Every finding on record at Langton Shores

Based on interview and document review the facility failed to ensure 1 of 5 residents (R1) was offered, educated and/or provided the pneumococcal vaccination series as recommended by the Centers for Disease Control (CDC), who were reviewed for immunizations. Findings include: A CDC Adult Immunization Schedule by age topic, dated 11/21/2024, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was [AGE] years old, admitted on [DATE], moderately cognitively impaired and has the following diagnoses: anemia (low red blood cells and hemoglobin levels in the blood), hypertension (high blood pressure), hyperlipidemia (high levels of fat in the blood), Alzheimer's disease, dementia, and anxiety. R1's Order summary report dated 11/21/24, indicated on 2/13/24 the provider gave the following two orders: 1) May receive pneumococcal vaccinations if not already received. 2) May receive pneumovax if not already received. R1's Minnesota Immunization Information Connection (MIIC) vaccination record dated 11/19/24, indicated R1 received the pneumococcal polysaccharide PPSV23 on 11/1/1994. In accordance with the CDC recommendations R1 was eligible for a dose any of the following pneumococcal conjugate vaccines: PCV15, PCV20, or PCV21. R1's Point Click Care Immunizations form dated 11/21/24, indicated R1's had refused the vaccination, however there was no evidence of this refusal in R1's medical record. R1's Pneumococcal vaccinations consent form dated 2/14/24, indicated R1's daughter had asked the facility to check R1's records to verify if R1 had received the vaccination or not and did not refuse it. R1's medical record lacked any evidence of follow up regarding the consent form, communication with the family, verification of that data, or any documentation it was administered. On 11/21/24 at 08:59 a.m., the Infection preventionist/registered nurse (RN)-A, stated upon admission the facility would offer influenza, COVID-19, and pneumococcal vaccinations to eligible residents. The vaccination consent order would be sent to the provider to be signed, and then administered after receiving order and vaccination, then documented in the chart. RN-A confirmed R1's consent stated the family member wanted R1's record reviewed, and RN-A confirmed R1's record was never verified, nor the family followed up with. On 11/21/24 at 11:09 a.m., the director of nursing (DON) expected if a resident was eligible for any of the offered vaccinations, those would be provided as soon as the facility was able to. The DON confirmed no follow up was conducted regarding R1. The DON stated there had been a different DON and infection preventionist at the time, and the vaccination had been missed. The DON stated the importance of providing vaccinations to the residents to keep infection rates down, and to prevent the spread of infection within the resident population. On 11/21/24 at 1:11 p.m., R1's family member confirmed the facility had not followed-up regarding vaccinations until today (11/21/24), when they had called to offer it. R1's family member stated they would normally prefer to keep R1's vaccinations up to date. On 11/21/24 at 1:17 p.m., RN-A stated if a resident were to refuse a vaccination at the time of admission, they would go back and offer them again upon discharge, however, RN-A had not been offering them again for long term residents, such as R1. The Pneumococcal Vaccination Policy last modified July of 2023, indicated all residents who have never received a pneumococcal conjugate vaccine will be offered the vaccine upon admission and as needed in accordance with current CDC recommendations.

Based on observation, interview, and document review the facility failed to ensure enhanced barrier precautions (EBP)-(an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities.) were implemented for management of a surgical wound to reduce the risk of infection to others for 1 of 1 resident (R2) reviewed for transfers. Findings include: R2's face sheet identified diagnoses of age-related osteoporosis with current pathological fracture of left lower leg and need of assistance with personal cares. R2's order summary dated 5/14/24, identified R2's incision was located on the left tibia was covered with dry dressings including xeroform/Adaptec, gauze fluffs, ABD, and ACE wrap. Keep dressing in place, clean and dry for two weeks. Change dressing only PRN (as needed) saturation greater than 60% every day shift. Incisions evaluated in clinic in 2-3 weeks and remove any staples or sutures as indicated. R2's Nurse Practioner (NP) visit note dated 5/15/24, identified R2 was hospitalized for Trauma Surgery with a closed fracture of left tibia and fibula due to a fall, R2 proceeded with an insertion of intramedullary rod left tibia and removal of hardware left tibia on 5/11/2024 and admitted to the facility for a short term stay on 5/14/24. R2's care plan dated 5/15/24, identified a focus, I require enhanced barrier precautions due to a surgical incision. Intervention indicated to follow enhanced barrier precautions in addition to standard precautions: wear gown and gloves during high-contact resident care activities. An additional focus dated 5/14/24 identified, I have limited physical mobility. Intervention included transfers, I require assist of two with a full lift and medium universal sling. During an observation on 5/22/24 at 5:08 p.m., upon entrance to R2's room an orange paper sign was hung on the wall to the right side of R2's door. Two red colored, STOP signs noted at the top on either side. Signage read: ENHANCED BARRIER PRECAUTIONS EVERYONE MUST: clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following activities. Dressing, Bathing/Showering, Transferring, changing linens, Providing Hygiene, Changing briefs or assisting with toileting. Device care or use: central line, urinary catheter, feeding tube, tracheostomy. Wound care: any skin opening requiring a dressing. Do not wear the same gown and gloves for the care of more than one person. The sign also had color pictures of hand cleanser, gloves, and gown. Nursing assistant (NA)-A and NA-B walked into R2's room without doing hand hygiene, did not utilize gloves or a gown. NA-A and NA-B transferred R2 from the bed to the recliner using a Hoyer lift. NA-A and NA-B did not perform hand hygiene after the transfer. During an interview on 5/22/24 at 5:16 p.m., NA-A and NA-B indicated an unawareness that EBP was to be used for high contact resident activities including transfers with R2. NA-B stated, I will go ask the nurse if we need to use EBP with R2. NA-B came back and stated, yes, we were supposed to use gown and gloves with the transfer for R2 due to R2 having a surgical wound to her left leg and indicated they should be using hand hygiene before and after cares with each resident and utilize gown and gloves with residents who are on EBP precautions to help prevent the spread of infection. During an interview on 5/22/24 at 5:23 p.m., interim clinical administrator stated, staff should be using EBP's with transfers for R2 due to a surgical wound on her left leg to help prevent the spread of infection. All residents with EBP have a sign clearly posted outside their room and staff should be looking for that and following our policy for EBP to help prevent the spread of infection. Facility policy, enhance Barrier Precautions Policy and Procedure, modified April 2024, identified a Purpose: PHS recognizes that our care center residents are at a higher risk of becoming colonized and infected with multidrug-resistant organisms (MDROs) as the prevalence of MDROs is higher in this care setting. As such, enhanced barrier precautions (EBP) which are a preventative approach to the use of personal protective equipment (PPE) to reduce opportunities of MDRO transmission during high-contact resident care activities will be implemented. Policy: 1. EBP (targeted gowns and gloves) are used in conjunction with standard precautions and will be implemented during high contact resident care activities for residents who: a. are known to be colonized or infected with CDC-targeted MDROs when Contact Precautions do not otherwise apply; and b. when caring for residents with wounds or indwelling medical devices even if the resident is not known to be colonized or infected with a MDRO. 2. EBP will be in place for the duration of a residents stay in the site or until resolution of the wound or discontinuation of the indwelling medical device for residents who are not colonized. 3. EBP is not intended to be a form of isolation and residents are not restricted to their rooms or limited from participation in group activities. 4. EBP should be followed when transferring residents in shared/common shower rooms and when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility. 5. EBP does not need to be followed when transferring residents in the dining or activity rooms where contact is anticipated to be shorter in duration. Definitions: Wounds generally include chronic wounds and longer lasting wounds. This includes pressure injuries, venous stasis and diabetic ulcers, and unhealed surgical wounds, including new ostomies. This does not include short lasting wounds (e.g., skin tears). High-contact resident care activities include dressing, bathing/showering, transferring, providing hygiene, changing briefs, or assisting with toileting, changing linens, and indwelling medical device care or use (e.g., central line, dialysis port, urinary catheter, feeding tube, tracheostomy). Procedure: 1. Identify residents requiring EBP during the admission screening process and as needed. Specifically, review available key documents (e.g., H&P, discharge summary, physician progress notes, laboratory testing results) for documentation of known colonization of CDC-targeted MDROs, wounds or indwelling medical devices. 2. Review new notation of resident colonization of CDC-targeted MDROs, wounds or indwelling medical devices during the IDT process. 3. Upon identification of a resident with a known colonization of a CDC-targeted MDRO, wounds or indwelling medical devices: a. Notify and educate the resident or resident representative, IDT and QST, direct care staff. Provide re-education as needed. i. Resident and resident representative notification and education should be documented in the resident's record. The Enhanced Barrier Precautions Notification Letter may be used, however, should still be documented as given. b. Place an EBP sign on the resident's door. c. Ensure adequate supply of gowns and gloves are available in the resident's room. Note: This does not require an isolation cart to be placed outside the resident's room as this is a preventative measure that should have as little impact as possible on the resident's homelike environment. d. Ensure there is a trash can and hand hygiene supplies placed near the exit of the resident's room to discard the gloves and gowns prior to exiting the room. If the resident has a roommate, ensure staff are discarding the gloves and gowns, and performing hand hygiene before providing care to the second resident. e. Update the resident's care plan and care/team sheets. f. Update the infection control log and document the type of CDC-targeted MDRO the resident is known to be colonized with. 4. When performing high-contact resident care activities staff should: a. Perform hand hygiene. b. Don gloves and a gown c. Complete the high contact activity d. Remove gloves and gown and dispose of in a trash can in the resident's room or if outside of the resident's room (e.g., shower/tub room or therapy gym) in a trash can contained within the area. e. Perform hand hygiene 5. If at any time a resident is requiring EBP they require additional precautions or isolation protocol, the more stringent precautions/protocol will apply.6. The Clinical Administrator, IP, or designee should audit staff adherence to this policy at random intervals using the Enhanced Barrier Precautions Observation Form.

