Every finding on record at Larksfield Place

The facility reported a census of 74 residents. Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for food borne bacteria, by failing to ensure the ice machine had an appropriate drainage air gap from the tubing to the floor drain, as required. Findings included: - During an initial tour of the kitchen on 10/07/24 at 10:35 AM, revealed the facility ice machine, used to supply ice to residents of the facility, did not have appropriate drainage. The draining tube from the ice machine fed directly into the floor drain, which contained small pieces of trash and debris, and lacked an air gap, as required. On 10/07/24 at 10:44 AM, Dietary Staff BB stated the draining tube from the ice machine should go into the floor drain. The facility policy for Ice Machine Safety, undated, included: The ice machine will be maintained and cleaned by the Environmental Service Staff. The facility failed to ensure the ice machine had an appropriate drainage air gap from the tubing to the floor drain, as required.

The facility reported a census of 74 residents with 20 residents sampled, including five residents reviewed for indwelling urinary catheter (a thin, hollow tube that is inserted into the bladder through the urethra to drain and collect urine). Based on observation, interview and record review, the facility failed to provide appropriate catheter care for two Residents (R)47, and R58 with indwelling urinary catheters, in a clean and sanitary manner. Findings included: - Review of Resident (R)47's electronic medical record (EMR) revealed a diagnosis of neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of one, indicating severe cognitive impairment. He had an indwelling urinary catheter (a thin, hollow tube that is inserted into the bladder through the urethra to drain and collect urine) and was dependent on staff for toileting needs. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 09/27/24, documented the resident had an indwelling urinary catheter due to a neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system). The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of two, indicating severe cognitive impairment. He had an indwelling urinary catheter and was dependent on staff for toileting needs. The bowel and bladder care plan, revised 09/23/24, instructed staff to provide daily catheter care, every shift. Review of the resident's EMR, revealed the following physician's order: Licensed Nurse (LN) to provide catheter care every shift, ordered 09/29/23. On 10/07/24 at 09:39 AM, the resident sat in his recliner in his room, with the door open. The resident's catheter bag rested directly on the floor and lacked a dignity bag. On 10/08/24 at 11:25 AM, the resident sat in his recliner in his room, with the door open. The resident's catheter bag was half in and half out of a dignity bag and rested directly on the floor. On 10/08/24 at 10:51 AM, Certified Nurse Aide (CNA) O stated all catheter bags should be kept in a dignity bag. On 10/08/24 at 11:25 AM, LN I stated staff should ensure catheter bags are always kept in a dignity bag. On 10/09/24 at 08:16 AM, Administrative Nurse D stated it was the expectation for staff to ensure resident's catheter bags are always kept fully inside a dignity bag. The facility policy for Catheters, dated 01/08/18, included: Catheter drainage bags shall be covered when the resident was out of the room or up in their chair. The facility failed to ensure this dependent resident's indwelling catheter bag was kept off of the floor at all times. 28560 - Review of Resident (R)58's medical record revealed diagnoses that included urinary retention (inability to empty urine from the bladder), renal failure, history of repair of femur (long bone in the upper leg), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 13, which indicated normal cognitive function. The resident had impairment on one side of the lower extremities and utilized a walker/wheelchair. The resident had a urinary catheter (a flexible tube that is inserted through the urethra [the external opening of a small tubular structure that drains urine from the bladder] and into the bladder to drain urine into a collection bag). The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 07/20/24, assessed the resident required assistance with toileting needs and incontinent episodes. The Care Plan reviewed 07/22/24, 08/12/24 and 10/08/24, instructed staff with the following interventions: On 08/08/24, the day nurse was to provide a leg bag (a slim bag low volume bag that attached to the leg) for urinary drainage daily, and a night bag (a large volume urine collection bag) at bedtime. Staff instructed to change the catheter monthly and as needed. Staff were to provide catheter care every shift and refer to urology as needed. A Physician's Order dated 08/08/24, instructed staff to insert a size 16 French (a type of catheter) urinary catheter with a 10-millimeter bulb (a balloon on the tip of the catheter to hold the catheter in place in the bladder and provide catheter care twice a day for hydronephrosis (a build-up of urine in the kidneys) and urinary retention. Observation, on 10/08/24 at 11:10 AM, revealed the resident seated in his wheelchair. The leg bag was attached to his right lower leg. The drain spout hung down from the lower edge of the bag and lacked a protective cap to keep it from touching unclean surfaces. Interview, on 10/08/24, at 11:10 AM, with Administrative Nurse F, confirmed the lack of drain cover, and after investigation, discovered the supplier sent the wrong leg bags and she would replace the resident's current leg bag with a leg bag with a protective cap. The facility policy Catheters dated 01/11/24, instructed staff to ensure the appropriate treatment and services are provided to the resident to prevent and/or treat urinary tract infections. The facility failed to ensure staff provided sanitary enclosed urine collection bag for this resident to prevent contamination/infection.

The facility reported a census of 74 residents with 20 residents sampled for review, including one resident reviewed for hospitalization . Based on observation, interview, and record review, the facility failed to complete an accurate Minimum Data Set (MDS) for one Resident (R)70, regarding discharge to an acute hospital. Findings included: - Review of Resident (R)70's electronic medical record (EMR) included a diagnosis of type II diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Modification of Admission Minimum Data Set (MDS), dated [DATE], documented the resident admitted to the facility on [DATE], from an acute hospital. She had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The resident's overall goal was to discharge to the community. The Return to Community Referral Care Area Assessment (CAA), dated 06/23/24, did not trigger. The Discharge MDS, dated [DATE], documented the resident discharged from the facility to an acute hospital on 07/09/24. She had a BIMS score of 14, indicating intact cognition. The baseline care plan, dated 06/19/24, documented the resident's goal was to discharge to the community with home health. Review of the resident's EMR revealed a physician's order for the resident to discharge to home, ordered 07/09/24. Review of the resident's EMR revealed a Discharge Summary, dated 07/09/24. Review of the resident's EMR included documentation that the resident discharged to home on 07/09/24 at 02:15 PM. On 10/09/24 at 11:35 AM, Administrative Nurse F stated the resident did not discharge to an acute hospital but had discharged to home. The Discharge MDS, dated [DATE], was inaccurate. The facility utilized the Resident Assessment Instrument (RAI) for the accurate completion of MDSs. The facility failed to complete an accurate discharge MDS for this resident who discharged to home.

