician orders [REDACTED]. The facility's actions contributed to the worsening of Resident #78 (who was a readmission to the facility) stage 2 pressure ulcer into a stage 3 and the development of an additional pressure ulcer over a month in time. Additionally, the facility failed to complete treatments for Resident #38 pressure injuries as ordered by the physician. Findings include: Cross-reference F867 for failure to have an effective quality assurance and performance improvement (QAPI) plan to prevent the development and worsening of pressure ulcers. I. Facility policy and procedure The Skin Management policy and procedure, revised (MONTH) (YEAR), was provided by the director of nursing (DON) on 4/17/19 at 2:30 p.m. The policy revealed: -When eschar is present, accurate staging is not possible until the eschar has sloughed or the wound has been debrided. -Upon admission or readmission, residents are assessed for skin integrity by completing a head to toe physical assessment of skin condition and completing the Braden Scale for Predicting Pressure Sore Risk. -Appropriate preventive surfaces will be implemented for residents identified at risk. -Resident admitted with skin impairments will have: interventions implemented to promote healing; a physician' order for treatment, and completion of the Weekly Pressure Ulcer Record. -A care plan is developed upon admission, and reviewed upon readmission, identifying the contributing risks for breakdown and the interventions implemented to promote healing and prevent further breakdown. - .Slough and eschar are not found on stage 2 ulcers. II. Resident #78 A. Resident #78 status Resident #78, over the age of 65, was admitted [DATE], hosptalized on [DATE] and returned on 3/18/19. According to the (MONTH) 2019 computerized physician orders [REDACTED]. -The residents pressure ulcer was not listed on his diagnosis. The 3/25/19 (re-admission) assessment revealed the resident required extensive assistance of two people with bed mobility, transfers, dressing, and toilet use. The assessment revealed the resident did not walk during the assessment period. He had one stage 2 pressure ulcer and he was always incontinent of bowel and bladder. The 4/3/19 facility assessment revealed his cognitive status was severely impaired with a brief interview for mental status (BIMS) score of two out of 15. He required extensive assistance of two people with bed mobility, transfers, toilet use, and personal hygiene. He was always incontinent of bowel and bladder and was not on a toileting program. He was at risk for the development of pressure ulcers and had three stage 2 pressure ulcers, one of which was present upon admission. He had a pressure reducing device on the bed and chair and was on a turning and repositioning program. B. Resident observations On 4/14/19 at 10:50 a.m., the resident was lying in bed on his back. Heel protectors were not on his feet and his heels were not being offloaded (raised to reduce pressure) by other means. He was observed again at 1:25 p.m. lying in bed. He had his sandals on while in the bed and his heels were not offloaded. On 4/15/19 at 10:16 a.m., the resident was lying in bed on his left side. The resident' inner right foot was lying against the mattress and his outer left foot was lying against the mattress. Pressure reducing boots were observed at the foot of the resident' bed on the floor. On 4/16/19 at 7:20 a.m., the wounds to the resident' coccyx and left buttocks were observed. The coccyx wound was noted to be covered with yellow slough and appeared to be approximately 1.0 cm x 1.0 cm in size. The left buttock wound displayed 80% pink granulation tissue and 20% yellow slough and appeared to be approximately 2.0 cm x 2.0 cm in size. Dark black eschar was observed on the resident' left heel and appeared to be approximately 2.0 cm x 2.0 cm in size. The resident was observed again at 2:23 p.m. lying in bed. He was lying on his back and the pressure relieving boots were observed at the foot of his bed on the floor. His heels were not offloaded by other means. C. Record review 1. Care plan The skin care plan initiated 3/27/19 (nine days after admission) and revised 4/11/19 revealed the resident had the potential for continued alterations in skin integrity with stage II development of left buttock cleft identified on 3/22/19. Bilateral feet with eschar wounds identified on 3/18/19. Coccyx UTD (unable to determine) due to eschar and slough 3/18/19. The interventions included: -3/27/19: Alternating pressure relieving mattress for wound healing. -3/27/19: Pressure relieving cushion for wheelchair when up. -3/27/19: Wound rounds weekly by wound team. -3/29/19: Turn and reposition in bed frequently. The care plan failed to identify the use of heel protectors at all times except during showers and skin inspections as ordered by the physician on 4/9/19 (see below). It also failed to specify a turning and repositioning program as identified on the 4/3/19 MDS assessment (mentioned above). 2. Braden scale assessment The Braden scale assessment for predicting pressure sore risk revealed the following: The 3/20/19, post-readmission Braden assessment revealed the resident scored a 21 which indicated he was not at risk for the development of pressure sores. The assessment indicated the resident was rarely moist, walked frequently, had no limitations in mobility and had no problems with friction or shearing. Based on the 3/25/19 MDS assessment, the Braden assessment did not accurately reflect the resident' status at the time of readmission. -This inaccuracy promoted delay in appropriate treatment for [REDACTED]. 3. Physician orders The order summary report from 3/18/19 through 4/16/19 revealed the following orders: -3/22/19: Pressure wound left buttock; Cleanse wound with wound cleanser. Apply calcium alginate, cover with border gauze use and Hyperfix (low allergy adhesive) tape. Change dressing every Monday, Wednesday, and Friday. (five days after readmission with a stage 2 pressure injury) -3/26/19: Alternating pressure mattress to bed for stage 2 pressure relief and wound healing. (nine days after readmission with a stage 2 pressure injury) -3/31/19: Coccyx and Buttocks wounds; Cleanse with wound cleanser, pat dry and apply skin prep to wound edges and intact periwound (skin around the wound) skin. Apply Calcium Alginate to wound bed and cover with dry dressing and secure with tape or transparent dressing. Change three times per week and PRN (as needed.) 4/3/19: Coccyx and Buttocks wounds; Cleanse wounds with wound cleanser and pat dry. Apply skin prep to wound edges and intact periwound skin. Cover with an adhesive foam dressing and change two times per week and PRN. 4/10/19: Continue current foam dressing to buttocks wounds. 4/10/19: Offload both feet with heel protectors. 4/10/19: Try to avoid shearing to the toes. 4/12/19: Weekly skin check on every Tuesday. 4/16/19: Coccyx; Cleanse wound with wound cleanser, pat dry and apply skin prep to wound edges and intact periwound skin. Apply Santyl ([MEDICATION NAME] agent to remove dead tissue) to wound bed. Cover with a normal saline moistened 2x2 gauze pad and cover with ABD (abdominal pad) and picture frame with tape. Change daily and PRN. 4. Pressure ulcer assessment and treatment failures: a. Review of the (MONTH) 2019 weekly pressure ulcer record, nursing progress notes, and treatment administration record (TAR) revealed the following failures: -The 3/18/19 admission nursing assessment revealed the resident was admitted with a wound to his left buttock but failed to reveal a comprehensive assessment of the wound was completed. No other wounds were identified on the admission skin assessment. -The 3/22/19 (four days after readmission) weekly pressure ulcer record revealed the resident was admitted with a stage 2 pressure ulcer on his left buttock which measured 2.5 cm (centimeters) x (by) 2.0 cm x 0.1 cm. The wound bed was described as beefy red and a scant amount of serosanguineous drainage was noted. -The assessment revealed no specialty interventions were in place. The assessment revealed the physician was notified and treatment orders were obtained. -No further assessments of the wound was completed in (MONTH) 2019. -The (MONTH) 2019 TAR revealed no treatment was administered to the stage 2 pressure injury until 3/25/19. The TAR also revealed the ordered treatment was not administered on 3/27/19 or 3/29/19 as ordered by the physician. -The (MONTH) 2019 TAR revealed a new order for a treatment to the coccyx, however, the facility was unable to provide documentation the wound was comprehensively assessed by the facility. b. Review of the (MONTH) 2019 weekly pressure ulcer record, nursing progress notes and TAR revealed the following failures: -The 4/3/19 physician progress notes [REDACTED]. Skin of coccyx, buttock, perianal and perineum is fragile due to old pressure injuries that have healed The note read, Two-stage 2 pressure injuries (I originally called them stage 3 but subcutaneous fat not seen). -The (MONTH) 2019 TAR revealed the treatment to the resident' coccyx and buttocks wounds were not administered as ordered by the physician on 4/3/19 as they were not initialed by the nurse on