Based on observation, interview and document review the facility failed to ensure the staff posting was updated with changes in staffing. This had the potential to affect all residents, staff and visitors. Findings include: On 3/4/20, at 2:29 p.m. the staff postings and daily assignment schedules 1/19/19 through 12/24/19 were reviewed with the facility scheduler. The review revealed that on 10 of 11 randomly selected dates, including weekdays, holidays, weekends and all shifts, the staff postings were not updated, even when staffing changes occurred on the daily assignment schedules. The scheduler acknowledged she was not updating the changes, which included staff not being replaced after call-in's, staff coming late, leaving early before the end of the shift and working split shifts. Also, the scheduler verified the staff posting was not updated to show the accurate number of staff in each category (registered nurses, licensed practical nurses and nursing assistants) when changes occurred. On 3/4/20, at 2:48 p.m. when the staffing coordinator was asked about the discrepancies, she stated the facility staff have been working on being proactive with updating the daily posted hours, including herself. If the scheduler is absent, the nurse manager should be updating the staff posting and daily assignment schedule. Over the last two weeks, the facility has been putting this process in place. On 3/5/20, at 9:25 a.m. the staff postings and daily assignment schedule for 2/11/20 through 3/1/20 were reviewed with facility scheduler. The review revealed that on 17 of 17 dates for the month of 2/2020 the staff postings were not updated, including 7 days that had staff postings absent. On 3/5/20, at 11:15 a.m. the administrator stated the expectation is that the daily posting will be updated to match the daily assignment schedule. Administrator stated that the facility has been working on this process over the past two weeks. The Nursing Hours Posting Policy, modified 7/2010, indicated the nursing staffing hours will be updated by the staffing personnel to include actual hours worked by direct nursing staff. The nursing staff is defined as registered nurses, licensed practical nurses, registered nursing assistants and trained medication aides.

Based on observation and interview the facility failed to ensue [MEDICATION NAME] injectable solution was dated when opened. this had the potential to affect 5 newly admitted residents (R241, R242, R243, R286, R287) who had received a [MEDICATION NAME] (TB) test upon admission to the facilty. Findings include During a tour of the medication room refrigerator on 4/30/19, at 1:02 p.m., a bottle of TB solution was in the refrigerator opened and undated. The TB solution had approximately five doses missing from the vial. On 4/20/19, at 1:02 p.m. registered nurse (RN)-D stated she was unsure when the vial was opened and verified the vial was not dated when opened. At 2:12 p.m. RN-B stated she was unable to identify when the bottle of TB solution was opened and stated she had called the pharmacy and they were unable to verify the date the TB solution was sent to the facility. R241's Admission Record indicated he admitted to the facility on [DATE]. R241's immunization record undated, indicated he received a TB skin test on 4/29/19. R242's Admission Record indicated he admitted to the facility on [DATE]. R242's immunization record undated, indicated he received a TB skin test on 4/29/19. R243's Admission Record indicated she admitted to the facility on [DATE]. R243's immunization record undated, indicated she received a TB skin test on 4/29/19. R286's Admission Record indicated she admitted to the facility on [DATE]. R286's immunization record undated, indicated she received a TB skin test on 4/28/19. R287's Admission Record indicated he admitted to the facility on [DATE]. R242's immunization record undated, indicated she received a TB skin test on 4/27/19. A facility policy was requested but not provided.

Based on interview and document review, the facility failed to provide clinical justification and identify effective non-pharmacological interventions to implement prior to as needed (PRN) [MEDICAL CONDITION] medication administration for 1 of 2 residents (R25) reviewed for unnecessary medications. Findings include: R25's Admission Record dated 4/310/19, indicated a [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE], indicated a brief interview for mental status (BIMS) score of 5 which indicated severe cognitive impairment. The MDS assessed behaviors that interfered in cares. The psychosocial assessment dated [DATE], did not address dementia and behaviors, and did not provide person centered interventions for behaviors. The record indicated that R25 was admitted from the hospital on [DATE], the admission orders [REDACTED]. The nurse noted resident was given a laxative since no bowel movement in 3 days, and pain medication. A phone order was obtained for [MEDICATION NAME] 12.5 milligrams (mg) by mouth every 8 hours as needed for agitation. The record lacked evidence of target behaviors for the use of [MEDICATION NAME] or target behavior monitoring. The Medication Administration Record [REDACTED]. A Progress Noted dated 4/10/19, indicated the nurse practitioner visited R25 and had a care conference with the family. The assessment noted '[MEDICATION NAME] for agitation at night there was no clinical indication provided for the use of an antipsychotic medication or an assessment of the change in behaviors for R25. It was noted that back pain had worsened and that staff reported agitation secondary to pain when out of bed. On 4/18/19, the dose of [MEDICATION NAME] was increased to 25 mg every 8 hours for agitation as needed. The MAR indicated [REDACTED]. Plan: Continue PRN [MEDICATION NAME] supportive care and pain interventions. There was no justification for increasing the dose. On 4/30/19, at 1:00 p.m., social worker (SW)-A was interviewed and stated that she did not know of the history of antipsychotic use for R25 but had a care conference with the team and family regarding pain medications. She stated she had done the psychosocial assessment for R25 but had not identified behavior interventions to decrease agitation. She stated they had tried music and turning on the radio or TV but did not know if these interventions were effective. The director of nursing (DON) was interviewed on 4/30/19, at 2:00 p.m. and stated she used to have a system to track antipsychotic use but was not currently using it. She verified that she could not find a clinical justification for the use of [MEDICATION NAME] as needed and stated it had a lot to do with the pain level for R25. She was not aware if an assessment for [MEDICAL CONDITION] had been completed. She verified the family had stated this behavior was new for R25. The DON was not able to identify the [DIAGNOSES REDACTED]. The facility policy titled [MEDICAL CONDITION] and Unnecessary Medication Use Policy dated 9/17, indicated that antipsychotic medications initiated at the facility would assess the resident for reversible conditions, such as an acute medical condition. The use of the PRN [MEDICAL CONDITION] must have a specific condition and indication for use. Antipsychotic medication may only be used for 14 days, the prescribing practitioner must directly examine the resident assess and document the effect of the PRN use and the need for continued use. The policy indicated when a dosage change occurred a rationale would be documented.

Based on observation, interview and document review the facility failed to honor preferences for wake times for 1 of 1 resident (R239) reviewed for choices. Findings include: During an interview on 4/29/19, at 4:17 p.m. R239 stated staff come into his room at 6:00 a.m. to take his blood pressure and stick his finger (blood glucose check). R239 stated he wished it could be around 7:00 a.m. and stated he had asked but either staff don't give him an answer or they tell him, that's the rules. R239's Admission Record indicated he admitted to the faciilty on 4/22/19. A Bowel, Bladder and Skin Risk assessment dated [DATE], indicated R239 preferred to sleep uninterrupted. A BIMS (brief interview for mental status), [MEDICAL CONDITION] and Communication assessment dated [DATE], indicated R239 had intact cognition. A TCU (transitional care unit) psychosocial assessment dated [DATE], indicated R239 stated it was very important that he choose his bedtime. The assessment did not address wake time however, indicated R239 stated, he is just not sleeping as well as normal. R239's care plan dated 4/23/19, identified a self care deficit and directed staff to assist with activites of daily living. The care plan further identified a risk for alteration in blood glucose and directed staff to complete lab tests per orders. R239's Order Summary Report identified an order dated 4/22/19, for Accu Checks before meals and at bedtime. R239's Weights and Vitals Summary dated 4/22/19 through 4/30/19, indicated blood glucose checks at the following times: 4/23/19, 5:29 a.m. 4/24/19, 5:04 a.m. 4/25/19, 6:00 a.m. 4/26/19, 6:58 a.m. 4/27/29, 6:35 a.m. 4/28/19, 6:13 a.m. 4/29/19, 6:31 a.m. 4/30/19, 6:37 a.m. During observation on 4/30/19, at 6:45 a.m., at 6:45 a.m. R239 was in his room with the lights off and the door closed. At 7:55 a.m staff entered the room with a wheel chair scale. At 8:07 a.m. R239 propelled himself to dining room in his wheel chair. During interview on 4/30/19, at 9:02 a.m. registered nurse (RN)-C stated blood glucose checks were scheduled at 6:00 a.m. so the overnight shift could do them. RN-C stated previously the a.m. blood glucose checks were not getting done. RN-C stated she had 13 residents to give medications to and five residents with blood sugars and they might not get done if night shift did not do them then, all of a sudden it's 9:00 a.m. and the schedule gets messed up. During interview on 4/30/19, at 9:10 a.m. RN-D stated blood glucose check were completed at 6:00 a.m per the company policy. RN-D stated if someone did not want to be wakened staff would reapproach later. RN-D stated an initial assessment for preferences was the time staff would ask about preferences and the floor nurse should have addressed it and passed it on to her. RN-D stated she was unaware R239 preferred to sleep uninterrupted, even though its was identified on R239's assessment. At 9:33 a.m. the director of nursing (DON) stated the staff worked 12 hour shifts and the idea was that blood glucose checks would be done between 6:30 a.m. and 7:00 a.m. The DON stated they were scheduled to pop up on the schedule at 6:00 a.m. so if therapy got a patient up or if they had a shower the blood glucose checks would not get missed. The DON stated if a patient had certain preferences the staff would accommodate them if the patient let them know. The DON stated if a patient preferred to sleep uninterrupted the nurses should have updated the care strip. The DON stated if a resident expressed concerns about sleep and sleeping uninterrupted she would expect staff to ask more questions and stated not being awakened for a blood glucose check was a reasonable request. Policies related to resident choices and blood glucose checks were requested but not received.

Based on observation, interview, and document review, the facility failed to determine if the practice of self-administration of medications (SAM) was safe for 1 of 1 resident (R183) who was observed to be self-administering a nebulizer (neb-medication that is a liquid form that is turned into a mist and inhaled through a mask) treatment during a random observation. Findings include: R183 [DIAGNOSES REDACTED]. R183's care plan dated 4/29/19, identified a history of pneumonia and directed staff to administer medications per orders. R183's five day Minimum Data Set (MDS) 4/15/19 indicated severely impaired cognition. R183's care plan dated 4/15/19, indicated impaired cognitive function. Interventions included to ask yes or no questions, break tasks into one step at a time, and cue, re-orient and supervise R183 as needed. On 4/30/19, at 7:55 a.m. during a random observation R183 was receiving a nebulizer (neb) treatment with no staff present in the area. R183 was observed to be lying in bed with the head of bed elevated approximately 30 degrees with mask on. On 4/30/19, at 8:00 a.m. registered nurse (RN)-A entered R183's room, shut off the neb machine and stated let's take that off. On 4/30/19, at 8:07 a.m. surveyor overheard RN-A state to the physical therapist (PT) that R183 had just received a neb treatment and that R183 just vomited. The therapist stated they would help to get R183 cleaned up and changed. A Physician order [REDACTED]. On 4/30/19, at 8:53 a.m. RN-A reviewed the physician orders [REDACTED]. RN-A stated I probably should have stayed with R183 the whole time. On 4/30/19, at 9:10 a.m. RN-B, verified R183 did not have an order or assessment completed prior to observation of receiving neb with no supervision. RN-B stated she was aware R183 had dementia, but stated RN-A thought R183 was able to do the neb treatment independently. The clinical coordinator acknowledged R183 did not have an order to self administer medication and should not have been left alone until the order and assessment had been completed. On 4/30/19, at 1:34 p.m. Director of nursing (DON) stated when a patient admits to the facility there is a sheet that staff should follow that indicates what assessments are to be completed. DON stated when residents come in with a neb treatment nurses should be assessing if resident can remove mask and call for help appropriately. DON indicated that staff were not to allow resident's to self-administer medications without an order from physician.