The facility identified a census of 74 residents with 20 residents sampled, including two residents reviewed for positioning. Based on observation, interview, and record review, the facility failed to ensure proper wheelchair positioning for one Resident (R)5. Findings included: - Review of Resident (R)5's electronic medical record (EMR) included a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of one, indicating severe cognitive impairment. She was dependent on staff for mobility in her wheelchair and all transfers. The Functional Abilities Care Area Assessment (CAA), dated 10/03/23, did not trigger. The Quarterly MDS, dated [DATE], documented the staff assessment for cognition revealed severe impairment. She was dependent on staff for mobility in her wheelchair and transfers. The care plan for Activities of Daily Living (ADL), revised 07/29/24, instructed staff the resident had impaired cognition and was dependent on staff for wheelchair mobility. Review of the resident's EMR, from 06/07/24 through 10/07/24, revealed the resident was dependent on staff for wheelchair mobility. On 10/07/24 at 11:01 AM, the resident sat in her wheelchair. Her left ankle crossed over her right ankle and her right foot dangled above the footrest of the wheelchair. On 10/08/24 at 08:53 AM, the resident sat in her wheelchair in the commons area. Her left ankle crossed over her right ankle and her right foot dangled above the footrest of the wheelchair. On 10/08/24 at 12:51 PM, the resident sat in her wheelchair near the nurses' desk. Her left ankle crossed over her right ankle and her right foot dangled above the footrest of the wheelchair. On 10/08/24 at 10:51 AM, Certified Nurse Aide (CNA) O stated the resident's feet did not come down far enough to rest on the footrests of the wheelchair. On 10/08/24 at 11:15 AM, CNA N stated the resident's feet did not usually come down far enough to reach the footrests of the wheelchair. On 10/08/24 at 01:07 PM, Licensed Nurse (LN) I stated she had not noticed the resident's feet not reaching the footrests of her wheelchair. On 10/09/24 at 08:16 AM, Administrative Nurse D stated therapy would need to evaluate the resident to determine if the resident's feet should reach the footrests. The facility policy for Wheelchair Mobility/Use of Footrests, dated 09/06/19, included: The facility shall keep all residents safe and to protect them from injury. Staff shall apply footrests to the wheelchair and place the resident's feet flat on the footrests. The facility failed to ensure proper wheelchair positioning for this dependent resident.

The facility reported a census of 74 residents with 20 residents sampled, including nine residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to ensure one Resident (R)3's toilet safety rail was secure and R 29, related to failure to ensure the resident was safe in the use of his lift chair. Findings included: - Review of Resident (R)3's electronic medical record (EMR) revealed the resident had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. She has no impairment in functional range of motion (ROM) and was dependent on staff for toileting hygiene. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 07/13/24, documented the resident was dependent on staff for toileting cares. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of three, indicating severe cognitive impairment. She has no impairment in functional ROM and was dependent on staff for toileting hygiene. The urinary incontinence care plan, revised 07/22/24, instructed staff the resident was dependent with toileting hygiene. Review of the EMR, from 08/01/24 through 10/07/24, revealed the resident was dependent on staff for toileting transfers and toileting hygiene. On 10/07/24 at 10:59 AM, the toilet safety rail in the resident's private bathroom was extremely loose and lacked the rubber boot where the rail met the floor. On 10/08/24 at 08:41 AM, the toilet safety rail in the resident's private bathroom was extremely loose and lacked the rubber boot where the rail met the floor. On 10/08/24 at 11:07 AM, Certified Nurse Aide (CNA) M and CNA P transferred the resident from her wheelchair to the toilet with the sit to stand mechanical lift (helps transfer patients from one seated surface to another) and placed her on the toilet. The resident rested her right arm on the toilet safety rail on the right side of the toilet. The safety rail moved several inches while the resident's arm rested on the rail. On 10/09/24 at 10:12 AM, Housekeeping/Maintenance staff U stated he checked the toilet safety rails monthly and had not seen the rubber boot missing from the resident's toilet safety rail. On 10/09/24 at 08:16 AM, Administrative Nurse D stated it was the expectation for resident equipment to be in good condition. The facility policy for Preventive Maintenance and Inspections, undated, included: The facility shall provide a safe environment for residents and promote the maintenance of fixtures and equipment in a state of good repair and condition. The facility failed to ensure this dependent resident's toilet safety rail was secure. - Review of Resident (R)29's electronic medical record (EMR) revealed a diagnosis of Parkinson's disease (slowly progressive neurological disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. He was dependent on staff for chair to bed to chair transfers, had no limitation in range of motion (ROM) and had not had any falls since his prior assessment. The Falls Care Area Assessment (CAA), dated 04/26/24, did not trigger. The Functional Abilities CAA, dated 04/26/24, documented the resident had impaired balance during transfers and required staff assistance. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of 12, indicating moderately impaired cognition. He was dependent on staff for chair to bed to chair transfers, had no limitation in ROM and had not had any falls since his prior assessment. The care plan for safety, revised 07/26/24, instructed staff the resident was at risk for falls related to a history of falls prior to admission, impaired mobility, and a diagnosis of Parkinson's disease. Review of the resident's EMR revealed the fall assessments which placed him at a high risk for falls, dated: 10/03/23, 08/25/24 and 10/08/24. Review of the resident's EMR revealed a lift chair assessment, dated 02/28/22, which indicated the resident was safe to use his lift chair recliner. Review of the resident's EMR revealed a lift chair assessment, dated 08/25/24 and 08/26/24, which indicated the use of a lift chair remote and/or chair was a safety risk. No other lift chair assessments were available. Review of the resident's EMR revealed on 08/25/24, at 08:15 AM, staff observed the resident on the floor of his room, resting on his left side, in front of the lift recliner which was in the fully extended position. The alert and oriented resident with confusion stated he had tried to get up to walk on his own and had fallen. The resident complained of left hip pain and no had no other obvious injuries, at that time. Staff assisted the resident back into his lift reclining chair and unplugged the recliner. Staff obtained a physician's order for a mobile x-ray of the left hip which showed no acute fracture. On 10/08/24 at 12:53 PM, a family member stated the resident had experienced increased confusion in August 2024. The resident utilized the remote control to raise his chair to a fully upright position and fell to the floor. The facility unplugged the lift chair and removed the remote control of the recliner from his room. On 10/08/24 at 10:51 AM, Certified Nurse Aide (CNA) O stated the resident's lift chair was unplugged due to him not being able to safely use the chair on his own. He had an increase in confusion and had lifted the chair fully upright and fallen from the chair. On 10/08/24 at 12:57 PM, CNA M stated the resident had been really confused when he used his remote control to lift his chair all the way up, causing him to fall to the floor. Since that time, the chair has been kept unplugged. On 10/08/24 at 01:07 PM, Licensed Nurse (LN) I stated lift chair assessments were not done on a routine basis. On 10/09/24 at 08:16 AM, Administrative Nurse E stated the resident experienced an increase in confusion at the time of his fall. Administrative Nurse E confirmed staff had not completed a lift chair assessment, at that time. On 10/09/24 at 08:16 AM, Administrative Nurse D stated staff were to complete lift chair assessments upon admission, with significant changes and following a fall from a lift chair. A resident would be considered safe to use a lift chair if they were able to demonstrate safe usage of the chair and remote control. Administrative Nurse D confirmed staff had not completed a lift chair assessment with the resident's significant change on 04/26/24. The facility policy for Lift Recliner Chair Policy, undated, included: Residents will be assessed for safe use of a lift recliner chair upon admission, after a fall, or upon experiencing a significant change in condition. The facility failed to complete a lift chair assessment for this dependent resident with a significant change in condition.

The facility reported a census of 74 residents with 20 residents selected for review, which included two residents reviewed for urinary catheters (a flexible tube inserted through the urethra [the external opening of the urinary tract] and into the bladder). Based on observation, interview, and record review, the facility failed ensure consistent monitoring of one Resident (R)58's penile erosion (a split in the urethra) caused by pressure of a urinary catheter. Findings included: - Review of Resident (R)58's medical record revealed diagnoses that included urinary retention (inability to empty urine from the bladder), renal failure, history of repair of femur (long bone in the upper leg), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 13, which indicated normal cognitive function. The resident had impairment on one side of the lower extremities and utilized a walker/wheelchair. The resident had a urinary catheter (a flexible tube that is inserted through the urethra [the external opening of a small tubular structure that drains urine from the bladder] and into the bladder to drain urine into a collection bag). The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 07/20/24, assessed the resident required assistance with toileting needs and incontinent episodes. The Care Plan reviewed 07/22/24, 08/12/24 and 10/08/24, instructed staff with the following interventions: On 08/12/24, the day nurse was to provide a leg bag (a slim bag low volume bag that attached to the leg) for urinary drainage daily, and a night bag (a large volume urine collection bag) at bedtime. Staff instructed to change the catheter monthly and as needed. Staff were to cleanse the upper right and left side of the urethral opening and down the shaft with a wound cleanser or normal saline, pat dry, and reapproximate (bring back together) the skin if able. Staff were to apply steri strips (a type of adhesive medical tape used to approximate edges) every three days if needed, and as needed if the dressing gets wet. Staff were to make sure the catheter anchor was applied securely. Staff were to provide catheter care every shift and refer to urology as needed. A Physician's Order dated 08/08/24, instructed staff to insert a size 16 French (a type of catheter) urinary catheter with a 10-millimeter bulb (a balloon on the tip of the catheter to hold the catheter in place in the bladder and provide catheter care twice a day for hydronephrosis (a build-up of urine in the kidneys) and urinary retention. A Nurse Note dated 09/13/24, documented R58's catheter care as completed, and the nurse noticed a small split to the penis. The nurse applied an ointment containing vitamin A and vitamin D, and educated the resident on the importance of the catheter anchor placement and effects of tugging on the catheter, and informed the nursing manager. A Nurse Note dated 09/17/24, documented the nurse completed catheter care, and noted a split in the resident's penis which measured 3 by 2 (no indication of unit of measure). Documentation revealed the resident occasionally pulled on the catheter and staff educated the resident , and the wound nurse and the medical team notified. A Physician's Order dated 09/18/24 , instructed staff to cleanse the upper right and left side of the urethral opening and down the shaft with wound cleanser or normal saline, pat dry and reapproximate the skin if able with steri strips every three days and as needed. Staff instructed to ensure the catheter anchor was in place and secure. A Physician's Order dated 10/08/24, instructed staff to cleanse the penile erosion with normal saline (a solution used for cleansing wounds), pat dry, approximate the edges of the wound with steristrips, and cover the penis with a mesh sleeve or wrap with Kerlix and secure, daily, and as needed until healed. Review of the September 2024 Treatment Administration