the TAR. -The 4/8/19 nursing progress note read, During skin check, noted area to top of left foot where ankle sock sits. area is open, dry with no drainage. left big toe has 1.5 x 1cm black area and a hard callus on top of knuckle. Left 2nd toe has a 1.5 x 1cm black area, left 3rd toe has a black hard callus area on knuckle, left 4th toe has two black areas, 0.5 x 0.5cm, left 5th toenail is black, possibly missing. none of the areas are draining. unable to palpate pedal pulse to left foot. Right foot 3rd toe with 1cm black area, left 2nd toe with 0.5cm black area. pedal pulse was noted to right foot. both feet are warm to touch, toes are cooler but not cold. both feet have mild discoloration. -The note revealed the physician was notified and was scheduled to see the resident the following day. -The 4/9/19 nursing progress note read, Nurse practitioner here to see resident and do skin check. Area observed to left lateral heel. 3cm x 2cm discoloration, not open at this time. -The 4/9/19 weekly pressure ulcer record for the left buttock pressure injury, completed by a registered nurse (RN), failed to identify measurements of the wound were completed. The wound was described as a stage 3 with 80% pink granulation tissue and 20% yellow slough. The documentation indicated the wound had improved, however, the assessment failed to reveal a comprehensive assessment to include the measurements of the wound. -The 4/9/19 weekly pressure ulcer record for the coccyx, completed by an RN, revealed the wound measured 1.5 cm x 1.2 cm and the depth was unable to be determined. The description read, Pressure ulcer to coccyx was classified as stage 3 per doctor. Today wound bed is 100% yellow slough greyish eschar mid center. Wound is stable. The assessment indicated the wound had deteriorated due to the increased slough to the wound bed. The plan was to continue the current treatment. -The 4/9/19 weekly pressure ulcer record for the left inner ankle revealed the pressure injury was acquired at the facility on 4/8/19. The area measured 2.0 cm x 0.5 cm and the depth was unable to be determined due to 100% dry eschar. -The 4/9/19 weekly pressure ulcer record for the left heel revealed the pressure injury was acquired at the facility on 4/9/19. The wound was unstageable and measured 2.8 cm x 3.0 cm and the depth was unable to be determined due to 100% dark discoloration. -The 4/9/19 weekly pressure ulcer record for the right 2nd toe revealed the wound was present upon admission and was unstageable. The wound measured 0.2 cm x 0.2 cm and the depth was unable to be determined due to 100% dry eschar. The description of the site revealed the right 3rd toe also had a wound which measured 0.2 cm x 0.2 cm and the depth was unable to be determined due to 100% dry eschar. This wound did not have a separate wound sheet. -The 4/9/19 weekly pressure ulcer record for the left great toe revealed the date of onset was 4/9/19. The wound was unstageable and measured 1.8 cm x 1.0 cm and the depth was unable to be determined due to 100% dry eschar. The description of the site read, 2nd 0.5 x 1.3 x UTD 100% dry eschar, 4th toe 1st knuckle 0.3 x 0.3 x UTD 100% dry eschar, 4th toe 2nd knuckle 0.3 x 0.3 x UTD 100% dry eschar, 5th toenail bed 0.4 00.4 x UTD 100% dry eschar. The areas identified in the description site did not have a separate pressure ulcer assessment forms. -The facility did not complete a weekly comprehensive assessment on 4/16/19 of the before mentioned pressure injuries. c. The facility provided additional information on 4/18/19, this information included the following: -The 4/18/19 physician progress notes [REDACTED]. I did see the dressing, but unable to remove them. -The 4/18/19 weekly pressure ulcer record for the left buttock was a stage 2 and measured 1.5 cm x 2.0 cm, no depth was recorded. The wound bed had 85% pink granulation tissue and 15% slough. This wound was previously identified as stage 3. -The 4/18/19 weekly pressure ulcer record for the coccyx revealed the wound was a stage 2 and measured 1.0 x 1.0 but the depth was unable to be determined. The description of the site read, Dr stage ulcer as a stage 2 pressure. Wound bed is 98% yellow slough. According to the physician progress notes [REDACTED]. In addition, according to the documentation, the wound bed was covered in slough and unable to be visualized which would impede the assessor's ability to determine the stage of the wound. 4. Staff interviews Certified nurse aide #10 was interviewed on 4/17/19 at 8:25 a.m. She said the resident requires assistance with repositioning in bed. She said pressure ulcer preventative measures used included rolling him from side to side and laying him down after meals. She said whenever a new skin condition is found she would report this information to the nurse. She said new preventative interventions would be reported to her by the nurse in shift report. Licensed practical nurse (LPN) #4 was interviewed on 4/17/19 at 8:30 a.m. She said the nurses working the floor were responsible to administer treatments as ordered. She said once the treatment was completed, this would be documented on the treatment administration record. She reported the facility had not had a treatment nurse for a while so it was the nurses working the floor responsibility to complete the weekly assessments of the wounds. She said the nurse who finds the wound should complete the assessment and notify the physician for treatment orders. She said this nurse should also initiate appropriate preventative measures. She said this could include an air mattress, repositioning schedule or supplements. She said a comprehensive assessment of the resident' skin should be completed upon admission and documented in the resident' clinical record. She said the Braden assessment was supposed to be completed upon admission and weekly thereafter for a month. The director of nursing (DON) was interviewed on 4/17/19 at 1:30 p.m. He stated treatments are to be completed as ordered and should be documented on the treatment administration record. Through a review of the resident' TAR, he verified the staff failed to administer the wound treatment as ordered on several days. He acknowledged the resident did develop additional pressure injuries after admission to the facility but indicated the facility had implemented interventions timely to prevent the ulcers from occurring. He was unable to provide evidence the wounds were deemed unavoidable by the physician. He stated a comprehensive assessment should be completed and documented in the resident' clinical record upon admission and weekly thereafter. He said the physician should be notified of new or worsening wounds and treatment orders should be obtained. Upon review of the wound documentation, he acknowledged the facility failed to complete a comprehensive assessment of the wound upon admission and weekly thereafter. He stated Braden assessments were supposed to be completed upon admission and should be an accurate reflection of the resident' status in order to initiate appropriate preventative measures. III. Resident #38 A. Resident status Resident #38, age 70, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 3/31/19 facility assessment revealed, the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of 0 out of 15. The resident required extensive assistance of two people with bed mobility and transfers. The resident utilized a wheelchair for mobility. The resident was at risk for development of pressure ulcers, required pressure reducing intervention of heel elevation as well as adaptive equipment to off set pressure. B. Record review The care plan, initiated 3/19/19, identified Resident #38 was at risk for impairment of skin integrity related to immobility and incontinence. Interventions included the resident to wear pressure relieving boots for wound management as well as significant care with wound changes and care. The care plan failed to include, the resident had an actual stage 3 pressure ulcer on coccyx and the wound care was to take place three times a day. The 4/2/19 physician order [REDACTED]. The (MONTH) 2019 treatment administration record (TAR) failed to show the coccyx pressure ulcer had been cleaned three times a day as ordered by the physician. The TAR failed to show the pressure ulcer was cleaned on 4/12/19 and 4/15/19 as there was no documentation. C. Staff interviews Licenced practical nurse (LPN) #3 was interviewed on 4/16/19 at 12:42 p.m. LPN #3 reviewed the record and confirmed the physician order [REDACTED]. The LPN said after reviewing the medical record, and confirmed there was no documentation showing the pressure ulcer was cleaned on 4/112/19 and 4/15/19. The director of nursing (DON) was interviewed on 4/16/19 at 12:55 p.m. The DON reviewed the medical record and confirmed the physician order [REDACTED]. The DON said the treatment administration record (TAR) needed to be changed to reflect the order. D. Facility follow-up On 4/15/19 at 3:02 p.m. the facility created a performance improvement plan that consisted of education to nursing, audit of physician orders, education on wound care and documentation. The number of times a day and the need to document care was addressed.