Based on observation, interview and document review the facility failed to implement interventions to maintain continence for 1 of 1 resident (R239) reviewed for bowel and bladder. Findings include: R239's Admission Record indicated he admitted to the facility on [DATE]. R239's care plan dated 4/23/19, identified a self care deficit and directed staff to assist with dressing, grooming and transfers. R239's care plan indicated he was continent of bowel and bladder and would continue to be continent through the review period. The care plan indicated R239 wore an incontinent product and, indicated toileting schedule: see skin risk care plan however the care plan did not address skin. On 4/29/19, the care plan was revised to include: assist of one to check and change every three hours and apply barrier cream. R239's Bowel, Bladder and Skin Risk assessment dated [DATE], indicated he was continent of bowel and bladder and was able to identify the urge to void/defecate. A nursing assistant care guide, untitled, dated 4/29/19, indicated R239 was incontinent of bowel and bladder and directed staff to check and change him every three hours. A BIMS (brief interview for mental status), [MEDICAL CONDITION] and Communication assessment dated [DATE], indicated R239 had intact cognition. During interview on 4/30/19, at 12:09 a.m., nursing assistant (NA) -A stated she had assisted R239 with morning cares that day. NA-A stated R239 had requested a urinal then said he was ready to get up. NA-A stated later she checked his incontinent brief and it was wet and a little BM (bowel movement) so she cleaned him up and changed his incontinent brief. NA-A stated sometimes R239 would call for help with toileting and sometimes staff had to ask him. During observation and interview 12:40 p.m. R239's buttocks was observed to be red. R239 stated he knew when he had to urinate but he had an enlarged prostate and would leak before he got there. He stated he did not always know when he needed to have a bowel movement. During interview on 4/30/19, at 12:49 p.m. registered nurse (RN)-D stated the floor nurses completed the data collection. RN-D stated in order to determine continence on admission, the nurse might get data from the hospital or ask the resident. RN-D reviewed the NA documentation starting from admission and stated R239 had been continent when he first came to the facility and had a decline since admission. RN-D stated the NA was responsible for telling the nurse if there was a change. RN-D stated R239 was changed to a check and change program the previous day because it was noted that he had moisture associated skin damage. When asked why a check and change program was initiated verses a toileting program, RN-D stated, that was our intervention at the time. During interview on 4/30/19, at 1:43 p.m. the director of nursing (DON) stated R239 may have come to the facility and stated he was continent and the plan may have been adjusted because he was not. The DON stated she was present during R239's skin assessment and based of that, he may have been changed to a check and change program stating, I couldn't say offhand. The DON was unable to explain why R239 was put on a check and change program instead of a toileting program to maintain continence.

Based on interview and document review, the facility failed to ensure Minimum Data Set (MDS) assessments were submitted timely for 2 of 2 residents (R3, R4) reviewed for Resident Assessments. Findings include: R3 was admitted on [DATE], and the Admission Record dated 4/30/19, indicated [DIAGNOSES REDACTED]. During review of R3's MDS with the Resident Assessment Instrument (RAI) Director on 4/30/19, at 9:45 a.m., R3's discharge return not anticipated MDS dated [DATE], was completed but not submitted to the the Quality Improvement and Evaluation System (QIES) system. R4 was admitted on [DATE], and the Admission Record dated 4/30/19, indicated [DIAGNOSES REDACTED]. During review of R4's MDS with the RAI Director on 4/30/19, at 9:45 a.m., R4's discharge return not anticipated MDS dated [DATE], was completed but had not submitted the QIES system. On 4/30/19, at 9:45 a.m. the RAI Director said MDS assessments should be submitted weekly. When asked if there was a system to check to make sure MDS's were submitted, the RAI director stated they did not have one. On 4/30/19, at 1:19 p.m. the director of nursing indicated there was an RAI coordinator that over saw each building and would over see the submissions to the QIES system. The RAI coordinator for the building was not available at the time of the survey. The policy for Resident Assessment Instrument (RAI) Process: MDS 3.0, Care Area Assessment, Care Planning and Submission (reviewed 12/2016) directed facility staff to submit MDS assessments into the QIES system in accordance with the timelines specified in the current RAI user's manual. In addition to these guidelines, facility policy mandates submission to occur at least weekly. The RAI manual, last updated in (MONTH) (YEAR), directed: For Entry, Discharge and Death in Facility tracking records, information must be transmitted within 14 days of the Event Date.