Record (TAR) revealed staff provided catheter care three times a day, (on each shift). The resident refused the care on 14 occasions, on the night shift. The resident received the daily care to the penile erosion without refusal. Review of the October 2024 TAR revealed the resident refused the night shift catheter care three times. Interview, on 10/08/24 at 09:26 AM with Licensed Nurse (LN) I, revealed the resident did cooperate with care of the penis erosion and staff ensured the catheter anchor was in place. LN, I stated the wound did not appear to improve but she did not measure the area. . Interview, on 10/08/24 at 10:15 AM, with Consultant Nurse HH, revealed she did not visualize the wound at the time of giving orders for treatment and would expect staff to document the effectiveness of the treatment. Interview on 10/08/24 at 11:02 AM, with Administrative Staff F revealed staff notified her of the wound on 09/18/24 and provided orders for treatment but did not visualize the wound at that time. Administrative Nurse F stated she used a phone application (app) that would take a picture of the wound and the application would provide measurements and documents the wound in the electronic medical record in the Wound and Skin Assessment tab but had not done so (20 days after notification). Observation on 10/08/24 at 11:10 AM, revealed the resident cooperative with examination of the penile erosion. The posterior area of the penis revealed the urethra split revealing a beefy red appearance of the tissue. The resident's penis lacked steri strips, however the catheter tubing was anchored. The resident denied pain. Administrative Nurse F obtained measurements with the phone app and obtained measurements of a length of 1.7 centimeters (cm) and a width of 0.8 cm. Administrative Nurse F cleansed the wound with normal saline, dried the area and applied steri strips. Consultant Nurse HH stated the resident may benefit from a urology consult and may be a candidate for a supra pubic catheter (a catheter that is inserted into the bladder through the abdominal wall). Interview, on 10/09/24 at 10:00 AM with Administrative Nurse D, revealed the facility had a treatment in place and was provided by the day shift nurse but did not realize the resident refused the night shift catheter care. Administrative Nurse D stated the Wound Nurse was responsible for monitoring wounds to determine the effectiveness of the treatments. Interview on 10/09/24 at 10:30 AM with Consulting Physician GG, revealed the erosion was probably due to the urinary catheter, and did not have a concern regarding treatment provided to ensure the catheter was secured in place appropriately. The facility policy Pressure Injury Prediction, Prevention and Treatment Program dated 01/11/24, instructed staff to notify the wound nurse who will utilize the electronic wound app for documentation of the wound to include location, size, length width depth and description the wound bed tissues, edges, and surrounding tissues. The interdisciplinary care plan team will evaluate the plane of care, and the wound team will evaluate wounds routinely until healed. The facility failed to ensure staff monitored this resident's penile erosion to determine the effectiveness of treatment to prevent further injury and infection.

The facility reported a census of 74 residents with 20 residents selected for review, which included six residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure staff followed physician orders for medication for one Resident (R)52 who received a lower dose a chemotherapy (medication used to treat cancer) than ordered by the physician. Findings included: - Review of Resident (R)52's electronic medical record revealed diagnoses that included malignant (cancerous) neoplasm (tumor) of the brain, and post operative repair of femur (bone in upper part of the leg) fracture. The Admission Minimum Data Set (MDS) dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 15, which indicated normal cognitive function. The ADL (Activity of Daily Living) Functional/Rehabilitation Care Area Assessment (CAA), dated 09/30/24, assessed the resident required skilled therapies after a left hip fracture and neoplasm of the brain and required assistance with ADLs due to impaired balance. The Care Plan dated 10/07/24, instructed staff to monitor the resident for effectiveness of pain medication. The resident desired to return home. A Physician's Order dated 10/04/24, instructed staff to administer Temozolomide (a medication used to slow or stop the growth of cancerous brain tumors), 240 milligrams (mg) daily, on an empty stomach (one hour before eating), for five days, for brain neoplasm, and repeat every four weeks. Review of the Medication Administration Record (MAR), for October 2024, revealed the resident received 240 mg of Temozolomide on 10/05/24, 10/06/24 and 10/07/24. Interview, on 10/07/24 at 10:43 AM, with the resident, revealed she was concerned with the administration of her chemotherapy medications and thinks staff did not provide the correct dose. Interview, on 10/08/24 at 08:15 AM, with the resident, revealed she had not received her 08:00 AM dose of Temozolomide, and her breakfast had been delivered and she did not want to eat it until she received her medication, and then waited an hour. Interview, on 10/08/24 at 08:15 AM, with Licensed Nurse K, revealed she was awaiting delivery from a pharmacy so she could administer the correct dose. Interview, on 10/08/24 at 08:30 AM, with Administrative Nurse EE, confirmed the resident received 200 mg of Temozolomide on 10/05/24 instead of the ordered 240 mg. Administrative Nurse EE stated the medication was special ordered from the pharmacy and was available in 100 mg and 140 mg capsules, and the facility initially received 5 capsules of each dose. Administrative Nurse EE stated the resident received two of the 100 mg capsules on 10/05/24 and thought perhaps one of the 100 mg capsules was dropped on the floor and discarded, so the pharmacy had to send out more of the 100 mg capsules Interview on 10/08/24 at 01:30 PM, with Licensed Nurse H, confirmed the resident received 200 mg of Temozolomide, on 10/05/24. The facility policy Medication Administration Policy dated 01/11/24, instructed staff to administer medication to residents as ordered by the physician. The facility failed to ensure staff administered the correct dose of Temozolomide as ordered by the physician to ensure effective treatment for cancerous brain tumor for this resident.