Based on record review and interviews, the facility failed to develop and implement appropriate quality assurance and performance improvement (QAPI) plans of action to correct identified quality deficiencies, potentially affecting all the residents in the facility. Findings include: I. Failure to prevent repeat citations Cross-reference F686 (formerly F314) Pressure ulcers This deficiency was cited previously during recertification surveys on 8/21/15, 9/13/16, and 2/12/18. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement with the failure to prevent the development or worsening of pressure injuries. II. Failure to identify quality deficiencies and initiate effective action plans to correct. The following deficiencies were cited on the recertification survey completed 4/17/19: -F686, pressure ulcer prevention and treatment: The facility failed to ensure Resident #78, who had a history of [REDACTED]. Multiple failures contributed to this outcome as evidenced by the facility failing to accurately and timely complete the Braden Scale for Predicting Pressure Sore Risk assessment upon readmission resulting in a delay in implementing preventive measures. Resident #78 pressure ulcers were not comprehensively assessed by staff upon admission and consistently thereafter. Moreover, the staff did not notify the physician to obtain treatment orders timely, complete the treatments for the pressure injuries according to the physician orders [REDACTED]. The facility's actions contributed to the worsening of Resident #78 (who was a readmission to the facility) stage 2 pressure ulcer into a stage 3 and the development of an additional pressure ulcer over a month in time. Additionally, the facility failed to complete treatments for Resident #38 pressure injuries as ordered by the physician. III. Review of the QA action plan/staff interview The nursing home administrator (NHA) and the director of nursing (DON) were interviewed on 4/17/19 at 3:00 p.m. The NHA reported the facility had a mock survey completed in (MONTH) 2019 and pressure ulcers were not found to be a concern. However, the DON stated a performance improvement plan (PIP) was initiated on 11/16/18 regarding skin breakdown. He said the facility did not currently have a specific wound nurse or a wound physician. He said ensuring consistent assessments of wounds had been a struggle with changes in staff. He said the facility was currently working on a contract with a wound physician to make wound rounds weekly. The DON stated a PIP was initiated on 4/4/19 regarding skin breakdown. He indicated oversight and education of the staff were the root causes identified on the PIP. The DON acknowledged the current PIP was ineffective as the weekly comprehensive assessments had not been completed timely during the survey. He stated, effective immediately, he would be responsible for ensuring weekly wound rounds were completed timely to include a comprehensive assessment of the wounds, implementation of interventions and ensuring appropriate treatment orders were in place and completed as ordered.

Based on record review and interviews, the facility failed to provide treatment and services in a timely manner to prevent worsening to an existing pressure injury, development of 13 new pressure injuries, and prevent infection to pressure injuries for one (#237) of three residents reviewed for pressure injury of 26 sample residents. Specifically, the facility failed to: -Assess the sacral pressure injury correctly on admission in order to provide the correct interventions; -Provide the necessary treatment when the wound was getting worse; and, -Inform the resident's primary care physician (PCP) of the condition of the wound and follow up timely to orders regarding laboratory tests. -Identify and respond to resident positioning and wound care refusals. The facility ' s failure contributed to a situation that resulted in the worsening of the existing pressure, the development of 13 new pressure injuries, the resident ' s discharge to the hospital for a change of condition related to the pressure injuries and signs of infection of the pressure injuries. Findings include: I. Facility policy and procedure Skin management system, last revised 07/2017, read in part: -Residents receive care to aid in the prevention or worsening of wounds and or pressure ulcers. An individual at risk is identified, assessed, provided treatment to promote healing, prevent infection and prevent new ulcers from developing. -Practice guidelines included, upon admission or readmission, residents are assessed for skin integrity from head to toe and complete the Braden scale for predicting pressure sore risk. The resident admitted with skin impairments will have amongst other, notification of the presence of the skin impairment to the resident's representative and the attending physician and documentation in the nursing admission data collection set or progress notes. Wound location and characteristics documented in the admission data collection set. -The licensed nurse would document daily monitoring of the pressure ulcer and document in the treatment administration record (TAR) to reflect the status of the dressing, surrounding skin color, skin and associated pain with the wound. A registered dietitian (RD) will timely assess the residents identify with skin impairment for nutritional status and document recommendations. Individualized turning and repositioning established for bed bound resident. II. Resident #237 A. Resident #237, under the age of 65, was admitted on [DATE] and transferred to the hospital on [DATE] for a change in condition. The resident did not return to the facility. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. B. Resident status on admission and facility response 1. Record review revealed the resident was identified with risk factors for pressure injuries and actual pressure injury during assessments the first week of admission. According to the 11/8/17 admission skin assessment, the resident was admitted from an acute hospital with right and left antecubital bruising from lab draws and intravenous placement at the hospital and sacrum pressure injury stage 2. The sacrum had the appearance of recurring pressure there was minor bleeding from pinhole size opening. The coccyx also displayed discoloration to the site that indicated frequent (pressure injury) recurrences to the area. The admission skin assessment did not include measurements or descriptions of other characteristics of the pressure injury. According to the 11/8/17 admission Braden scale assessment, The resident had no sensory impairment. The skin was occasionally moist. Confined to bed. Had very limited changes in body or extremity position, unable to make frequent or significant changes independently. The resident eats over half of most meals. Eats four servings of protein (meat, dairy products per day. Occasionally will refuse a meal, but will usually take a supplement when offered. Friction & shear Problem, she requires moderate to maximum assistance in moving. Moderate risk = 14. Initial care plan addressed pain, skin - pressure ulcer. According to a skin assessment completed on 11/10/17, the resident's skin was intact. Daily skilled nursing documentation completed on 11/10/17 and 11/11/17, documented the resident's coccyx had dark discoloration. There was no documentation the Primary care provider (PCP) was notified of the dark discoloration. According to the 11/15/17 minimum data set (MDS) assessment, The resident required extensive assistance from two persons for bed mobility, toilet use and personal hygiene. She was totally dependent on others for transferring. She was admitted with an indwelling catheter and was occasionally incontinent of bowel. She was admitted with a stage 2 pressure ulcer. 2. Facility response to identified risks and pressure injury The facility developed care plans to address the resident's pressure injury risk and her immobility, assessed and care planned her nutritional risk and obtained orders for wound care, among others. The care plan, initiated 11/9/17 and revised 11/30/17, identified actual impairment to skin integrity of the coccyx r/t (related to) impaired mobility. She had open wounds to bilateral glutes (buttocks). Interventions included: Resident to keep hands and body parts from excessive moisture, keep fingernails short. The staff to educate the resident/family/caregivers of causative factors and measures to prevent skin injury. Encourage good nutrition and hydration in order to promote healthier skin. Staff to follow facility protocols for treatment of [REDACTED]. The care plan, initiated 11/9/17 and revised 11/9/17, identified activity of daily living (ADL) decline due to (d/t) hydro[DIAGNOSES REDACTED] with AKI (acute kidney injury), metabolic acidosis and back pain. Interventions included: Extensive assistance by one staff to turn and reposition in bed. She requires Halo bars for increased bed mobility The resident requires extensive assistance by one staff with mechanical Hoyer lift for transfers, personal hygiene, toilet use and oral care. An admission assessment by the registered dietitian (RD), dated 11/14/17, revealed the resident's caloric need was 1463 -756 kcal (kilocalories), protein estimated need was 59-70 grams and fluid need was 1756-1956 cc (cubic centimeters) per day for increased intake related to wound healing as evidenced by having a stage 2 pressure wound. The care plan, initiated 11/14/17 and revised 11/14/17, identified a nutritional problem or potential nutritional problem r/t obesity,[MEDICAL CONDITION]([MEDICAL CONDITION] reflux disease), recent poor p. o. (by mouth) intake and stage 2 sacral pressure injury. Interventions included: Double protein portions . Monthly weights with a review for significant changes. Provide and serve supplements as ordered such as Prostat 30 ml (milliliter) once a day. Provide and serve regular diet as ordered. Observe intake and record q (every) meal. The (MONTH) (YEAR) CPO included instructions for: -11/14/17, Prostat 30 ml daily and record percentage of intake. -11/9/17, Foley catheter care every shift, placed for the wound. - 11/9/17, [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) 10-325 mg (milligram) tablet Q (every) 8 hours PRN (as needed) for pain. -11/10/17, Clean and dry Coccyx/Sacrum, apply a thin layer of [MEDICATION NAME] lotion BID (twice a day) and PRN for excoriation. 