The facility failed to provide the necessary care and services, including repositioning and assessment, to prevent the development of three unstageable ulcers (obscured full-thickness skin and tissue loss) for 2 of 3 residents (R30, R13) reviewed for pressure ulcers. This resulted in actual harm for R30 who developed unstageable ulcers. Findings include: On 6/11/18 at 6:28 p.m., R30 was observed wearing a CAM boot, hard sided black boot, on her right leg and foot. R30 was observed to have an ice pack wrapped in a pillow case on her right toes. R30 lifted her leg a little and said, Ow, I could cry all day long. R30 stated she had pain in her right foot and lower leg. R30 said her pain was frequently moderate to severe. On 6/12/18 at 9:01 a.m., R30 was observed eating in her bedroom with a nursing assistant (NA)-G present. R30 was observed to be wearing the hard sided boot on her right foot. R30 stated she continued to have horrible pain in her right foot and leg stating, I think it's going backwards with the healing. R30's face sheet dated 6/13/18, indicated R30 had [DIAGNOSES REDACTED]. A hospital discharge summary for R30 dated 5/10/18, included: may resume normal activities as tolerated. Wear CAM (Controlled Ankle Movement) boot to right leg when up out of bed. The discharge summary did not identify any skin issues. R30's most recent comprehensive Minimum Data Set (MDS) assessment dated [DATE], indicated R30 had been assessed as having severe cognitive impairment. R30's physician order [REDACTED]. Wear CAM boot while out of bed and R (right) ankle: Daily dressing changes to R ankle nonadherent dressing/Kerlix/Ace then CAM boot in the morning for R ankle. R30's (MONTH) and (MONTH) (YEAR) MAR/TAR (medication administration record/treatment administration record) were reviewed. The (MONTH) TAR included directions to: Perform skin checks about the boot daily, every day shift with a start date of 5/5/18, and a discontinue date of 5/10/18. There were no further instructions related to inspection of skin covered by the CAM boot after 5/10/18. The TAR documentation indicated staff had completed the daily dressings as prescribed, and had applied the CAM boot. Notes from R30's initial comprehensive nurse practitioner (NP) visit dated 5/11/18, included: To wear CAM boot at all times while ambulating .closed fracture dislocation of right ankle joint with nonunion, Impaired mobility and ADLs (activities of daily living). R30's orthopedic NP-B visit note from 5/14/18, included: incisions well approximated CDI (clean dry and intact) healing, no redness, irritation, swelling or inflammation. Sutures all intact. +1 [MEDICAL CONDITION] of RIGHT ankle and foot. R30's pressure ulcer care area assessment (CAA) completed 5/17/18, included: (R30) is at risk for developing pressure areas d/t (due to) needing assistance with bed mobility, B&B (bowel and bladder) incontinence, Pain, Depression, Anxiety, CKD4 ([MEDICAL CONDITION]). Body audit 5/17 documents blanchable redness to sacrum and R ankle surgical site but other skin intact. She has a HPRM (house pressure reduction mattress) on her bed and staff monitor skin with cares and weekly body audits, and staff assist with repositioning. The CAA did not address risks associated with the use of a CAM boot. R30's care plan last updated 5/29/18, included: I am at risk for skin integrity, chair-bound, cognitive impairment, friction and shearing, incontinence or moisture, [MEDICAL CONDITION], and [MEDICAL CONDITION]. The goal included: My skin will remain intact through the next review date. Interventions included: Elevate heels off bed surface using pillows or heel elevation products as needed. Follow facility policies/protocols for the prevention of skin breakdown. I require a pressure reducing mattress. Notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration noted during bath or daily care, and another focus area included: I have a non-pressure alteration in skin integrity. The goal included: My alteration in skin integrity will remain free of infection. Interventions included: Complete treatments as ordered and monitor for effectiveness. Elevate heels off bed surface using pillows or heel elevation products as needed. I require a pressure reducing mattress. I require a pressure reducing wheelchair cushion. Repositioning: I require assistance upon rising, after meals, and at HS (see mobility CP for assist level). R30's care plan did not include any focus areas, goals or interventions related to the use of the CAM boot. R30's most recent body audit dated 6/7/18, indicated there was a dressing on R30's ankle as well as multiple surgical incisions to her right foot and ankle region related to recent right ankle surgical repair. It was unclear if the dressing was removed to observe the skin under the dressing. The feet and toes were described as clear and other, and the heels were described as clear. A Skin and Wound assessment dated [DATE], indicated R30 had a new unstageable (obscured full-thickness skin and tissue loss) pressure ulcer on the right calf, measuring 1.5 cm (centimeters) in length and 0.6 cm in width. The wound bed was described as 100% slough, superior to the heel and lateral. Additionally, the assessment indicated R30 had developed other new unstageable ulcers: 1) to the right heel measuring 1.3 cm in length, and 0.6 cm in width. The wound bed was described as 10% [MEDICATION NAME] tissue and 90% slough, superior to the heel and medial. 2) an unstageable pressure ulcer on the right heel measuring 4.0 cm in length and 6.5 cm in width. The wound was described as 10% [MEDICATION NAME]; 50% slough and 40% eschar. Each wound was documented as having light serous drainage, and moderate pain. Signs of infection to watch for were identified as including: fever and increased pain. A note on the 6/12/18 assessment included: Pressure areas seen by (primary physician) and (orthopedic nurse practitioner). Felt that the pressure area was caused by the CAM boot. New orders written to D/C the CAM boot, start NWB (non-weight bearing), dressing changes ordered BID (twice daily). Pt (patient) is running a temp (temperature) of 100.0 today. Stat CBC (complete blood count lab) ordered. Blue boots placed on bilateral feet. On 6/13/18 at 10:42 a.m., registered nurse (RN)-F responsible for completing R30's MDS, CAA and care plan, reported R30 did not have any pressure ulcers at the time of her admission assessment even though R30 was using the CAM boot at that time. RN-F stated R30's use of a CAM boot was overlooked when she completed the CAA and care plan, and verified the use of the CAM boot should have been incorporated. RN-F also acknowledged R30's use of the CAM boot put her at risk for pressure ulcer development, but stated she had completed a visual assessment of R30 to complete the CAA, rather had relied on documentation from the medical record. On 6/13/18 at 11:14 a.m., nursing assistant (NA)-F stated she assisted R30 with transfers and toileting. NA-F stated the day prior, R30 had screamed in pain, saying her leg and foot hurt. NA-F said she had informed the nurse about R30's pain. On 6/13/18 at 11: 15 a.m., RN-E stated she had conducted R30's dressing changes only once, but stated R30 wore her CAM boot pretty much all the time. On 6/13/18 at 2:15 p.m., RN-D (the nurse manager), stated R30 had been having increased pain and yelling over the last few days. RN-D stated the facility had completed skin risk and Braden assessments, weekly body audits and daily dressing changes to R30's right ankle, but verified there was no assessment related to the CAM boot and how it might impact R30's skin integrity or how to mitigate the risks. RN-D further reported she did not know the type of CAM boot R30 was using and said she did not have the manufacturer's recommendations available. RN-D described the CAM boot as black and being a short boot she wore whenever she was out of bed. RN-D stated skin integrity interventions were addressed in R30's care plan, but nothing specific to R30's use of a CAM boot. RN-D reported R30's use of a CAM boot should have been included in her care plan. On 06/14/18 at 1:50 p.m., RN-D informed the surveyor she was unsure whether anyone had identified concerns with R30's skin prior to NP-B having identified the pressure ulcers. RN-D stated after review of the chart, it appeared no one had charted any other skin concerns. RN-D said if there were concerns identified, they should have been charted. RN-D also verified there were no instructions for daily skin inspections however, stated with daily dressing changes, the nurses should have inspected R30's skin under her boot. On 6/14/18 at 9:36 a.m., R30's physical therapist (PT)-A reported R30 wore a CAM boot whenever she was out of bed. PT-A acknowledged it was possible the CAM boots put R30 at an increased risk of pressure ulcer development. PT-A further stated therapy staff had not had a role in selecting the CAM boot, and was not aware of the type of CAM boot R30 was using. PT-A reported it was a big black boot that opened on the front, had hard plastic on the sides,with Velcro over shin and top of foot. PT-A further reported R30 had exhibited increased complaints of right leg pain during the past week. On 6/14/18 at 9:45 a.m., R30's primary NP-A reported R30's CAM boot was not made to offload the heel. NP-A reported R30's orthopedic providers had chosen the CAM boot for R30. NP-A reported it was highly likely the CAM boot was the cause of R30's three pressure ulcers. NP-A reviewed pictures of R30's pressure ulcers available in R30's medical record, and stated the pressure ulcers were noted as unstageable. NP-A verified R30 had complained of increased pain earlier in the week from her hip to her ankle. On 6/14/18 at 10:17 a.m., the interim director of nursing (DON) stated R30 was not admitted with pressure ulcers, but had surgical wounds and a post surgical fracture. The DON explained the CAM boot could put R30 at a greater risk of pressure ulcers and stated the nurses should have observed R30's skin with daily dressing changes to her right ankle. When questioned about whether an assessment of how the CAM boot could potentially impact skin had been conducted, the DON reported the facility had not done that, but thought the orthopedic physician may have. The DON stated she did not know what type of CAM boot R30 was using, and did not have manufacturer's recommendations. The DON stated she did not feel it was the facility's responsibility to know the type of CAM boot, or to have the manufacturer's recommendations available for reference. Upon review of R30's care plan, the DON stated there was a care plan for skin integrity and non pressure ulcer skin concerns, but nothing specific related to R30's use of the CAM boot. The DON stated R30's use of the CAM boot should have been included in her care plan. On 6/14/18 at 11:09 a.m., the administrator and corporate consultant verified there were pictures of R30's wounds, but stated the pictures were unavailable to provide to the surveyor. During interview with NP-B on 6/14/18 at 12:37 p.m., NP-B confirmed she had discovered R30's three pressure ulcers during a routine visit on 6/12/18. NP-B stated she was not aware of the type of CAM boot used by R30, and stated R30 was admitted with it from the hospital. NP-B reported she had seen R30 once prior to 6/12/18 (on 5/14/18), and her skin at that time had been totally intact with no skin integrity issues. NP-B reported she would expect staff to remove R30's CAM boot and thoroughly inspect the skin daily. NP-B stated when she'd first discovered the wounds, she'd been told by RN-D that a facility nurse had noticed skin discoloration a week prior. NP-B stated she hadn't been notified of any concerns or would have visited right away. NP-B stated any device, such as a CAM boot, can put a resident at risk of pressure ulcers. NP-B also stated staff had been inspecting R30's skin under her CAM boot daily from a previous admission from 5/5/18 to 5/8/18, but when that the order had been discontinued, due to R30's hospitalization , it had not been restarted at the time of R30's readmission to the nursing home on 5/10/18. NP-B further stated she believed there would have been signs of potential concerns of pressure ulcer development over multiple days and staff should have identified the pressure ulcers prior to her visit. NP-B stated the CAM boot was removable, and even if there weren't physician or nurse practitioner orders to observe the skin under the CAM boot, it would have been within a nurse's scope of practice to write an order to observe skin under the CAM boot. The facility's policy Skin Integrity Management dated (MONTH) (YEAR), included directions for staff: Risk factors and potential cause(s), should be reviewed individually, addressed in the analysis, and interventions implemented. Care plan interventions according to the resident Risk Skin Risk Assessment and/or individual risk factors identified. The policy further directed staff Remove orthotics on a regular basis for skin inspection. R13 was observed continuously on 6/3/18 from 7:00 a.m. until 10:42 a.m. (3 hours, 42 minutes), without any offer of assistance to meet her toileting needs. At 7:00 a.m.,. R13 was lying in bed on her back with the head of the bed elevated 30 degrees. At 8:21 a.m. registered nurse (RN)-A was observed to administer R13's medications via a gastrostomy tube, but there was toileting care offered. R13 continued to be positioned on her back in bed with the head of the bed elevated 30 degrees without a check and change for incontinence until 10:42 a.m. when nursing assistant (NA)-B entered the room to provide morning cares. During observations at 10:42 a.m. on 6/13/18, NA-B removed R13's incontinent brief which was saturated with a large amount of urine. The skin on R13's buttock was observed to have multiple red creases/craters and wrinkling of the skin. There were two dime sized reddened areas on the right buttocks in close proximity to each other. NA-B was observed to use the walkie talkie to request a nurse to come observed the areas. On 6/13/18, at 10:56 a.m. registered nurse (RN)-A entered the room to evaluate the two reddened areas. RN-A stated the two red areas were reoccurring areas on R13's buttocks that had previously been open pressure ulcers. RN-A applied a barrier ointment for moisture associated skin damage and stated, She (R13) is at risk for breakdown because of the incontinence. When interviewed on 6/13/18, at 11:15 a.m. NA-B verified she had not gotten in to provide care earlier that morning. NA-B stated, I tried to get into the room earlier, but was busy with other people. The Care Area Assessment (CAA) dated documented 1/8/18, and a skin risk assessment dated [DATE], indicated a high risk for skin breakdown with inability to offload independently requiring staff assist of 2 persons with bed mobility and transfers using the full lift. Furthermore, the assessment included: Resident is completely immobile and does not make even slight changes in body or extremity position without assistance. Resident is currently on a scheduled turning and repositioning program every 2 hours A Minimum Data Set assessment dated [DATE], indicated R13's cognition was severely impaired. R13's plan of care related to skin integrity included: I have the potential for alteration in skin integrity related to decreased motility, hx (history) of MASD (moisture associated skin damage) on coccyx, incontinence, HOB (head of bed) requires elevation due to tube feeding, s/s (signs and symptoms) of [MEDICAL CONDITIONS] healed stage 2 pressure ulcer on Sacrum 9/2017. The plan of care revised 10/9/17, included: .staff to turn/reposition every 2 hours in the wheelchair and in bed from side to side. When interviewed on 6/13/18, at 2:00 p.m. the director of nursing verified the facility's expectation would be to reposition R13 every two hours according to her individual resident assessment and plan of care. The facility's 9/2015 policy Positioning the Resident, indicated the goal was: To relieve pressure and prevent skin breakdown.