The facility had a census of 59 residents. The facility had a large main kitchen and a satellite kitchen for the long term/skilled branch of the facility. Based on observation, interview, and record review the facility failed to ensure the light fixtures above the food preparation areas in the main facility kitchen were cleaned and the storage shelving without rust. This deficient practice placed residents at risk for food borne illness. Findings included: - On 12/15/22 at 11:00 AM, observation in the main kitchen revealed 19 overhead lights and 10 of the lights had lint on the surface and some small objects inside the cover. On 12/15/22 at 11:20 AM, observation in the main kitchen revealed metal shelving holding steam table pans had a small amount of rust at the edges of three of six of the shelves. The pan were turned upside down directly on the shelves. On 12/15/22 at 11:25 AM, Dietary Staff (DS) BB verified the findings and stated maintenance was responsible for the care and cleaning of the light fixtures and had last checked them in October of this year. The facility's Equipment Maintenance Schedules stated the maintenance department was responsible for maintaining records of equipment maintenance. The schedules did not include light fixtures or shelving. The facility's General Cleaning and Maintenance of Resident Environment policy, dated 04/21/21, stated staff would provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, functional and comfortable interior. The facility failed to ensure the light fixtures above the food preparation areas in the main facility kitchen were cleaned and the storage shelving without rust, placing the residents at risk for food borne illness.

The facility had a census of 59 residents. The sample included 15 residents. Based on record review and interview, the facility failed to provide two sampled residents, Resident (R)7 and R37 (or their representative) the completed Skilled Nursing Facility Advanced Beneficiary Notices (ABN) form 10055, (CMS) Centers for Medicare and Medicare Services. This placed the residents at risk for uniformed decisions regarding skilled services. Findings included: - The Medicare ABN form 10055 informed the beneficiary that Medicare may not pay for future skilled therapy services. The form included an option for the beneficiary to receive specific services listed, and bill Medicare for an official decision on payment. The form stated 1) I understand if Medicare does not pay, I will be responsible for payment, but can make an appeal to Medicare, (2) receive therapy listed, but do not bill Medicare, I am responsible for payment for services, (3) I do not want the listed services. Form 10055 was to include the monetary amount it would cost the resident to continue to receive therapy at the facility. The facility lacked documentation staff provided R7, or his representative, the CMS form 10055 which included the estimated cost documentation for the services to be able to make an informed choice whether or not the resident wanted to receive the items or services, knowing he/she may have to pay out of pocket. The resident's skilled nursing services ended on 07/19/22. The facility lacked documentation staff provided R37, or her representative, the CMS form 10055 which included the estimated cost documentation for the services to be able to make an informed choice whether or not the resident wanted to receive the items or services, knowing he/she may have to pay out of pocket. The resident's skilled nursing services ended on 10/11/22. 12/19/22 01:55PM, Social Services Staff X verified she had not provided the residents the ABN forms when the residents discharged from Medicare Part A. The facility's Medicare Beneficiary Notices policy, dated 04/01/2022, stated the facility would provide the CMS form 10055 to a beneficiary upon discharge from Medicare Part A services so he/she could decide whether or not to get the care that may not be paid for by Medicare. The facility failed to fully inform R7 and R37 of the liability or cost of their continued stay with therapy in the facility after Medicare Part A services ended. This deficient practice placed the two residents at risk to make an uninformed decision regarding the cost of their continued stay.

The facility reported a census of 65 residents, with one main kitchen. Based on observation and interview the facility failed to store foods in a safe and sanitary manner by the failure of staff to date and reseal opened food items, and failure to discard expired food items. Findings included: - On [DATE] at 08:18 AM during initial tour of the main kitchen the following are observed: In the dry storeroom there were two bags of spaghetti noodles, opened, with no open date and one bag of chicken fry mix dated but not resealed closed. In the freezer, noted one bag of chicken breasts with ten pieces inside, one bag of fish fillets with 12 pieces, one bag of French fries, and one bag of potato cakes-- all opened and were not resealed and not dated. In the refrigerator, noted one 30 ounce (oz) container of roasted red pepper pesto, five 30 oz. containers of southwest chipotle pesto, all expired on [DATE]; one five pound tub of whipped whole milk ricotta with a best by [DATE] date (Dietary Staff B stated it would not be used today), one 12 oz tub of hollandaise sauce with a best by [DATE] date, and 10 individual serving containers of Lite and Fit Delish yogurts of various flavors with a best by [DATE] date. During an interview on [DATE] at 08:48 AM Dietary Staff (DS) B removed all items and verified that all items opened should be dated and resealed, and all expiration dates should be observed. DS B expected the staff to follow the policy and reseal and date all opened items and expected all expired items be removed from use. During an interview on [DATE] at 11:10 AM DS C verified the policy instructed the staff to date with an open date and items sealed closed after opening. DS C expected staff to follow the policy. Review of facility policy regarding Labeling and Dating dated [DATE] documented staff would tightly reseal and date all food after opening. The facility failed to store foods in a safe and sanitary manner by the failure of staff to date and reseal opened food times, and failure to discard expired food items.