3. Failure in facility response Review of the admission assessment above revealed no measurement of the resident's sacral and coccyx discoloration and no measurements until 11/15/17, despite the resident's known risks and documentation that the sacrum and coccyx appeared to evidence recurring pressure. C. Decline in status 11/22 - 11/25/17 1. Review of wound documentation revealed the resident's sacral wound worsened. The resident was seen by the wound physician 11/22/17 for Moisture Associated Skin Damage (MASD) of the sacrum and painful rash of the buttocks. Review of daily skilled document revealed the resident began refusing dressing changes as well as repositioning and on 11/25/17 was identified with two new pressure injuries. a. Pressure injury assessed as unstageable Review of weekly pressure injury documentation on 11/15/17 revealed the resident's pressure injury on her sacrum measured 18 cm (centimeters) x 14 cm x UTD (unable to determine), unstageable. 100% necrotic tissue. Debrided but unable to get to healthy tissue. Wound bed very unstable, moderate drainage to the site. Wound bed was black and very foul odor. No pain. The intervention included low loss air mattress, the positioning device and was deteriorated. Treatment change, add Alginate. Review of wound documentation on 11/16/17 revealed the sacrum pressure measured 18 cm x 15cm x zero depth. 80% slough and 20% healthy granulation tissue. Skin very frail and easily sloughs off. Epidermis compromise unable to visualize wound bed. No drainage and no odor present. No pain. The intervention included Santyl to wound bed. The wound was unchanged from the previous observation (11/15/18). Review of the nurse daily skilled documentation dated 11/16/17, revealed the sacrum pressure injury was unstageable. An SBAR (Situation, Background, Assessment and Recommendation) Communication Form dated 11/16/17 documented the resident was immobile due to inability to change position. The registered nurse (RN) assessment documented the resident had a breakdown to her sacrum and the family and the resident's primary care physician (PCP) were notified. New orders dated 11/16/17 read, Cleanse wound to sacrum with wound cleanser, pat dry with 4x4, apply hydrogel gauze to the wound bed, cover with foam and secure with tape. Change daily and PRN. b. Pressure injury not improving, behavior changes and new pressure injuries -According to the nursing daily skilled documentation dated 11/21/17, the resident refused morning wound care; stating she wanted wound care at night when going to bed. -According to the nursing daily skilled documentation completed on 11/22/17, the resident refused wound care and meals however, review of progress notes revealed the nurse changed the wound dressing that morning due to soiling. The skin looked raw, pink with blood present, but no signs/symptoms of infection. -According to the 11/22/17 Braden Scale assessment, The resident was high risk for pressure injury. She had slightly limited sensory perception, response to verbal commands, but cannot always communicate discomfort or the need to be turned. The skin was occasionally moist. Confined to bed. Had very limited changes in body or extremity position, unable to make frequent or significant changes independently. Nutrition was probably inadequate. She required moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. [DIAGNOSES REDACTED], contractures or agitation leads to almost constant friction. -A skilled wound care (SWC) note by the wound physician dated 11/22/17 revealed the resident's sacral wound measured 18 cm (length) 15 cm (width), depth was undetermined and wound area was 270 sq. cm (square centimeters). The overall prognosis for the resident was moderate. The goal was for the wound to dry up the MASD. Interventions included: offloading, turn per facility protocol and continue low air loss mattress. -According to the 11/24/17 nurse note, the nurse performing the wound care documented the wound care was performed to coccyx area. Area contaminated with fecal matter. Black tissue edges, bleeding present. Wound bed pale in some areas and pink in others. The resident was non-compliant with staying off area. She was frustrated with staff for placing cushion wedges in WC (wheelchair) to prevent skin breakdown. ADON (assistance director of nursing) notified of wound concerns from this nurse, as she is part of wound care team. -On 11/24/17, the wound care doctor ordered the new wound treatment to cleanse wound to sacrum with wound cleanser and pat dry with 4 x 4. Apply Santyl to yellow areas, Calcium Alginate to the wound bed, cover with foam dressing and secure with tape. Change daily and PRN for infection prevention. Physical therapy (PT) and occupational therapy (OT) to evaluate and treat and skincare per facility protocol. -According to the daily skilled documentation 11/24/17, the resident resisted active range of motion and refused to turn to prevent skin breakdown. -Review of ADL care documentation completed between 11/9/17 and 11/30/17, the resident refused to be repositioned 17 out of 56 opportunities. -According to the daily skilled documentation 11/25/17, the resident refused to comply with turning schedule or to participate in ADL care. The coccyx wound was documented as a stage 2, with new wounds documented as stage 2 on the resident's left and right thigh. According to 11/25/17 night nurse documentation, the wound care was performed to coccyx area, area soiled through with fecal matter. Nursing noted large area of the slough, other areas of pink tissue, and edges are dark purple/black in color. Appears raw. No drainage noted or foul odor. The resident tolerated well, however, has a constant stream of stool, soft. The wound was changed x2 on HS (the hour of sleep) shift, and once on day shift yesterday due to this. Will continue to monitor. 2. Failures in facility response -See above; the wound nurse failed to identify the new stage 2 wounds on the resident's left thigh found in the daily skilled documentation above. -See care plans above; there were no care plan updates to address the resident's frequent refusals to participate in measures to prevent decline and promote healing of her pressure injuries, including repositioning and dressing changes. There was no documentation the interdisciplinary team met to consider ways to promote the resident's compliance. -Review of daily skilled documentation and progress notes revealed no communication with the resident's PCP on 11/25/17 about the new stage 2 wounds that had been identified. -Review of daily skilled documentation and progress notes revealed no communication with the RD of the resident's new stage 2 wounds. -Review of physician orders, the medication and treatment administration records showed no order was in place for a specialty low-loss air mattress, even though the 11/15/17 pressure injury documentation (see above) documented this was a planned intervention. D. Decline in status 11/29 - 12/5/17 1. Record review revealed further debridement of the sacral wound 11/29/17, signs of possible infection (foul odor) 12/4/17, additional resident refusals and hospital transfer 12/5/17 due to [MEDICAL CONDITION]. -According to the daily skilled documentations, on 11/29/17, the resident refused food and became verbally aggressive toward staff. There was no evidence in the documentation the PCP was notified of the behavior. -According to the weekly pressure injury documentation 11/29/17 read: facility acquired new non-pressure skin condition to right gluteal fold. Measured 10.5 cm x 5.5 cm x UTD. Full thickness, no drainage, and a foul odor were present. Interventions included low loss air mattress and the dressing was Hydrogel with foam dressing. New facility acquired non-pressure to left gluteal fold. Measured 6.5 cm x 6 cm x UTD. Pink tissue with an area of a yellow slough noted. Unable to debride or visualize wound bed. Unsure if the pressure was of MASD at this time and no evidence of pressure. Full thickness and the very foul odor were present. New orders dated 11/29/17 read, Cleanse wound to right and left gluteal folds with wound cleanser and pat dry with 4 x 4. Apply hydrogel gauze to wound bed, cover with foam dressing and secure with tape. Change dressing daily and PRN. -According to 11/29/17 documentation by the wound doctor, there was no change (to the sacral wound) since the 11/22/17 visit. Subcutaneous tissue debridement performed by surgical excision. The postoperative wound measurement was 18 cm x 14 cm (252 sq. cm). New dressing included Calcium Alginate and Santyl. The resident would require weekly debridement as she was experiencing 100% necrotic tissue. The prognosis for sacrum was good. Continue the interventions. -According to 11/29/17 physical therapy documentation, the resident and the certified nurse aides were trained on compensatory strategies, positioning/pressure relieving techniques, positioning maneuvers and use of adaptive equipment specifically, bed rail and gel cushion due to skin breakdown. The resident was apprehensive due to wound care management but able to tolerate AROM (Active range of motion) to left lower extremity. The resident agreed to compliance to changing positions when bed rail is affected. -According to 12/4/17 nurse note documentation, wound care was provided to the coccyx area. Foul odor present, coming from blackened tissue/slough on wound bed surface. Edges are bright pink, some bleeding spots. The area is difficult to maintain cleanliness due to frequent fecal contamination due to the patient being incontinent. No drainage present. No pain noted during a dressing change, dressing changed per orders. Will continue to monitor. -According to the daily skilled documentation on 12/5/17, the resident refused meals, not actively participating in therapy. -According to 12/5/17 SBAR, the resident had an abnormal laboratory. The B/P (blood pressure) was 85/48, pulse was 97, respiration was 19, temperature was 97.4 F and oxygen saturation was 96% RA (room air). The RN assessment summary was [MEDICAL CONDITION], abnormal labs, critically high WBC (white blood cells) 23.45 and critically low RBC (red blood cells) 2.14. The resident was transferred to the acute hospital and the family was notified. 