Based on observation, interview and record review, the facility failed to ensure comfortable temperature levels in the dining area for 7 of 7 residents (R6, R12, R194, R29, R24, R37, and R20) reviewed for environment. Findings include: During an observation of the evening meal in the second floor long term care dining room on 6/11/18, from 4:55 p.m. through 6:00 p.m., residents were observed wearing coats, shawls and blankets. Cold air could be felt coming from the air vents. On 6/11/18 at 4:55 p.m., R6 was observed seated in the dining room and stated loudly, It's freezing in here! Although R6's most recent annual Minimum Data Set (MDS) assessment from 3/18/18, indicated R6 had severe cognitive impairment, R6's comment was very clear. On 6/11/18 at 5:46 p.m., R12 and R194 told the surveyor it was always chilly in the dining room. R12 stated, staff never listen when residents complain about the temperature. During a follow up interview with R12 in the dining room on 6/12/18 at 8:53 a.m., R12 stated, it's hard on people, we keep on complaining and they haven't done anything (regarding the dining room temperature). R12 was observed wearing a blanket over her shoulders. R12's most recent MDS dated [DATE], revealed R12 was cognitively intact. When interviewed on 6/11/18, at 6:00 p.m. R29's family member (F)-A expressed concern about the cold dining room and stated, It has been cold in here for weeks now, they just can't get it adjusted and I have to be sure (R29) wears a jacket in here for the meals. When interviewed on 6/11/18, at 5:55 p.m. R24 stated the dining room had been cold for several weeks now and stated, it doesn't do any good to complain because we have, and the dining room continues to be very cold. According to the medical record, R24 was assessed as cognitively intact on 5/9/18. Multiple thermostats were observed mounted on the walls in the dining room however, all registered different temperatures, and were difficult to read due to the design of having a top number and a bottom number. When interviewed on 6/11/18, at 6:20 p.m. the director of maintenance (DM) stated I heard they were cold in there tonight and I adjusted the thermostat 4 degrees. The DM was not aware the residents had been complaining about the cold temperatures in the dining room for over a week. On 6/12/18 at 8:58 a.m., the interim administrator stated staff should report resident complaints of cold temperatures to maintenance staff. She acknowledged she had been informed of cold temperatures in the dining room on the evening of 6/11/18. When interviewed in the dining room on 6/12/18, at 8:55 a.m. R24 stated, It's cold in here. R24 again stated residents have been complaining about the cold dining room for a long time, at least a couple of weeks, and it has been terrible. R24 stated, staff are aware, because we keep complaining. On 6/12/18, during a conversation in the dining room with R37 at 8:57 a.m., R37 stated the cold air blasted her from the air vent above where she sat and cooled her food. R37 stated the dining room had been cold for awhile now. R37's most recent MDS dated [DATE], indicated R37 had moderate cognitive impairment. On 6/12/18 at 10:24 a.m., R20 stated it had been cold in the dining room for weeks. R20's medical record indicated the resident had severe cognitive impaired, however the resident was able to clearly express being cold. On 6/13/18, at 8:00 a.m. dietary aide (DA)-A verified (R12) and other residents have reported complaints about the cold dining room. DA-A stated she had reported the complaints about the cold temperature of the dining room to her supervisor. Review of the facility's Concern Logs indicated no concerns had been documented in (MONTH) or (MONTH) (YEAR) regarding the cold dining room. The facility's undated policy Quality Concerns/Grievance Process, indicated forms are available to any resident, resident representative, visitor, staff or vendor. The steps to the process included: #2. If a concern/grievance is being filed orally-the staff member receiving the information should write a brief description of the concern . #4. The concern/grievance will be addressed minimally within five working days and action items will be communicated to the individual filing the grievance unless indicated as anonymous.

Based on observation, interview and document review, the facility failed to ensure infection control measures were implemented for 1 of 1 resident (R36) observed during the provision of wound care, and failed to ensure a mechanical lift was sanitized following use for 1 of 24 residents (R29) who utilized a mechanical lift for transfers. Findings include: R36 was admitted to the facility on [DATE] for intravenous therapy due to a cutaneous abscess of right lower limb. The medical record indicated R36 had other [DIAGNOSES REDACTED]. On 6/13/18, at 8:33 a.m. registered nurse (RN)-B was observed to position R36 legs on the bed so wound treatments could be completed on the resident's inner right (R) thigh, right great toe and the left foot. RN-B was observed to wear gloves while cleansing R36's R inner thigh wound with a saturated Kerlix square (a type of gauze dressing). RN-B removed the gloves, then discarded the gloves and soiled Kerlix square, into a plastic bag. RN-B then donned new gloves and covered the thigh wound with a dry dressing. After applying the dressing, without changing his gloves, RN-B proceeded to remove the right foot's Kerlix dressing, and discarded the dressing into the plastic bag. RN-B opened a package from the treatment bucket and painted R36's right great toe with a [MEDICATION NAME] solution. While wearing the same gloves, RN-B wrapped the right foot in a new Kerlix dressing. Still without changing his gloves or washing his hands, RN-B moved to the next treatment area that needed a dressing change. RN-B removed the Kerlix dressing from R36's left foot, sprayed an antiseptic wash on the top portion of R36's left foot, and removed a soiled [MEDICATION NAME] dressing from the top of the foot. The soiled dressing was placed in the plastic bag. RN-B then removed his soiled gloves and applied a new pair, without performing any hand hygiene. RN-B removed an [MEDICATION NAME] dressing from a package and applied the dressing to a wound on the top left part of R36's foot, then wrapped the foot in Kerlix. RN-B then picked up the resident's socks and put them on the resident. RN-B picked up a spray bottle of hand foam sanitizer from the floor, and placed it in the wound treatment bucket. RN-B then removed his gloves and discarded them in the trash. RN-B then used the hand sanitizer to cleanse his hands. RN-B picked up the treatment bucket from the room, and took it to the nursing office. RN-B was interviewed on 6/13/18 at 1:30 p.m. RN-B confirmed R36 was being treated with an intravenous antibiotic for an abscess to the right inner thigh, and verified he had not washed his hands when going between wound sites, or when going from dirty to clean dressings. RN-B verified he had not followed the facility's infection control standards. RN-B further verified the treatment bucket remained in the room, and was not aware who had left the hand sanitizer on the floor. RN-B indicated the bucket was taken to the nursing station, so it could be cleaned out of unnecessary products. The facility's Infection Prevention and Control Manual revised in (YEAR), included: hand hygiene must be performed after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn, immediately after gloves are removed; and when otherwise indicated to avoid transfer of microorganisms to other residents, personnel, equipment and the environment. Specific examples include but are not limited to: before and after touching wounds of any kind; before and after changing a dressing; after handling soiled or used linens, dressing, bedpans, catheters, and urinals; after touching any item or surface that may have been contaminated with blood or body fluids, excretions or secretions (e.g measuring graduate, commode); after handling soiled equipment or utensils. During an observation on 6/13/18, at 10:30 a.m. R29 was transferred out of bed using a mechanical stand device. No hand hygiene was performed on R29 with morning cares. Nursing assistant (NA)-B instructed R29 to grab onto the handle bars designated for resident use on the mechanical stand. R29 was wheeled into the bathroom and lowered to the toilet while holding onto the area of the device designated for the resident to grasp. R29 was transferred into the wheel chair using the mechanical lift after urinating in the toilet. The mechanical device was removed and put in the hallway for use with out any having been sanitized after use. When interviewed on 6/13/18, at 10:40 a.m. nursing assistant (NA)-B and NA-C verified the routine practice was not to clean the mechanical stands in between resident use unless they were visibly soiled. When asked about R29 having been on the toilet and not having hands washed prior to grabbing onto the mechanical devise grab bars, both NA's stated because the device was not visibly soiled, it would not have been cleaned between resident use. When interviewed on 6/14/18, at 2:00 p.m. the director of nursing (DON) verified the facility did not have a policy to sanitize/disinfect the mechanical stands between resident use unless they were visibly soiled. Also present at that time, registered nurse (RN)-D, responsible for the facility's infection control, verified there was no policy to disinfect lifts and stands between resident use. RN-D stated the devices were treated as durable medical equipment that did not require sanitizing between resident use unless visibly soiled. According to the nurse, the third floor long term care unit had 10 of 24 residents who utilized the mechanical standing lift. Document review of the manufacturer recommendations for sanitizing the lifts dated 1/23/13, was obtained from the manufacturer on 6/14/18. The recommendations: Care and Maintenance of the Liko: Mobile Lifts, Ceiling Lifts, Sit to Stand Lifts, and Lift Stretchers included: To avoid possible transmission of infectious disease, it is important to clean the lift if it has become soiled, or if it is to be used by another patient

Based on observation, interview and document review, the facility failed to follow up on consultant pharmacist recommendations for 1 of 5 (R6) residents reviewed for unnecessary medications. Findings included: R6 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of R6's monthly pharmacist recommendations included communication to the physician dated 4/18/18: This resident's drug regimen includes [MEDICATION NAME] 25 mg (milligrams) daily and [MEDICATION NAME] 7.5 mg at bedtime. When reviewing the nursing notes it appears the resident's behavior has been stable. The last 2 PHQ-9 (health questionnaires for depression) scores were 0. Are both medications still needed? Could one antidepressant be discontinued and if behaviors are seen, increase the antidepressant still being given? R6's active physician orders [REDACTED]. R6's medication administration records (MAR) reviewed for April, (MONTH) and (MONTH) (YEAR). The MARs indicated both [MEDICATION NAME] 25 mg and [MEDICATION NAME] 7.5 mg continued to be given during April, May, and (MONTH) (YEAR). R6's care plan included use of antidepressant medication related to depression, agitation and decreased appetite. During an interview on 6/14/18, at 1:17 p.m. the director of nursing (DON) verified the consultant pharmacist's 4/18/18 recommendation, had not been processed and forwarded to the physician. The DON stated she would communicate with the physician now. The facility's policy [MEDICAL CONDITION] and Unnecessary Medication Use dated (MONTH) (YEAR), included: Pharmacist Review . 3. All pharmacist recommendations will be reviewed with the primary physician/NP (nurse practitioner) prior to implementation, and with a physician's orders [REDACTED].>

Based on observation, interview and document review, the facility failed to ensure 1 of 3 residents (R13) identified as incontinent of urine, received necessary care and services to meet toileting needs. Findings include: R13 was observed continuously on 6/3/18 from 7:00 a.m. until 10:42 a.m. (3 hours, 42 minutes), without any offer of assistance to meet her toileting needs. At 7:00 a.m,. R13 was lying in bed on her back with the head of the bed elevated 30 degrees. At 8:21 a.m. registered nurse (RN)-A was observed to administer R13's medications via a gastrostomy tube, but there was toileting care offered. R13 continued to be positioned on her back in bed with the head of the bed elevated 30 degrees without a check and change for incontinence until 10:42 a.m. when nursing assistant (NA)-B entered the room to provide morning cares. During observations at 10:42 a.m. on 6/13/18, NA-B removed R13's incontinent brief which was saturated with a large amount of urine. The skin on R13's buttock was observed to have multiple red creases/craters and wrinkling of the skin. There were two dime sized reddened areas on the right buttocks in close proximity to each other. NA-B was observed to use the walkie talkie to request a nurse to come observed the areas. On 6/13/18, at 10:56 a.m. registered nurse (RN)-A entered the room to evaluat the two reddened areas. RN-A stated the two red areas were reoccurring areas on R13's buttocks that had previously been open pressure ulcers. RN-A applied a barrier ointment for moisture associated skin damage and stated, She (R13) is at risk for breakdown because of the incontinence. When interviewed on 6/13/18, at 11:15 a.m. NA-B verified she had not gotten in to provide incontinence care earlier that morning. NA-B stated, I tried to get into the room earlier, but was busy with other people. The Care Area Assessment (CAA) dated documented 4/7/18, indicated R13 required a check and change program to meet her incontinece. The CAA indicated the check and change program was designed for those residents who are physically unable to sit on the toilet, or who have cognitive impairment or behaviors that make it difficult to use the toilet (may be appropriate for residents who are cognitively impaired, functionally disabled). The CAA interventions indicated staff were to check and change R13 every two hours due to bowel and bladder incontinence. A Minimum Data Set assessment dated [DATE], indicated R13's cognition was severely impaired. R13's plan of care related to incontinence, included: I have functional bladder/bowel incontinence r/t (related to) Dementia, impaired mobility, inability to communicate needs. Interventions included for staff to check and change R13 for incontinence with each repositioning change, every two hours. When interviewed on 6/13/18, at 2:00 p.m. the director of nursing verified the facility's expectation would be to check and change R13 every two hours according to her individual resident assessment and plan of care. The facility's policy for Incontinence Care was requested, but not received by the time of the exit.