The facility census was 65 with 16 residents sampled. Based on observation, interview, and record review, the facility failed to verify Resident (R) 10, R157, R48, and R155's Advance Directives (a legal document in which a person specified what actions should be taken for their health), and the facility provided conflicting information regarding the residents code status (decision whether or not to withhold medical intervention in the event the resident's heart stops) to the staff responsible for R10, R157, R48 and R155's care. Findings included: - Review of the [DATE] Care Plan documented R10 had a Do Not Resuscitate (DNR; or no code, a written legal order to withhold cardiopulmonary resuscitation (CPR), in respect of the wishes of a person in case their heart stopped or they stopped breathing) order in chart and staff were to honor R10's decision and would not transfer R10 to the hospital due to the DNR. Review on [DATE] of the Electronic Health Records (EHR) Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record paper chart on [DATE] and [DATE] documented a signed DNR by the physician on [DATE]. The chart also had a red label on the outside, indicating DNR status. A review on [DATE] of the resident home screen via the computer charting system utilized by facility staff, documented Resuscitate: Yes-No CPR/DNR. An observation made on [DATE] at 01:41PM revealed R10 had a green bracelet on her table, that she chose not to wear. An observation made on [DATE] at 10:23AM revealed R10 did not wear a bracelet at all. An interview with R10 on [DATE] at 11:02 AM revealed If my heart stops, just let me go. I don't want it. An interview on [DATE] at 10:34AM with Certified Medication Aide (CMA) I revealed R10's code status could be found on the care card in the bathroom, the computer, and the paper chart. CMA I explained a green label indicated full code and a red label indicated DNR. CMA I stated R10 had a green label on the paper chart and the care card and was therefore a full code. CMA I also stated that residents would wear a bracelet (green or red) to indicate code status, and because R10 did not wear a bracelet, she was a full code. CMA I also stated sometimes residents would remove the bracelets, so it was better to look at the chart. An interview on [DATE] at 11:05AM with CMA D revealed R10 was a DNR. CMA D stated R10 had a signed DNR in her chart indicating she was a DNR but would be considered full code if a printed sheet stated FULL CODE in the front of the chart. CMA D stated the computer charting listed R10 as Resuscitate: Yes-No CPR/DNR and that it confused him, so he would determine R10's code status by looking at the paper chart. An interview on [DATE] at 11:14AM with Licensed Nurse (LN) F revealed she would find R10's code status on the wrist band R10 wore; red indicating DNR and green indicating full code. She would also look at the paper chart and the computer chart which followed the same color code. After looking at the computer chart and seeing Resuscitate: Yes-No CPR/DNR, LN F looked in the paper chart and found a signed DNR but stated R10's code status was confusing, because of conflicting information. LN F stated R10 did not have a DNR order in her chart and became more confused and stated she would call the provider for clarification. In a second interview on [DATE] at 01:45 PM, LN F stated after she spoke with the provider about the concern, the provider called R10's family. LN F stated that the provider wished to have R10 a full code until the family and resident could decide. LN F stated she would place a FULL CODE sheet in the paper chart and said Medical Records staff would update the computer chart with a full code status. During an interview on [DATE] at 02:38 PM Administrative Staff A revealed the only way to have a DNR status is for the physician to order it and then the code status would show up on the banner in the EHR. Administrative Staff A stated a resident could not be a DNR without the order and said on admission, the Social Services Staff obtained the resident's advanced directives (a written document which indicated the medical decisions for health care professionals when the person could not speak) and ensured the label on the chart was completed, the order was entered, and the wrist band was placed on the resident. Administrative Staff A said the Social Services Staff also started the process of getting the order for the DNR if the resident wished to be a DNR, and once the facility received the provider order, the ribbon changed in the computer to a DNR. Administrative Staff A expected this to be done immediately upon receiving of the physician order. Review of the facility Cardiopulmonary Resuscitation/ Do Not Resuscitate policy dated [DATE] documented the facility color coded the outside spine of the resident's chart, placed colored bands on the residents, and with each contact the staff were to verify the placement of the bands on each resident. The facility failed to ensure each resident's code status was clearly defined and reflected in the charting system, in order to honor R10 code status in the event of an emergency situation. - Review of R155's Electronic Health Record (EHR) noted the banner on the opening page documented the resident as a full code (a technique of basic life support to oxygenate the brain and heart until appropriate medical treatment can restore normal heart and ventilation action). Review of R155's Baseline Care plan dated [DATE] documented Do Not Resuscitate (DNR) (a written legal order to withhold cardiopulmonary resuscitation (CPR), in respect of the wishes of a person in case their heart stopped or they stopped breathing) as her code status. Review of the Signed Physician Visit completed on [DATE] documented R155 as a DNR. Review of the facility staffs' Report Sheet documented R155's status as full code. A review of R155's paper chart showed a red label (Facility's indication of DNR) on the spine of the chart. The Advance Directive (a written document that indicated the medical decisions for health care professionals when the person could not speak) tab documented a DNR signed by the resident's physician on [DATE]. During an interview on [DATE] at 10:55 AM, Certified Nurse Aid (CNA) G revealed to find a residents code status staff looked in the EHR, on the Report Sheet that they were to carry, or on the resident's chart. During an interview on [DATE] at 01:14 PM, Licensed Nurse (LN) K revealed to find the residents code status staff looked on the Report Sheets they pick up daily that listed each resident's code status or in the EHR. When asked what she would do if they did not match, she would investigate and look through the chart, and if she could not find a signed DNR, she would contact administration to get them changed to match, which she would do anyway. During an interview on [DATE] at 02:38 PM Administrative Staff A revealed the only way to have a DNR status is for the physician to order it, and then the code status would show up on the banner in the EHR. Administrative Staff A stated a resident could not be a DNR without the order and said on admission, the Social Services Staff obtained the resident's advanced directives and ensured the label on the chart was completed, the order was entered, and the wrist band was placed on the resident. Administrative Staff A said the Social Services Staff also started getting the order for the DNR if the resident wished to be a DNR. Once the facility received the provider order, the ribbon changed in the computer to a DNR. Administrative Staff A expected this to be done immediately upon receiving the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility Cardiopulmonary Resuscitation/ Do Not Resuscitate policy dated [DATE] documented the facility color-coded the outside spine of the resident's chart, placed colored bands on the residents, and with each contact, the staff was to verify the placement of the bands on each resident. The facility failed to ensure each resident's code status was clearly defined and reflected in the charting system to honor each resident's code status in the event of an emergency. - Review of R48's Electronic Health Record (EHR) noted the banner on the opening page documented the resident as a full code (a technique of basic life support for the purpose of oxygenating the brain and heart until appropriate medical treatment can restore normal heart and ventilation action). Review of R48's Baseline Care plan dated [DATE] documented no code status and contained items updated as late as [DATE]. Review of the Signed Physician Visit completed on [DATE] documented R48 as a Do Not Resuscitate (DNR) ( a written legal order to withhold cardiopulmonary resuscitation (CPR), in respect of the wishes of a person in case their heart stopped or they stopped breathing. Review of the facility staffs' Report Sheet documented R48's status as full code. Observation on [DATE] at 01:58 PM revealed R48's wore a red bracelet on his wrist. Interview on [DATE] at 01:58 PM revealed R48 stated the red bracelet on his wrist meant he had chosen to be a DNR. During an interview on [DATE] 03:11 PM Certified Nurse Aid (CNA) J revealed to find a residents code status staff looked in the EHR, on the report sheet that they were to carry, or on the residents chart. During an interview on [DATE] at 03:12 PM Licensed Nurse (LN) H stated to find the residents code status staff looked on the resident's chart or in the EHR. When asked what she would do if they did not match, she stated she would contact the physician. During an interview on [DATE] at 02:38 PM Administrative Staff A revealed the only way to have a DNR status is for the physician to order it and then the code status would show up on the banner in the EHR. Administrative Staff A stated a resident could not be a DNR without the order and said on admission, the Social Services Staff obtained the resident's advanced directives (a written document which indicated the medical decisions for health care professionals when the person could not speak) and ensured the label on the chart was completed, the order was entered, and the wrist band was placed on the resident. Administrative Staff A said the Social Services Staff also started the process of getting the order for the DNR if the resident wished to be a DNR, and once the facility received the provider order, the ribbon changed in the computer to a DNR. Administrative Staff A expected this to be done immediately upon receiving of the physician order. Review of the facility Cardiopulmonary Resuscitation/ Do Not Resuscitate policy dated [DATE] documented the facility color coded the outside spine of the resident's chart, placed colored bands on the residents, and with each contact the staff were to verify the placement of the bands on each resident. The facility failed to ensure each resident's code status was clearly defined and reflected in the charting system, in order to honor each resident's code status in the event of an emergency. - Review of R157's Electronic Health Record (EHR) noted the banner on the opening page documented the resident as a full code (a technique of basic life support to oxygenate the brain and heart until appropriate medical treatment can restore normal heart and ventilation action). Review of R157's Baseline Care plan dated [DATE] documented Do Not Resuscitate (DNR) (a written legal order to withhold cardiopulmonary resuscitation (CPR), in respect of the wishes of a person in case their heart stopped or they stopped breathing) as her code status. Review of the Signed Physician Visits completed on [DATE] and [DATE] documented R157 as a DNR. Review of the facility staffs' Report Sheet documented R157's status as full code. A review of R157's paper chart showed a red label (Facility's indication of DNR) on the spine of the chart. The Advance Directive (a written document that indicated the medical decisions for health care professionals when the person could not speak) tab documented a DNR signed by the resident's physician on [DATE]. During an interview on [DATE] at 10:55 AM, Certified Nurse Aid (CNA) G revealed to find a residents code status staff looked in the EHR, on the Report Sheet that they were to carry, or on the resident's chart. During an interview on [DATE] at 11:00 AM, Certified Nurse Aid (CNA) N revealed to find a residents code status she would have to ask the nurse. During an interview on [DATE] at 08:26 AM, Licensed Nurse (LN) O revealed to find the residents code status staff looked on the Report Sheets, in the EHR, or on the residents chart. She stated they all should match with the same order for each individual resident. During an interview on [DATE] at 02:38 PM Administrative Staff A revealed the only way to have a DNR status is for the physician to order it, and then the code status would show up on the banner in the EHR. Administrative Staff A stated a resident could not be a DNR without the order and said on admission, the Social Services Staff obtained the resident's advanced directives and ensured the label on the chart was completed, the order was entered, and the wrist band was placed on the resident. Administrative Staff A said the Social Services Staff also started getting the order for the DNR if the resident wished to be a DNR. Once the facility received the provider order, the ribbon changed in the computer to a DNR. Administrative Staff A expected this to be done immediately upon receiving the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility Cardiopulmonary Resuscitation/ Do Not Resuscitate policy dated [DATE] documented the facility color-coded the outside spine of the resident's chart, placed colored bands on the residents, and with each contact, the staff was to verify the placement of the bands on each resident. The facility failed to ensure each resident's code status was clearly defined and reflected in the charting system to honor each resident's code status in the event of an emergency.

The facility reported a census of 65 residents, with 16 sampled and four for falls. Based on interviews, observations, and record review, the facility failed to adequately ensure R38's fall interventions were in place to prevent future falls and failed to implement new interventions related to two falls with noted lack of appropriate footwear on R38. Findings included: - Review of R38's pertinent diagnoses from 10/07/20 Physician's Order Electronic Medical Records (EMR) documented: overactive bladder, cognitive impairment (trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life), abnormalities of gait and mobility (difficulties in walking), repeated falls, and pain. Review of the 10/14/20 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 12, indicating moderately impaired cognition. The resident required extensive one-person assistance for all activities of daily living (ADL) but could eat with limited assistance. R38 was occasionally incontinent of urine and not on a toileting program. The MDS noted R38 experienced a fall two to six months prior to admission but had no falls since admission. Review of the 01/12/21 Quarterly MDS documented a BIMS of 15, indicating intact cognition. R38 required extensive one to two-person assistance for all ADLs, except eating. R38 was occasionally incontinent of urine and not on a toileting program. R38 experienced two falls