2. Failures in facility response There was no documentation the PCP was notified of signs of possible infection on 12/4/17 or the resident's continued refusal to engage in meals and therapy. E. Hospital (Wound) records review 1. According to the hospital admission record (for wound assessment ) completed on 12/6/17, the record revealed the resident was admitted with multiple pressure injuries that had not been identified at the facility. The record read the resident's pressure injuries included: -Unstageable pressure injury to sacrum wound bed presents with 100% adherent soft black eschar, redness to wound edges, a small amount of yellow drainage and periwound [DIAGNOSES REDACTED] noted. The wound has a foul odor. -Unstageable pressure injuries to bilateral ischial tuberosities - Left wound bed with 100% adherent yellow slough and right with yellow slough and black eschar. Yellow drainage, periwound [DIAGNOSES REDACTED], and foul odor. Wound care implemented as follows: cleanse with NS (Normal Saline) pat dry apply saline-moistened gauze to wound beds, cover with ABD pads secured with [MEDICATION NAME] tape. Wound doctor consulted, pending debridement. -Unstageable pressure injury to left lateral malleolus wound bed presents with 100% black eschar, no drainage and periwound with [DIAGNOSES REDACTED]. -Left heel presents with two deep tissue pressure injuries to the medial and lateral aspect, lateral with blister intact, medial violet in color. DTPI (Deep Tissue Pressure Injury) to left medial malleolus wound bed is deep violet with blood-filled blisters intact. -Bilateral Achilles with unstageable pressure injuries; wound beds have 100% black eschar, no drainage, and periwound free of [DIAGNOSES REDACTED]. Wound care implemented to all; cleanse with soap and water, paint with [MEDICATION NAME]; PRAFO (Pressure relief ankle foot Orthosis) boots at all times when in bed as tolerated by the patient. -Bilateral upper medial thighs with moisture associated [MEDICAL CONDITION] that has deep tissue and unstageable pressure injuries presents, injuries appear to be from the catheter. Wound care implemented as follows; cleanse with Sage barrier wipes and apply ABD pads to both thighs for added protection. -Right lateral knee unstageable pressure injury 100% adherent yellow slough, no drainage, periwound [DIAGNOSES REDACTED] noted. Interventions included, will paint with [MEDICATION NAME] at this time pending further interventions from surgical team. Wound images capture refer to images and worklist documentation for measurements and characteristics. 2. According to the 12/6/17 hospital wound records, the wounds measurement were: #1 & #2 - Sacrum measured 15.0 cm X 7.4 cm and 14.7 cm x 7.2 cm. #3 - Left medial malleolus measured 3.9 cm x 2.0 cm. #4 - Left foot, heel; medial measured 3.4 cm x 1.8 cm and 1.5 cm x 0.8 cm. #5 - Left ankle, posterior measured 0.8 cm x 0.4 cm. #6 - Left lateral malleolus measured 2.8 cm x 1.9 cm. #7 - Lower right leg, lateral measured 2.8 cm x 1.7 cm. #8 - Right ankle, posterior measured 1.2 cm x 0.7 cm. #9 - Right ischial tuberosity measured 4.4 cm x 3.0 cm. #10 - Left ischial tuberosity measured 9.2 cm x 5.9 cm. #11 - Right knee, lateral measured 1.7 cm x 1.5 cm. #12 - Left foot, heel: lateral measured 4.6 cm x 1.2 cm. #13 & #14 - Right thigh, medial; both upper thighs measured 4.0 cm x 1.1 cm and 8.2 cm x 3.5 cm. III. Staff Interviews A. The assistant director of nursing (ADON) was interviewed on 2/8/18 at 2:55 p.m. She said the resident was admitted on [DATE] with stage 1 wound to her sacrum. She said the wound was dark and the skin intact. She said about a day or two later the wound opened up and the shearing appeared. - She said the resident refused to move from one place to another place. She said the resident received air mattress on 11/15/17, after the wound was getting bigger and migrated to the sacral-coccyx. She said after that, she followed the resident for wound care. She said the resident was included on the weekly wound round with wound doctor. She said she saw resident once a week and the floor nurse continue with daily dressing and PRN. - She said another issue with the wound was the position of the wound made it difficult to get the stool out of the wound itself. She said the wound had not opened up enough. She said the wound had a necrotic tissue, was foul smelling and resident went out to the hospital after laboratory results were abnormal. She said the wound progressed quickly. She said the resident was in the building less than a month. B. The ADON was interviewed again on 2/12/18 at 12:44 p.m., in the presence of the interim director of nursing (IDON) and the district director clinical service (DDCS) in the IDON's office with a timeline of what happened from 11/8/17 until the resident was discharged to the acute hospital. - She said on admission, the resident presented with stage 2 pressure injury. She said did not check on the resident until the following week. She said she relied on the floor nurse skin assessment. The ADON said the resident was added to the wound care rounds for an observation 11/15/17. - She said on 11/15/17, the wound was a stage 2 and macerated. She said the wound was the same, according to the admitting nurse. She said an order was written for the daily and PRN dressing changes to the wound. - She said some of the nurses were documenting their observations of the wound during the dressing changes and they were supposed to document if there were any changes to the wound and report to her immediately. - She said on 11/16/17, one of the certified nurse aides (CNAs) reported to her the wound was getting bigger in size and there was a slight odor. She said she cleaned the wound and the odor went away. She said she filled out the SBAR and received a new order for the wound. She said would follow-up that is checking on the wound more often only if the nurses had informed her the wound was getting worse. -She said on 11/22/17, during wound care rounds with the wound doctor, it was discovered the wound was increasing in size and there was more odor. She said on 11/24/17, an intervention to reposition the resident was included in the treatment when one of the nurses informed her about the wound size. She confirmed she did not inform the resident PCP about the changes in wound size. She also confirmed she did not inform the RD to let her know about the changes in the wound. - She said on the 11/29/17, the wound had increased in size and another opened area emerged; she said at this point, she called the resident's PCP and received an order for [REDACTED]. She said did not follow up immediately; the laboratory results were not faxed to the resident's PCP until 12/5/17. - She said the resident was not discussed in the weekly at risk for pressure injury meeting and was not seen by the RN after 11/14/17 when the RD completed her assessment. She said the resident was sent out to the hospital after the laboratory results were faxed. She said the laboratory results were abnormal. - At 1:40 p.m., she said, she should have assessed the wound on admission and documented the assessment. She said she should have put an intervention in place. The ADON said she should have continue to monitor the wound to prevent worsening. C. The IDON was interviewed on 2/12/18 at 1:48 p.m. She said after reviewing the wounds before and after pictures of the resident's wound, the initial assessment was not accurate. She said she was not sure if the wound could have been prevented due to the resident comorbidities, but she said she would have looked into the laboratory results and put interventions in place. She said the expectation would be that the resident's PCP and wound doctors would come together for a quick meeting and, discuss the situation with the family and the resident. - She said the facility has since; (MONTH) 18, (YEAR) employed a wound nurse, since the situation occurred, who works daily to take care of all the wounds in the facility with the wound doctor. She said the wound nurse performs the skin assessment with the admission nurse. She said in addition, the wound nurse makes rounds with the wound doctor weekly, documents and brings the wound logs to the at-risk weekly pressure injury meeting. She said the interdisciplinary team (IDT) discusses resident with the RD. D. The DDCS was interviewed on 2/12/18 at 1:54 p.m. She said the facility's process in addressing wounds was not followed. She said the wound care nurse, at the time, should have notified the resident's PCP, family and the resident regarding the changes in the wound. She said the wound nurse should have assigned a nurse to be in charge, to look at what interventions to have in place and who was responsible for making sure the interventions were followed. She said the facility has put in place clinical wound rounds to ensure reporting of changes in the resident conditions.