Based on interview and record review the facility failed to ensure that one of six residents (R1) reviewed was free from significant medication error when LPN-J placed an order for [REDACTED]. R1 was harmed when admitted to the hospital for an upper intestinal bleed. Findings include: R1's medical record was reviewed and her [DIAGNOSES REDACTED]. A care plan dated 04/05/18, indicated R1 required the assistance of one staff person for dressing, grooming, and ambulation. R1 was able to make her needs known. A physician's order dated 04/05/18, indicated R1 had a physician order for [REDACTED]. A progress note dated 04/10/18, indicated that after surgery R1 had an acute blood loss. R1's hemoglobin dropped from 14.1 on 03/26/18, to 7.2 on 04/05/18. A Medication Administration Record [REDACTED]. A physician's order dated 04/12/18, indicated R1 had a physician's order for [MEDICATION NAME] tablet ([MEDICATION NAME] Sodium) give 8 mg by mouth one time only, and the communication method was on the telephone. There were no other [MEDICATION NAME] orders written by R1's physician. laboratory results dated [DATE], indicated R1's hemoglobin was low at 7.3. A nurse's note dated 04/13/18, at 1:48 a.m., by LPN-H indicated a medication error. LPN-H gave R1 [MEDICATION NAME] 8 mg in error on 4/12/18. LPN-H notified the physician as soon as medication error noticed which was approximately 3 hours after administration. LPN-H assessed R1 and R1 had no had no signs of bleeding. Vital signs and hourly checks were completed. A nurse's note dated 04/13/18, at 11:59 p.m., indicated an international normalized ratio (INR) check twice a day was not done. The INR was crossed off the lab calendar (an INR is used to determine the clotting tendency of blood, in the measure of [MEDICATION NAME] dosage). A nurse's note dated 04/14/18 3:04 p.m. indicated staff needed to monitor R1 for signs and symptoms of bleeding every shift and for side effects of [MEDICATION NAME] until 04/15/2018. R1 had no signs and symptoms bleeding. A nurse's note dated 04/15/18, at 7:48 p.m. indicated R1 refused her medications, complained of nausea, and had an emesis. R1 had a low blood pressure at 108/65, and her pulse was high at 109. The nurse called R1's Physician. A nurse's note dated 04/15/18, at 8:52 p.m. indicated R1 had loose stools the day before, and refused to take Senna a laxative. A nurse's note dated 04/16/18, at 1:35 a.m., R1 had increased weakness, lethargy, weak pulses, and white color. R1 had a high pulse at 123, a high respiratory rate at 30. R1 had a large black tarry stool (which indicated intestinal bleeding) at 1:00 a.m. Staff notified the on-call doctor and sent R1 to the hospital. An ambulance arrived at 1:36 a.m. Staff notified R1's family. A facility internal investigation dated indicated R1 received [MEDICATION NAME] that was ordered for a different resident. A hospital discharge summary dated 04/20/2018, indicated, R1's hospital records indicated the resident arrived in the hospital with signs of an upper intestinal bleed with [MEDICAL CONDITION] (low blood pressure) and hemorrhagic shock. A CT scan revealed a [DIAGNOSES REDACTED] hemorrhage (bleeding in the intestines). The resident's hemoglobin was 6.4 in the emergency room , and his/her INR was 2.8. The hospital staff administered a blood transfusion, and vitamin K an antidote to [MEDICATION NAME]. The hospital discharged the resident to a different facility. During an interview on 05/07/18, at 1:27 p.m., the nurse practitioner (NP-C) stated s/he visited R1 the morning after the R1 received the wrong medication, [MEDICATION NAME]. The nurse notified the on call doctor notified the night before, and the on call doctor gave an order to monitor the resident for signs and symptoms of bleeding. NP-C stated s/he did not check R1's INR (to see if the medication increased the resident's risk of bleeding) or consider giving R1 vitamin K (which is an antidote that reverses the effects of [MEDICATION NAME]) because the [MEDICATION NAME] was a small dose. During an interview on 05/07/18, at 2:09 p.m. the Clinical Coordinator Nurse (CN-C) stated she discovered that the resident received the wrong medication when s/he returned to work four days after the event. CN-C stated nurses take verbal orders over the telephone for medications and put the order directly into the electronic medical record. The providers sign the orders later. The orders are not double-checked. Typically, the day shift nurse will check the INR, obtain the [MEDICATION NAME] order from the provider, and give the [MEDICATION NAME] at 5:00 p.m. On 04/12/18, the Transitional Care Unit (TCU) was very busy and an agency nurse (LPN-E) worked the day shift. At approximately 6:15 p.m. the agency nurse asked CN-C to help obtain [MEDICATION NAME] orders for two residents. CN-C determined that both residents missed lab draws for INRs that day due to miscommunications. Both residents needed INR draws to obtain [MEDICATION NAME] orders, and if no lab result was available, the nurse needed to call the doctor with all the [MEDICATION NAME] order information, and the previous INR result to obtain a new [MEDICATION NAME] order. At approximately 6:30 p.m. LPN-J arrived at work and the agency nurse was busy so CN-C told LPN-J to obtain [MEDICATION NAME] orders for both residents. Typically, the nurses give each other report but things were very hectic that day. CN-C then went home and came back to work after R1 went to the hospital. LPN-I obtained [MEDICATION NAME] orders for both residents and placed one order into R1's chart by mistake. LPN-H gave the [MEDICATION NAME] to R1 later in the evening when the order appeared on her MAR indicated [REDACTED]. During an interview on 05/10/18, at 10:28 a.m. LPN-E stated that she worked on 04/12/18, it was a very busy day and she had at least two resident's that needed INRs that the lab did not draw. LPN-E stated she worked closely with her CN-C in an attempt to obtain orders for [MEDICATION NAME] for those residents. She did not recall the residents' names. She stated if the INR was not drawn, usually for communication reasons, the doctor needed to be notified and an order to continue the [MEDICATION NAME] dose obtained. She stated that the nurse that obtained the [MEDICATION NAME] orders did not always give the [MEDICATION NAME]. Sometimes the day nurse obtained the INR and the [MEDICATION NAME] order, and the evening nurse gave the [MEDICATION NAME]. During an interview on 05/10/18, at 11:18 a.m., RN-F stated that the nurse that checked the resident's INR, obtained the [MEDICATION NAME] order, and filled out the [MEDICATION NAME] flow sheet was not necessarily the nurse that gave the [MEDICATION NAME] that day. Typically, the nurse that obtained the INR lab result filled out the [MEDICATION NAME] flow sheet and obtained a [MEDICATION NAME] order via telephone. The nurse that passed medications gave the [MEDICATION NAME] without checking the [MEDICATION NAME] flow sheet or INR result. During an interview on 05/10/18, at 3:06 p.m. R1's physician stated it is prudent the check to the hemoglobin and an INR if a resident received a onetime dose of [MEDICATION NAME] by mistake. He stated he would not anticipate a problem in R1's case and no action other than following the hemoglobin was necessary. During an interview on 05/11/18, at 8:20 a.m., Licensed Practical Nurse (LPN-H) stated she cared for R1 and gave R1 [MEDICATION NAME] 8 mg on 04/12/18, according to an order in R1's chart. LPN-H stated the INR and flow sheet were completed on the day shift and she had no reason to check those. LPN-H stated the day nurse normally puts the [MEDICATION NAME] order in the residents chart, and LPN-E (the day nurse) did not because RN she was busy and LPN-J (evening nurse) put the [MEDICATION NAME] orders in the chart that night. During an interview on 05/17/18, at 1:17 p.m. LPN-J stated on 04/12/18, she worked an extra shift from 6:30 p.m. to 10:00 p.m. to help pass medications. When she arrived at work a staff person called in late and she was given an admission. The admission attempted to elope, required lots of attention and things were very chaotic. CN-C gave LPN-J two residents that had missed lab draws on the day shift and needed INR and [MEDICATION NAME] orders obtained right away. Both the residents that required [MEDICATION NAME] had recently moved into new rooms. One of those residents had a lab sheet with the name partially visible but the room number clearly visible. LPN-J could not find the name of the resident that was supposed to get the [MEDICATION NAME] 8 mg on the computer screen so she used the room number. R1 had moved into that room number. LPN-J stated CN-C showed her R1's name on the lab calendar where it showed R1 needed a complete blood count (cbc) the next day. LPN-J added an INR to R1's name on the lab calendar, and put the order for [MEDICATION NAME] 8 mg in R1's chart. She typed up the order for [MEDICATION NAME] 8 mg, and an INR check for the next day, into R1's MAR. LPN-J faxed the order to the pharmacy. LPN-J called the pharmacy twice that evening, requested the [MEDICATION NAME] and used the correct resident's name. Each time the pharmacy replied they would send it in ten minutes. Later that evening R1 completed the lab request for the cbc and INR and realized she put the [MEDICATION NAME] order into R1's chart in error. She did not recall the names of either resident that was supposed to get the [MEDICATION NAME]. LPN-J asked LPN-H if she gave R1 the [MEDICATION NAME]. LPN-H replied yes. LPN-H called R1's provider and received an order to monitor R1 to monitor R1 for signs of bleeding. LPN-J called R1's family, filled out an incident report, and notified the clinical manager. During an interview on 05/31/18, at 10:27 a.m., R1 stated the nurse came into her room one evening and told R1 she had [MEDICATION NAME] to give to R1. R1 stated she told the nurse, three times, that she did not take [MEDICATION NAME]. The nurse insisted that R1 had a doctor's order to take [MEDICATION NAME]. R1 took the [MEDICATION NAME]. The nurse came to R1's room later that evening and told R1 that the nurse gave R1 the [MEDICATION NAME] in error. R1 stated that she later went to the hospital with a bleeding ulcer. R1 did not recall the nurse's name. R1 did not recall which day she went to the hospital. A policy titled, Medication Administration Policy, dated 08/2015, indicated a significant medication error is one which causes the resident discomfort or jeopardizes the resident's health or safety. A medication error occurs when the medication is administered to the wrong person. Staff is to follow three general guidelines in determining whether a medication error is significant or not: #2 Drug Category -- If the drug is from a category that usually requires the resident to be titrated to a specific blood level, a single medication error could alter that level and precipitate a reoccurrence of symptoms or toxicity. This is especially important with a drug that has a Narrow Therapeutic Index (NTI) (i.e., a drug in which the therapeutic dose is very close to the toxic dose). Examples of drugs with NTI are as follows: [MEDICATION NAME].