Based on record review, and resident and staff interviews, the facility failed to ensure one of five sampled residents (#4) received all proper behavioral management to prevent abusive behaviors toward other residents, which led to the injury of another facility resident. The facility failures contributed to resident #4 seriously injuring resident #3, who required immediate medical attention. The findings included: A. Resident Status: Closed record review revealed resident #4, age 55, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was noted on the hospital discharge summary as standing 6 foot 5 inches. The resident was also noted on his five-day admission MDS (minimum data set) as having a BIMS score of 3/15, indicating severe cognitive deficits, with numerous documented notes also indicating the resident had significant and ongoing confusion. 1. First Behavior with Injury: A Resident Transfer Form was completed on 4/22/14 for resident #4. The reason for the transfer was documented as "sudden aggressive behavior - punched other resident." Resident was noted to have a right eyebrow laceration and cheek bruise. A Change of Condition form was completed on 4/22/14 due to "residents striking at each other." This form noted that resident #4 was going to be sent to the hospital for a "psych eval." 2. Second Behavior with Injury: A Resident Transfer Form was completed on 9/9/14 for resident #4. The reason for the transfer was documented as "beat another resident in face and head with a cane." Resident #4's usual mental status was noted as "alert, disoriented, but can follow simple instructions." The resident's usual functional status was noted as "ambulates independently." This form also documented that the facility was "not accepting him back." The victim of this incident was resident #3. The victim assaulted by resident #4 on 9/9/14 was resident #3, an [AGE] year-old man. The hospital discharge summary on 9/10/14 for resident #3 noted his injuries as: "The gentleman (who) was admitted has been assaulted at a nursing facility by a resident. Multiple facial traumas and contusions. Lacerations of the scalp and face with swelling, soft tissue swelling about the right eye that is about swollen shut." -An interview (below) with the Director of Nursing indicated that a nurse had not properly informed management that the resident had been attacking the staff. Because of this, the facility had changed the resident's supervision from one-on-one (1:1) to 15-minute checks. Yet, nursing notes (below) continuously indicated numerous attacks on staff and residents. If there had been proper monitoring of resident records, the behaviors of the resident would have been apparent, and closer supervision and protection of other residents could have been provided. B. Failures in facility response to resident #4's abusive behaviors 1. Failure to follow physician orders: -A physician order [REDACTED]. This was developed after the incident that occurred on this date, which resulted in injuries. -A physician order [REDACTED]." This order was made after the resident to resident abuse with injuries. -A physician order [REDACTED]. The physician wrote an order (above) to have the resident sent to the hospital after the first resident to resident incident on 4/22/14 that resulted in injuries, and have a psychological evaluation done. This order was not fulfilled, and there was no evidence of follow-up from the physician or the facility. 2. Informed consent failures A Psychoactive Medication Consent form was created on 5/28/14 for the use of Ativan and Seroquel. The resident signed this document on 5/28/14 and indicated approval of the medications. A nurse signed this document, yet the physician never properly signed the form. The resident was also noted on his five-day MDS as having a BIMS score of 3/15 indicating severe cognitive impairment, yet signed to approve receiving antipsychotic medication. -The resident was documented as approving the use of Seroquel and Ativan on the consent form, yet the resident was consistently noted as being confused and incapable of making such a decision (see MDS and nurses' notes). The physician also did not sign this consent form. 3. Failure to adequately respond to documented behaviors a. Social Progress Notes: -3/31/14, "He does wander the facility and does go into other residents' rooms; but is easily redirected." -4/9/14, "Has had increased wandering so we moved him to another hall with less residents and that is more quiet." -4/23/14, "He had problems with that hall, he got confused and he kept going into other residents' rooms. On 4/21/14 he was in another resident's room and another resident yelled at him to get out of that room and he punched the other gentleman. They were separated and evaluated. He then punched another resident, took the other resident's cane and was hitting him. The other resident took his cane back and hit him in the head ... We sent him to the hospital to be evaluated for his aggressive behavior and to get his head looked at." -4/28/14, "He is on a one to one with staff monitoring him. He has no recollection of hitting other residents." -6/25/14, "Had another resident to resident on 6/18/14. The other resident touched him on the shoulder and (resident) hit him on the hand. No injuries were reported." -9/11/14, "On 9/9/14 (resident) went into a resident's room. The other resident told him to leave then he turned around. (The victim) stated 'that was when he hit me in the back of my head. I turned around and he had my cane and just started hitting me. I tried to protect my eyes with my hands. I had to get away from him so I pushed him with my scooter into the wall and left to get someone.' (Resident #4) and the other resident (resident #3) were separated. Police and AMR (ambulance) was notified. Police took (victim's) statement and pictures. " b. physician progress notes [REDACTED]. A physician progress notes [REDACTED]." The physician did not document why the physician order [REDACTED]. No further documentation as to the necessity of this order was noted in the resident's chart. The facility physician met and documented progress notes for the resident on 3/26/14, 4/24/14, and 7/18/14. The resident was seen by his oncology physician on all other dates. The oncologist documented only concerns related to the resident's [DIAGNOSES REDACTED] diagnosis, and not resident behavioral needs. Ongoing resident behaviors were not documented under the physician progress notes [REDACTED]. 4. Care Plan failures -A Care Conference Attendance Record noted the facility had a meeting to discuss the resident's needs on 3/28/14, after admission. Only two individuals were noted to have attended: the MDS coordinator and a dietary staff member. No one else was noted as attending. -A Care Conference Attendance Record noted the facility had a meeting to discuss the resident's plan of care needs on 7/28/14. Only the social service staff member and two family members were noted as attending. -On 5/22/14 a care plan was developed for Exhibition of Behavioral Symptoms as evidenced by: verbal abuse, physical abuse, socially inappropriate/disruptive, resists care, related to a [DIAGNOSES REDACTED]. The approaches included in pertinent part: check for discomfort, pain; modify environment, situations, and/or treatment to minimize external stressors; redirect as needed; be alert for triggers of potential evidence of pending behavioral episodes; notify MD as needed; administer medications as ordered, observe for effectiveness and side effects; 1:1 and 15 minutes checks (added 8/20/14). On 8/1/14 a care plan was developed for the administration of psychoactive medications Ativan and Seroquel, due to traumatic brain injury. The mood and behavior indicators were noted as agitation, aggression, physically abusive, verbally abusive, pacing, and resistive with care. Approaches noted were periodic reviews of medications by interdisciplinary team to determine potential dose reductions; observe for potential side effects of medication administered; observe for medication effectiveness and document via flow checklists; and psych services as ordered. The resident's care plan was not updated regarding his aggressive behaviors from 4/22/14 until 5/22/14, one month later. The approaches noted 1:1, yet also indicated 15 minute checks. If the resident was receiving ongoing 1:1, 15 minute checks would not have been necessary. -The care plan was not revised and updated to include any actual observed aggressive behaviors during the resident's stay (see nurses' notes below). -The care plan to address the resident's psychoactive medication use was not developed until 8/1/14, yet the resident was on Ativan and Seroquel for numerous months prior (see below). -The resident was noted as having numerous aggressive behaviors against staff and other residents, yet this was not noted as being discussed or evaluated during care plan meetings. 5. Failure to adequately document and assess medication effectiveness and behaviors a. Medication Evaluations: -A Psychoactive Medication Quarterly Evaluation was completed on 8/1/14. This form indicated that the resident was on Ativan 0.5mg as needed for agitation, striking out, yelling out, and pacing. Ineffective interventions noted were 1:1, redirection, reassurance, activities, and calm environment. Under the evaluation of the use of this medication and its benefit, whether the medication was effective or not, nothing was noted. -A Psychoactive Medication Quarterly Evaluation was completed on 8/1/14 for the use of Seroquel 25mg daily. The resident was noted to have aggression, hitting others, throwing objects, and being combative with care. Interventions noted as ineffective included 1:1, redirection, reassurance, and calm environment. Under the evaluation of the use of this medication and its benefit, whether the medication was effective or not, nothing was noted. b. Medication Administration and Behavioral Monitoring: The documentation of the resident's use of Ativan and Seroquel on the MARS did not properly indicate dates of use. -Many of the behavioral monitoring forms were missing, not completed, or did not correlate to a behavior requiring their use. The behavioral monitoring forms indicated on many instances that the use of Ativan and Seroquel were noted as ineffective, yet no documentation revealed that this was discussed with the physician for evaluation. -Although the nursing daily skilled sheets were to be completed daily, per staff interview, there were numerous weeks when no documentation of the resident was written down. These notes could not be found by the medical record department. Specifically: April 2014 -The resident received Ativan only on 4/23/14 and 4/29/14. On the