Based on observation, interview, and document review the facility failed to ensure the safety of 2 of 74 residents, (R1 and R2), reviewed for bed grab bars. R1 was harmed when R1 was found not breathing with her head between the mattress and the grab bar on the bed and died . R2 had the potential for entrapment due to the large gap between the mattress and grab bar. Findings include: The facility had no policy, procedure, or system to ensure the proper sizing of mattresses, the fit of the grab bars, and the space between the mattresses and the grab bars device was safe to reduce the risk of entrapment. The Food and Drug Administration (FDA) hospital bed system dimensional and assessment guidance to reduce entrapment dated [DATE], indicated the area between the mattress and a single rail support (such as a grab bar) is a potential area of entrapment, known as zone three. The FDA guideline indicated facilities should consider mattress compressibility which may change over time due to wear, shift of the mattress, and loose rails. The FDA guideline cautioned that a restless resident may enlarge the space by compressing the mattress, and the space may also change as the head section of a bed is raised. The FDA guideline dimensional limit recommendation for zone three is a space of less than 4 ¾ inches between the grab bar and the mattress. The bed manufacturer's guidelines dated [DATE], indicated compliance to the dimensional guidelines set by the FDA for reducing the risk of entrapment is primarily the responsibility of the facility. The guidelines described the Panacea Flip mattress to have a softer heel section and a built-in foam perimeter. The guidelines indicated the mattress had a soft side and a firm side, which was labeled on the mattress. The guidelines specified for the Panacea Flip mattress to have the labeled head end of the mattress positioned at the head of the bed. The Panacea Flip mattress had a specific head end and foot end documented on the foam core as well as the mattress cover. The guide indicated a maintenance inspection should be performed on the Panacea Flip mattress at least every three months to determine fire barrier intactness and soundness of the foam core. On [DATE], at 2:30 p.m. to 3:30 p.m. and [DATE], at 1:00 p.m. to 2:07 p.m. observation was conducted of the engineering manager (EM)-H, who measured zone three (the area between the grab bar post and the mattress edge) of all 85 facility beds. R1's bed and mattress were in storage room 103. R1's mattress measured 1 ¾ inch in zone three on the left and right sides of the bed. Print on the mattress indicated it was a Panacea Flip mattress. R1's mattress was observed to have the head end at the foot end of the bed, and the soft side was facing up. R1's medical record was reviewed. R1 was admitted to the facility due to cellulitis, pain and weakness. R1's assessment for use of physical devices dated [DATE], indicated R1 required the use of left and right grab bars attached to the sides of R1's bed due to weakness, fatigue, and to facilitate independence. R1's communication, hearing, vision, and oral assessment dated [DATE], indicated R1 had clear speech, adequate hearing, adequate vision with glasses, and was able to make her needs known. R1's updated use of physical device form dated [DATE], indicated R1 was frequently self-transferring in her bedroom, had Parkinson's disease, confusion, and was inconsistent in locking the wheelchair breaks. R1's Brief Interview of Mental Status (BIMS) dated [DATE], with a score of 14 out of 15, indicated R1 was cognitively intact. R1's room was directly across the hall from the nurse's station. A facility resident occurrence report dated [DATE], indicated R1 was found by licensed practical nurse (LPN)-A at approximately 5:30 a.m. R1 was unresponsive and lying face down with her head between the mattress and grab bar on her bed with her legs hanging off the bed. R1 was not breathing and had no pulse. Cardiopulmonary resuscitation (CPR) was initiated by facility staff, 911 was called, and R1 died at the facility. The medical examiner examined R1 at the facility and removed her. An interview was conducted with LPN-A at 10:15 a.m. on [DATE]. LPN-A stated she had gone to R1's room to check her vital signs for the morning. LPN-A entered R1's room and went around the curtain when she saw R1 on the bed, face down with her legs and feet off the side of the bed, and her toes touching the floor. LPN-A called for LPN-E and they lifted R1 off the bed and onto the floor. LPN-A stated she checked R1's pulse, breathing, and started compressions while LPN-E called 911. An interview was conducted with LPN-E at 9:44 a.m. on [DATE]. LPN-E stated he saw R1 at about 4:00 a.m. and at that time R1 had been lying on her back in bed with the call light on her chest. LPN-E stated a little while later he heard LPN-A call out for help. LPN-E stated he went into R1's room and saw R1 lying face down on the bed. LPN-E stated R1's head was wedged between the mattress and the grab bar and R1's feet were touching the floor. LPN-E assisted LPN-A to lift R1 off the bed and onto the floor. LPN-E stated there was a reddened mark in the shape of the grab bar on R1's left cheek and a reddened area where the mattress touched R1's right cheek. LPN-E stated he did CPR until emergency medical services (EMS) came on site. An interview was conducted with a medical examiner (ME)-F at 3:26 p.m. on [DATE]. ME-F stated R1's injuries were consistent with a compromised airway which lead to death by asphyxia due to entrapment of the head. ME-F stated there was an abrasion on the left side of R1's chin, pressure zones (areas where an object was pressing) on R1's abdomen, and a freshly bruised area on the front right side of R1's neck. ME-C stated asphyxia could also be due to pressure on the abdomen, as R1 was found lying face down on the bed with her arms underneath her abdomen. R2's bed and mattress were observed on [DATE], at 1:51 p.m. in R2's bedroom. The mattress on the bed was measured by EM-H. R2's bed had a 4 ½ inch gap on the left side of the bed in zone three between the mattress and the grab bar and a 6 inch gap on the right side of the bed in zone three between the mattress and the grab bar. R2's medical record was reviewed. R2's [DIAGNOSES REDACTED]. R2's care plan dated [DATE] indicated R2 attempted to self-transfer at times. R2's skin integrity care plan dated [DATE], indicated staff were to encourage R2 to sleep in his bed in order to elevate his lower extremities. R2's physical devices assessment dated [DATE], indicated R2 required a grab bar on his bed on both the left and right sides. R2's bed mobility care plan dated [DATE] indicated R2's bed was supplied by a custom medical supply company. An interview was conducted with the administrator (ADM)-F at 10:36 a.m. on [DATE]. ADM- F stated new grab bars were installed in the fall of 2016 on the resident beds that previously had half rails on them. ADM-F stated the facility relied on the manufacturer to ensure the rails, mattresses, and beds were all compatible. ADM-F stated the facility had no policy for maintenance of grab bars, mattresses, or beds but had maintenance staff fix things as issues came up. ADM-F stated the facility had no schedule for inspection of new bed and mattress sets or ongoing measurement of zones of entrapment. An interview was conducted with EM-H at 4:00 p.m. on [DATE]. EM-H stated the grab bars were replaced on beds that previously had half rails. EM-H stated there was no policy to measure beds for zones of entrapment when new beds arrived or on an ongoing basis.

Based on observation, document review and interview the facility failed to ensure a resident identified at risk for skin breakdown consistently received services and treatments identified in the plan of care and modified the interventions to prevent further breakdown in skin for 1 of 1 (R98) resident reviewed for skin break down. The facility also failed to explain risks and benefits to resident/family regarding refusal of care. Findings include: On 8/24/16 at 8:24 a.m. the nursing assistant (NA)-C provided morning cares for R98. After changing an incontinence pad the registered nurse (RN)-D brought in treatment creams for R98. RN-D indicated the excoriated open area on the buttocks was less than 1 inch and had two small open areas above it. The open area was bright red and there was no drainage. [MEDICATION NAME] (moisture barrier) was applied to the area. R98 was assisted with dressing, transferred to wheelchair and was taken to the dining room for breakfast. RN-D indicated the unit clinical coordinator took the wound measurements and charted on the wound. RN-D added R98 refuses to lay down during the day or be checked and changed. R98 had [DIAGNOSES REDACTED]. The annual minimum data set ((MDS) dated [DATE] indicated R98 did not have a pressure ulcer but was at risk and did have a moisture associated skin damage (MASD). The MDS identified R98 had severe impaired cognition, needed extensive assist of one for all transfers, bed mobility and toileting, and was always incontinent and not on a toileting program. The annual MDS did not identify any behaviors. The quarterly MDS, dated [DATE] identified R98 with severe impaired cognition, at risk for pressure ulcers, did have MASD, and needed extensive assist for all turning repositioning and toileting. No behaviors were noted. A review of the most current medical doctor's notes dated 6/16/16 indicated R98 had a coccyx wound and was getting [MEDICATION NAME] to the area. A review of body audit forms for 8/21/16 indicated the resident's buttock was red and excoriated. A progress note by the dietician dated 8/22/16 referred to body audit and excoriated buttocks and groin. Review of the July 1, 2016 Wound Assessment Flow Sheet (WAFS) progress note indicated R98 had three open areas on the buttocks, the areas appeared as slit like openings. The areas were intact and resolved on 7/22/16. On 8/23/16 an area identified as moisture acquired skin damage(MASD) on the left buttocks that was .6 x .6 and 100% granulated tissue. The wound had scant serosanguineous drainage. Pass treatment of [REDACTED]. On 8/25/16 the WAFS indicated the wound was 4.8 x 2.0 with 90% hard red raised skin. [MEDICATION NAME] cream was applied with mepiplex to cover. The note indicated the nurse practitioner had been requested to assess the area. The most current skin risk and braden assessment completed on 8/23/16 identified R98 as a moderate risk for skin breakdown, The assessment indicated the resident had an air mattress and cushion in wheelchair, had a turn and reposition schedule of 2 -21/2 hours and had a check and change schedule for urinary incontinence. The assessment indicated the resident did not have any preferences or resistance to a particular position. The summary indicated interventions as specific turning and repositioning and pressure reducing devices, a scheduled turning and repositioning check and change, pressure reliving air mattress [MEDICATION NAME] cream and dressing to prevent further breakdown. The evaluation of interventions indicated resident had a history of [REDACTED]. Excoriation noted on left buttock with minimal bleeding. There was no indication of refusal of turning/repositioning schedule or of checking and changing of incontinent products, The current care plan, reviewed on 8/23/16, identified the resident was at risk for skin break down and had a history of [REDACTED]. The care plan identified R98 needed extensive assistance from one staff for repositioning and changing of incontinent products, however it lacked direction of approaches to resident's refusal of being repositioned and checked for incontinence. The care plan lacked evidence risks and benefits of refusals of cares had been explained to resident/family. 8/24/16 at approximately 1:00 p.m. R98 was sitting in the wheelchair in room with a tray table pulled close to the chair and a glass of orange beverage was near by. On 8/24/16 at 2:15 p.m. NA-C reported she repositioned R98 after breakfast and to check her, but R98 refused and would not lay down. NA-C attempted to reposition R98 in her wheelchair. NA-C indicated she also offered to lay R98 down in the afternoon and again R98 refused. NA-C verified R98 had been in the wheelchair since 8:30 a.m. and was still in the same incontinence brief. On 8/24/16 at approximately 2:45 p.m. RN-C reported R98 had refused to be repositioned or to lay down in bed this shift. On 8/24/16 at 1:45 p.m. the registered nurse clinical coordinator (RN)-C verified the open areas on the buttocks were reoccurring and they had just healed in July. The area had been reoccurring since February 2016. RN-C reported the wounds kept returning due to resident's incontinence of bowel and bladder and ongoing refusals to lay down and to be repositioned. RN-C verified the care plan did not address the behavior of continued refusals of identified cares and repositioning. RN-C also indicated there was no documentation that indicated risks and benefits had been discussed with the resident or family. On 8/25/16 from approximately 9:00 a.m. R98 was eating breakfast in main dining room and was taken to her room at 9:42 a.m. R98 sat in her room in the wheelchair with window shade opened. The nursing assistant asked if she wanted to lay down and R98 declined. The nursing assistant told R98 she would return later. At 10:13 a.m. the clinical coordinator, the nursing assistant and the nurse practitioner entered the room and spoke to R98. The nursing assistant asked R98 if she could lay her down, and R98 refused. The RN-C explained because the wound had changed, the nurse practitioner was going to assess the area. Because R98 refused, the team agreed to try at a later time. On 8/25/16 at approximately 2:00 p.m. the RN-C reported the wound was assessed by the nurse practitioner, however documentation was never provided. The care plan had been updated to indicate new interventions developed as well as risks and benefits had been explained to resident and guardian. A copy of the nurse practitioner note and a policy for care plans and skin breakdown were requested however, not provided. | | |