back of this form it noted the resident received Ativan on 4/23/14 and 4/30/14. -The resident was started on Ativan on 4/23/14, yet no behavioral monitoring form was found for this month. May 2014 -The resident received Ativan 15 times during the month of May according to the medication administration record (MAR). However, on the back of the form where effectiveness was noted, the resident was only documented as having received the medication 12 times. -The behavioral monitoring form for Seroquel was started on 5/27/14, although the resident began receiving the medication on 5/25/14. Seven behaviors were noted, and the resident was documented as having unchanged behaviors after the administration of the Seroquel for five of the incidents. -The behavioral monitoring form for Ativan revealed the resident had 17 incidents for the month. Of these behaviors, 10 incidents revealed no change in outcome after the administration of the Ativan. June 2014 -The resident was noted on the MAR as receiving Ativan on 19 days for the month of June. On the back of the MAR where effectiveness was noted, the resident was noted as having received Ativan on 10 days. -The behavioral monitoring form for Seroquel noted the resident had 21 incidents. Of these, six incidents indicated that there was no improvement in behaviors after the use of Seroquel. -The behavioral monitoring form for Ativan noted the resident had 25 episodes of inappropriate behaviors. The form indicated the Ativan was ineffective for three of the incidents. July 2014 -The resident was noted on the MAR as receiving Ativan on six occasions. On the back of the form where effectiveness was noted, the resident was documented as having received Ativan only twice. -The behavioral monitoring form for Ativan indicated the resident had only two behavioral episodes. -The July behavioral monitoring form for the resident's use of Seroquel was not found in the resident record. August 2014 -The behavioral monitoring form for the resident's use of Ativan indicated the resident had seven noted behaviors for the month. Two of the incidents noted no change in behavior after receiving the Ativan. -The behavioral monitoring form for the resident's use of Seroquel was not found in the resident record. September 2014 -The MAR for September noted the resident received Ativan on 9/1-9/5/14. However, the documentation for effectiveness revealed the resident received Ativan on 9/1-9/4/14 and then on 9/8/14, and that the medication was effective. -The behavioral monitoring sheet for the resident's use of Ativan indicated the resident had one behavior on 9/3/14. Some dates and shifts were not completed. The dates of 9/1, 9/2, 9/4, 9/5, and 9/8/14 (in correlation to the MAR) did not indicate any observed behaviors requiring the use of Ativan. -The behavioral monitoring form for the resident's use of Seroquel was not found in the resident's record. c. Nurses' Notes (in pertinent part): -4/21/14, resident punched another resident in face with closed fist and injured his face. -4/22/14, hitting at staff. Cursing loudly. -4/22/14, resident to resident altercation. Resident and another resident hitting each other with fists. Did not see what happened before this resident then picked up the other resident's cane and hit him over the head. Both residents separated. MD here. States to send resident out for psych eval. -4/22/14, 10:10 a.m., AMR here for transfer -4/22/14, 7:00 p.m., resident moving about in wheelchair -4/22/14, 7:15 p.m., resident interviewed upon returning to facility from the ER at approximately 5:30 p.m. Resident denies any recall of either altercation. -5/5/14, resident punched CNA (certified nursing assistant) in the face. CNA has immediate red area and was in tears. -5/8/14, trying to hit CNA -5/18/14, medicated times one today with Ativan for increased agitation/combative with staff -5/20/14, hurrying down E hall self-propelling wheelchair, tried to go into last room on the left, said he thought he was on his hallway, redirected easily and appropriately -5/22/14, combative behavior (verbal) to staff -5/30/14, refused vital signs, hitting CNA, no redness, bruising related to head-butting CNA this afternoon -6/17/14, CNA was assisting resident with ADLs and toileting - CNA had bent down to pick up article off the floor - resident swung and hit staff member on right side of face and cheek. Resident has been agitated all day with staff. -6/18/14, resident hit another resident when resident approached him and put his hand on his shoulder and said 'how are you doing.' Resident hit other resident on right hand, no injuries occurred. Resident was taken to room where there was less stimulation and laid down. -6/19/14, resident combative with care and swings at CNA when anyone touches him -No nurse documentation from 6/21/14 through 7/16/14. -No nurse documentation from 7/18/14 through 8/11/14. -8/21/14, resident hit both staff members in the face when trying to be redirected out of other resident's room. Resident becomes very angry when being told when he cannot do something or if you invade his space. -9/9/14, Change in Condition form: assaulted another resident today. (Resident) was in another resident's room. -A noted interview with resident #4 after the incident on 9/9/14 prior to his discharge revealed, "I just scrapped with a man back there because he kept yelling and yelling that I was in his place and he wouldn't stop so I punched and punched him. No he didn't hit me. I didn't get hurt." (See hospital discharge summary above for details on injuries suffered by resident #3, including multiple facial traumas and contusions, lacerations of scalp and face, with swelling.) C. Staff and Resident Interviews: An interview with a licensed practical nurse (LPN #1) on 10/14/14 at 11:14 a.m. revealed the completed and most accurate care plans for each resident were located in the residents' charts, and not elsewhere. An interview was conducted with resident #3, the victim of the 9/9/14 altercation on 10/14/14 at 1:50 p.m. The resident stated that he had returned to his room after getting some popcorn, to find resident #4 in his room going through his belongings. Resident #3 stated he told the man to leave his room, but the individual picked up his cane and hit him over the head with it three times. The resident stated that he "saw stars," and had a lot of blood coming from his head. The victim stated that the assailant also stepped or kicked his right shin with his very big feet. The resident said that he was sent to the emergency room and was stitched up in the intensive care unit. The resident stated that when he returned from the hospital he was informed the assailant, resident #4, was taken away by the police. The victim stated he had not been attacked by this resident before, but "had heard that he may have been aggressive with other people" before him. Resident #3 stated that his right leg is still "giving him fits" and the doctors were not sure what was wrong with it yet. An interview with a registered nurse (RN #1) on 10/15/14 at 10:00 a.m. confirmed that nursing daily skilled sheets should be "done daily" and should all be located with the resident's record. An interview with the Director of Nursing (DON) on 10/24/14 at 10:00 a.m. revealed the facility staff charted in resident records "by exception." The DON stated that resident #4 had "been misbehaving for awhile." The DON stated that the nurse on duty had documented that the resident had struck out at a staff member, but had failed to report it. The DON stated that because the nurse had not informed the staff that the resident had hit a staff member, they had changed the resident's supervision from one on one (1:1) to 15 minute checks instead. The nurse had been in-serviced to ensure proper reporting. The DON stated that the resident had been receiving cancer treatments and for a few months had been behaving and staying his room. She stated that this was why there probably "wasn't very much documentation." The DON agreed that due to the lack of charting it was not possible to determine if resident #4 had been behaving just prior to the attack on resident #3. An interview was conducted with Medical Records on 10/24/2014 at 11:21 a.m. The staff member confirmed that many staff members were new, and that he had just begun assessing the medical records at the facility. The staff member confirmed that there was "a bunch of stuff missing." At 1:00 p.m. the staff member stated that all the medical records for resident #4 had been provided and no other documentation could be found. An interview with LPN #1 was conducted on 10/24/14 at 1:04 p.m. regarding the behavioral monitoring forms for resident #4. The LPN confirmed that there should be a behavioral monitoring form for all benzodiazepine and antipsychotic drugs being given. The LPN stated that from what she understood, "They have to show why each drug is being given, and what those behaviors are. " An interview with the Social Service Director (SSD) on 10/24/14 at 1:45 p.m. was conducted regarding the behaviors of resident #4. The SSD stated that the resident was sent to the hospital on [DATE] to have a psychological evaluation done after a resident to resident abuse incident. The SSD confirmed that the hospital only provided a medical check on the resident's injury, and then sent him back to the facility. The SSD revealed that they have had problems with the hospital not doing proper psychological assessments when requested. The SSD said that the facility medical director does not always get back to the facility timely about the staff's resident concerns. She stated that this was probably why the physician did not prescribe the resident an antipsychotic medication until another month after the resident to resident abuse on 4/22/14. -The SSD was not sure why the physician had not done more progress notes for the resident, considering the aggressive behaviors that had been ongoing. The SSD also revealed that they had talked to the physician about "being more proactive." -The SSD said that resident #4 was sent to the hospital again for a psychological evaluation after injuring resident #3 on 9/9/14. She stated that the hospital tried to return the resident to the facility again after a few hours, most likely without doing another psychological evaluation. The SSD said that they told the hospital they would not take him back. She stated that the resident was apparently put in jail for a few days and eventually went home with family. She said that she had attempted to find different placement for resident #4, but had no success. The SSD confirmed that behavioral monitoring sheets for the resident should have been completed properly every month for both Ativan and Seroquel.

Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards and that one out of three sample residents (#1) received adequate supervision and assistive devices to prevent accidents. Specifically, the facility failed to provide sufficient assistance while the resident was being bathed. The resident fell out of the shower chair and fractured his tibia. The findings include: Resident #1, a [AGE] year old male, was admitted to the facility on [DATE]. According to his face sheet, his [DIAGNOSES REDACTED]. According to the most recent Minimum Data Set (MDS) assessment, dated 10/22/13, the resident was a two plus person physical assist for bathing support and totally dependent. The MDS indicated the resident was not able to participate in a brief interview for mental status (BIMS) due to cognitive impairment. 1. Resident Status The resident's care plan revealed the facility had identified the resident was dependent on staff and at risk for injuries due to multiple factors, including seizures, weakness, poor balance. Care plan review revealed: (1) A care plan initiated on 8/27/12 and last updated on 10/17/13 titled, 'Activities of daily living' (ADLs) which read the resident required extensive to total care utilizing one to two staff members and was totally dependent on staff for ADLs. Approaches included to gather and provide needed supplies, allow individual adequate time to complete tasks, encourage active participation in tasks, praise all efforts, provide cueing with tasks as needed, refer to therapy services as indicated, individual caregiver education as needed, and ensure effective pain management prior to ADL activities. (2) A care plan initiated on 8/27/12, stated the resident was at risk for injury related to seizure disorder and interventions included: Administer medications as ordered by MD (physician), observe for any seizure activity, keep room free from clutter, keep bed in lowest position as resident allows, draw labs as ordered and communicate results to MD, and notify MD of any seizure activity. (3) A care plan for transfers, initiated on 8/7/13 and last updated 10/17/13, indicated the resident had a potential for injury, impaired ability to self transfer related to: weakness, predisposing disease CVA (cerebro-vascular accident) and right hemiparesis, required use of mechanical lift (2 person assist required at all times) and sling to/from toilet, chair and bed. Approaches included to place call light within reach, provide mechanical lift for full body lift, to/from chair/bed, provide appropriate sling, interdisciplinary team (IDT) referral to therapy physical/occupational/restorative/speech therapy as needed, educate resident to mechanical lift, educate family to mechanical lift, use calm, patient approach with using mechanical lift. (4) A care plan for falls, initiated on 8/27/12 and last updated 10/30/13, revealed the resident was at risk for falls due to new admission, balance problem/standing, and narcotics in use (CVA, fracture and seizure was not checked). Approaches included to encourage resident to ask for assist, ensure resident has proper footwear, therapy as needed, orient resident to room/environment, provide assistive devices wheelchair as indicated and accepted, place call light within reach, observe for potential patterns of falls to identify possible causes, place frequently used items within reach, observe for potential medication related causes. Therapy notes revealed: -A 1/1/13 physical therapy discharge note read the resident was able to sit at the edge of the bed unsupported up to one minute. -A 6/10/13 occupational therapy plan of treatment noted the resident as totally dependent. 2. Fall during shower on 10/30/13 Record review of an incident/accident report stated the resident had a fall with injury on 10/30/13 at 10:15 a.m. The resident was in a C hall shower room while taking a shower with a certified nurse aide (CNA). Bowel movement (BM) was noted on the floor. The CNA bent down to clean up the BM. The resident coughed hard and jerked forward and fell to the floor from the shower chair. Initially the report stated a strap was used as a restraint; however, this was crossed out and it was noted the resident did not have a restraint but had a safety strap on. It stated the equipment involved was a shower chair. The licensed practical nurse (LPN) notified the nurse practitioner at 10:45 a.m. and the son at 10:47 a.m. The report read the treatment provided was to clean forehead and apply steristrips to forehead at 10:20 a.m. The resident was then sent to a local emergency room via emergency medical transport. A post-fall review, dated 10/30/13 at 10:15 a.m., documented a witnessed fall occurred when a CNA was assisting resident#1 with a shower in the C hall shower room. The CNA stated bowel movement was noted on the floor of the shower room. The CNA leaned down to clean the bowel movement off the floor when the resident coughed and jerked forward; the resident fell to the floor from the shower chair face first. The shower chair was noted to have a safety strap seatbelt tied to the shower chair when one side of the strap came undone. The review further stated the shower chair had one prong broken and the CNA was not able to fully fasten the seat belt. The shower chair was removed and placed outside the facility. A diagnostic imaging from the local hospital, dated 10/31/13, revealed a fracture of the tibia. Additional hospital progress notes, dated 10/30/13, revealed the resident also had a laceration of the head requiring staples. The resident returned to the facility 11/1/13. 3. Failure to ensure the resident's safety in the shower 10/30/13 and thereafter. a. Interviews Interviews revealed the facility failed to ensure the resident received the level of assistance with bathing identified on the MDS (see above) which indicated the resident required two plus person physical assist for bathing support. Moreover, interviews revealed he had not been assessed after the fall for safety needs in the shower. The CNA assisting the resident at the time of the fall was interviewed on 11/25/13 at 1:29 p.m. -The CNA indicated that his account of the shower was as noted above; however, he stated the belt on the shower chair came undone at the buckle, not at the attachment point to the chair. He stated the belt was only on the chair as a safety precaution but it would not have prevented the resident from falling over when he coughed. He added that if the seatbelt had stayed buckled, he believed the entire chair would have gone down with the resident and increased his injuries. -The CNA stated that he always showered the resident by himself and the resident only required assistance of two staff when being put into the Hoyer lift. He said he used the facility's automated system to find the information indicating how much assistance the resident needed. However, when asked, he was unable to pull up the information in the automated system and he was not able to verify what assistance the resident needed during bathing. -The CNA stated they have an alternate system with a gurney for bathing people who cannot sit in the shower chair but they did not use that system with resident #1. -The CNA said was not aware that the resident had a history of [REDACTED]. The nursing home administrator (NHA) was interviewed on 11/12/13. The NHA said the facility's response to the resident fall was to remove the equipment (the shower chair with a safety belt tied to it) from facility use. Another CNA who was a bath aide at the time of the resident's fall was interviewed on 11/25/13 at 1:50 p.m. She said she had been a bath aide for over two years. She stated that she hardly ever used a care plan to find out residents' assistance needs; she said she counted on the other CNAs and the nurse to update her on resident needs. She stated that she used whichever chair was available in the facility to bathe residents and that resident #1 only required two people to assist him getting in the shower chair. She could not recall having received any training on transfers or on determining a resident's level of assistance needs in the recent past. The therapy director (TD) was interviewed on 11/25/13 at 4:21 p.m. She stated that after looking at resident #1's therapy notes, she determined the resident had never been evaluated for seatbelt use during a shower, that he lacked trunk strength, and that with his lack of trunk strength, she would not have recommended a seat belt for safety. She stated that since the resident's fall with the seat belt 10/30/13, they would have to reevaluate the resident; however, she had not received a request or order to treat or evaluate him as of 11/25/13, and she confirmed he had not been evaluated since his fall. She added that they had a shower gurney with straps for residents who had no trunk control. The Director of Nurses (DON) was interviewed on 11/25/13 at 4:36 p.m. -She said it was her understanding the resident was only a two person transfer, then a one person assist in the shower. She stated the facility did not have any residents who required two people to assist during the shower. She stated she understood the resident had some trunk control. (But see therapy interview above indicating otherwise.) -She stated the resident was not evaluated after his fall because her understanding of the incident was that the seat belt tie had come undone from the chair; however, after talking to the CNA earlier in the day, she learned the seatbelt unfastened at the buckle. She stated that they would evaluate the resident for safety during showers and until the resident was evaluated, the resident could use the shower gurney. She added that they would evaluate all residents with poor trunk control and determine if they were safe to shower in a regular shower chair. b. Record Review Review of a transfer evaluation form, dated 11/1/13 and completed by a LPN included no total score, but when tallied, resulted in a score of 19. The evaluation indicated category 4 - caregiver performs 100% of the task and equipment was a mechanical lift. On the back side, the LPN noted the resident was high risk with a score of 16. See resident care plan above; after the resident's fall, the care plan was updated on 10/30/13 to read, "Purchased new shower chair." However, the care plan was not updated to alert staff of the resident's poor trunk strength or to clarify his level of assistance needs. No new safety interventions were added. Observation: Observation of the resident on 11/12/13 at 3:45 p.m., revealed a completely dependent man in his bed, who could not answer any questions and was not able to shake head or nod.