Based on observation, interview and document review, the facility failed to revise the comprehensive care plan to include interventions for skin breakdown and reflect the refusal of care for 1 of 1 resident (R98) reviewed for non pressure related skin concerns. The care plan did not identify risks and benefits explained to the guardian/resident. Findings included: On 8/24/16 at 8:24 a.m. the nursing assistant (NA)-C provided morning cares for R98. After changing an incontinence pad the registered nurse (RN)-D brought in treatment creams for R98. RN-D indicated the excoriated open area on the buttocks was less than 1 inch and had two small open areas above it. The open area was bright red and there was no drainage. [MEDICATION NAME] was applied to the area. R98 was assisted with dressing, transferred to wheelchair and was taken to the dining room for breakfast. RN-D indicated the unit clinical coordinator took the wound measurements and charted on the wound. RN-D added R98 refuses to lay down during the day or be checked and changed. R98 had [DIAGNOSES REDACTED]. The annual minimum data set ((MDS) dated [DATE] indicated R98 was at risk for skin break down, did not have a pressure ulcer but was at risk and did have a moisture associated skin damage (MASD). The MDS identified R98 had severe impaired cognition, needed extensive assist of one for all transfers, bed mobility and toileting, and was always incontinent and not on a toileting program. The annual MDS did not identify any behaviors. Review of the July 1, 2016 Wound Assessment Flow Sheet (WAFS) progress note indicated R98 had three open areas on the buttocks, the areas appeared as slit like openings. The areas were intact and resolved on 7/22/16. On 8/23/16 an area identified as moisture acquired skin damage(MASD) on the left buttocks that was .6 x .6 and 100% granulated tissue. The wound had scant serosanguineous drainage. Pass treatment of [REDACTED]. On 8/25/16 the WAFS indicated the wound was 4.8 x 2.0 with 90% hard red raised skin. [MEDICATION NAME] cream was applied with mepiplex to cover. The note indicated the nurse practitioner had been requested to assess the area. The current care plan, reviewed on 8/23/16, identified the resident was at risk for skin break down and had a history of [REDACTED]. The care plan identified R98 needed extensive assistance from one staff for repositioning and changing of incontinent products, however it lacked direction of approaches to resident's refusal of being repositioned and checked for incontinence. The care plan lacked evidence risks and benefits of refusals of cares had been explained to resident/family. 8/24/16 at approximately 1:00 p.m. R98 was sitting in the wheelchair in her room with a tray table pulled close to the chair and a glass of orange beverage was near by. On 8/24/16 at 2:15 p.m. NA-C reported she repositioned R98 after breakfast and checked the brief, but R98 refused and would not lay down. NA-C attempted to reposition R98 in the wheelchair. NA-C indicated she also offered to lay R98 down in the afternoon and again R98 refused. NA-C verified R98 had been in the wheelchair since 8:30 a.m. and was still in the same incontinence brief. On 8/24/16 at approximately 2:45 p.m. RN-D reported R98 had refused to be repositioned or to lay down in bed this shift. On 8/24/16 at 1:45 p.m. the registered nurse clinical coordinator (RN)-C verified the open areas on the buttocks were reoccurring and they had just healed in July. The area had been reoccurring since February 2016. RN-C reported the wounds kept returning due to resident's incontinence of bowel and bladder and ongoing refusals to lay down and to be repositioned. RN-C verified the care plan did not address the behavior of continued refusals of identified cares and repositioning. RN-C also indicated there was no documentation that indicated risks and benefits had been discussed with the resident or family. A copy of a policy for care plans and skin breakdown were requested however, not provided.

Based on record review and interview, the facility failed to develop a care plan that included non pharmalogical interventions for 1 of 5 residents (R192) who was reviewed for unnecessary medication. Findings include: During random observations during stage one, R192 was observed visiting with his wife in his room. When approached R192 appeared very calm and agreeable but unable to participate in an interview. On 8/24/16 at 2:15 p.m. R192 was sitting in a wheelchair at his doorway to his room. Several staff persons stopped by and spoke to the resident R192 would ask about his wife and was told he had just gotten off the phone with her. Afterwards when staff had left the area, R192 continued to sit in the area and softly call out help me and ask where's my wife. A review of R192's medical record indicated physician orders [REDACTED]. A Psychoactive Drug Assessment (PDA) dated 8/12/16 indicated the resident was currently receiving an anti psychotic medication ([MEDICATION NAME]) for delusional disorder and indicated that non pharmalogical interventions currently being used for R192 included reassurance, validation and talking about his wife. The Psychoactive Drug Assessment indicated R192 currently was receiving an anti depressant medication for failure to thrive. Target behaviors included aggression, kicking hitting, refusal to go to bed and refusal of cares, yelling and calling out help me and paranoid statements. Non pharmacological interventions currently being used included reassurance R192's wife would visit, listening to favorite radio station, staff talking to him, calling his wife, repositioning and giving him something to drink. It was noted R192 like to sit in the entry way of his room and people watch. A review of R192's care plan, last revised 12/10/15, identified a focus that read: I use [MEDICAL CONDITION] medications, antipsychotic and antidepressant r/t (related to) Dementia with behavioral disturbance. Depression, I have episodes of refusal of cares, refusal to get out of bed, yelling kicking depressive statement withdrawn, little interest in eating, asking for staff to take me home, directions to parking lot . Interventions included allow resident to sleep during the night, however it lacked other non pharmacological interventions identified on the PDA. During an interview with nursing assistant (NA)-B on 8/24/16 at 2:30 p.m. indicated R192's behavior would be yelling out most of the time and when his wife did not visit, R192 would be yelling for her and refusing cares. R192 would refuse to go to meals as well, and staff would encourage him to attend by telling him what special foods were being served. On 8/24/16 at 1:45 p.m. the unit clinical nurse coordinator (RN)-B verified the care plan lacked non pharmacological interventions that would direct staff techniques to address R192.

Based on observation, document review and interview, the facility failed to develop non pharmalogical interventions for the continual use of psychoactive medication for 1 of 5 residents (R192) who was reviewed for unnecessary medications. Findings include: During random observations during stage one, R192 was observed visiting with his wife in his room. When approached R192 appeared very calm and agreeable but unable to participate in an interview. On 8/ 24/16 at 2:15 p.m. R192 was sitting in a wheelchair at his doorway to his room. Several staff persons stopped by and spoke to the resident R192 would ask about his wife and was told he had just gotten off the phone with her. Afterwards when staff had left the area, R192 continued to sit in the area and softly call out help me and ask where's my wife. A review of R192's medical record indicated physician orders [REDACTED]. A Psychoactive Drug Assessment (PDA) dated 8/12/16 indicated the resident was currently receiving an anti psychotic medication ([MEDICATION NAME]) for delusional disorder and indicated that non pharmalogical interventions currently being used for R192 included reassurance, validation and talking about his wife. The Psychoactive Drug Assessment indicated R192 currently was receiving an anti depressant medication for failure to thrive. Target behaviors included aggression, kicking hitting, refusal to go to bed and refusal of cares, yelling and calling out help me and paranoid statements. Non pharmacological interventions currently being used included reassurance R192's wife would visit, listening to favorite radio station, staff talking to him, calling his wife, repositioning and giving him something to drink. It was noted R192 like to sit in the entry way of his room and people watch. A review of R192's care plan, last revised 12/10/15, identified a focus that read: I use [MEDICAL CONDITION] medications, antipsychotic and antidepressant r/t (related to) Dementia with behavioral disturbance. Depression, I have episodes of refusal of cares, refusal to get out of bed, yelling kicking depressive statement withdrawn, little interest in eating, asking for staff to take me home, directions to parking lot . Interventions included allow resident to sleep during the night, however it lacked other non pharmacological interventions identified on the PDA. During an interview with nursing assistant (NA)-B on 8/24/16 at 2:30 p.m. indicated R192's behavior would be yelling out most of the time and when his wife did not visit. R192 would be yelling for he, refusing cares, would refuse to go to meals as well, and staff would encourage him to attend by telling him about the special foods that were being served. On 8/24/16 at 1:45 p.m. the unit clinical nurse coordinator (RN)-B verified the care plan lacked non pharmacological interventions that would direct staff with techniques to address R192's behaviors.