without injury since admission. R38 received seven out of seven days of diuretics (medication that causes increased urination). Review of the 10/14/20 ADL Functional/Rehabilitation Protentional Care Area Assessment (CAA) documented R38 required extensive one-staff assistance with toileting. Review of the 10/14/20 Falls CAA documented R38 had a history of falls due to impaired gait and mobility and required staff assistance with transfers. Review of the Fall Risk Assessment completed on 09/08/20, stated that R38 had a score of 14, indicating high risk for potential falls, and documented R38 was to wear appropriate footwear and non-skid socks to help prevent falls. Another Fall Risk Assessment completed on 11/21/20, stated that R38 had a score of five, indicating low risk for potential falls, and documented R38 was to wear appropriate footwear and non-skid socks to help prevent falls. Another Fall Risk Assessment completed on 01/23/21, stated that R38 had a score of 14, indicating high risk for potential falls, and documented R38 was to wear appropriate footwear and non-skid socks to help prevent falls. Review of the 12/20/20 Care Plan documented R38 was not to be left on the toilet unattended or in the bathroom waiting, initiated on 12/02/20. R38 required extensive one to two-person assistance with a gait-belt for all transfers and toileting, initiated on 10/07/20. Review of the 06/08/20 Admission Data Collection Tool documented R38 required extensive assistance with ADLs and was unsteady on her feet, with a history of falls. Review of the 03/28/21 Post Fall Nursing Report documented R38 thought she could get herself back to the toilet and ended up falling to the floor. A level two injury (hematoma; bruise, large goose egg) noted on the left-side of her forehead post fall. Vital signs (VS), assessment and range of motion (ROM; ensuring that R38 was able to move all body parts appropriately) completed, and neurological checks (neuro checks; ensuring R38 was alert and oriented, without loss of cognition) initiated. The staff applied an ice pack to R38's eye and notified the doctor. The immediate safety intervention identified instructed staff to not leave the resident alone in the bathroom. Review of the Fall Risk Assessment completed on 04/30/21 with a score of 11, indicating high risk for potential falls. The assessment documented R38 was to wear appropriate footwear and non-skid socks to help prevent falls. The Fall risk review and Post Fall Observation Tool were completed on 03/28/21. Witness statements were completed; according to [staff member], R38 requested privacy in the bathroom and to be alone, which staff granted and noted five minutes later, R38 yelled for help. The Interdisciplinary Post Fall Risk Cause Analysis dated 03/29/21 noted R38 received narcotics (pain medication), psychotropics (medication that affect a person's mental state), diuretics (medication to lower blood pressure by increasing urination), and cardiac (heart) medications. The facility identified the causal factor of the fall as R38's self-transferred to the toilet and the facility educated the staff on following care cards and to not leave the resident alone on the toilet. The New fall intervention follow-up was completed on 04/05/21 and signed by the Director of Nursing (DON). The Care Plan was not updated post fall as the interventions were previously listed on the care plan dated 12/02/20. Review of the 04/12/21 Post Fall Nursing Report documented the staff assisted R38 to the floor from the wheelchair. The staff noted no injuries to the resident and notified the provider. The immediate safety intervention identified proper footwear was not in use by R38. The Fall risk review and post fall observation tool were completed on 04/12/21. The 04/13/21 Interdisciplinary Post Fall Risk Cause Analysis identified R38 received narcotics and [CONDITION(S)] medications. The facility identified the causal factor of the fall as the lack of shoes or non-skid socks and no use of a gait belt R38. The facility completed staff education. New fall intervention follow-up was completed and signed by the DON on 04/21/21. The Care Plan intervention updated on 04/12/21 instructed the staff to ensure R38 wore non-skid footwear was in place for all transfers. Review of the 04/15/21 through 04/17/21 Progress notes documented R38 complained of pain in her neck and face. The facial x-ray was obtained showed no fracture (broken bone). An observation on 04/29/21 at 01:46 PM revealed R38 sat in a wheelchair in her room. The door to the room was open and the room was free of clutter and tripping hazards. R38 noted to have a bruise on her left cheek. The call light noted within reach of R38 and she wore shoes. An observation on 05/04/21 at 10:30 AM revealed R38 sat in a wheelchair in her room, with the door open. The bruise on her left cheek appeared smaller from prior observation on 04/29/21. The call light was within reach of R38 and she wore shoes. An interview with R38 on 04/28/21 at 09:30 AM revealed staff left her alone on the toilet at night and she fell off, hitting her head. R38 states she ended up with a goose egg and bruise on her head that was still healing. An interview on 05/04/21 at 11:14AM with Certified Medication Aide (CMA) D revealed the staff were not to leave R38 alone on the toilet due to a fall from the toilet. R38 was a one to two-person transfer depending how strong R38 felt on any particular day. An interview on 05/04/21 at 02:29PM with Certified Nurse Aide (CNA) E revealed R38 could toilet herself prior to her fall. After the fall, staff were to remain with R38 while toileting. The fall caused F38 to hit her head and left her with a bruise to her eye and cheek, but she did not go to the hospital. CNA E stated R38 was placed on a toileting program and checked every two hours. The staff rearranged R38's room so she could be seen by staff from the doorway and said R38 was a high fall risk prior to her falls, and she required extensive one to two-person assistance with all transfers and toileting. An interview on 05/03/21 at 03:18 PM with Licensed Nurse (LN) F revealed R38 had a recent fall off the toilet and she hit her face. LN F said R38 was bruised but nothing was broken. She got a facial x-ray on 04/17/21 because she complained of pain, but Xray did not show a fracture and R38 received pain medication. An interview on 05/04/21 at 02:38 PM with Administrative Nurse A revealed when a resident had an unwitnessed fall, staff notified the nurse and the nurse assessed the resident. The facility completed the fall packet and notified all parties, including the provider and Administrative Nurse A. The Fall Prevention Program dated 04/18/20 stated staff were to encourage residents to wear proper footwear. The facility failed to adequately ensure R38's fall interventions were in place to prevent future falls and failed to implement new interventions related to three falls all with noted lack of appropriate footwear on R38.

The facility reported a census of 65 residents with 16 sampled including three for Activities of Daily Living (ADL). Based on observation, interview, and record review the facility failed to provide ADL assistance to include bathing services to maintain good grooming for Resident (R) 155, who required extensive assistance of two staff with bathing. Findings Included: - Review of R155's Electronic Health Record (EHR) documented the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R155's Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. The resident required extensive assistance of two staff with all ADLs, except eating which required supervision of one staff. The MDS indicated no bathing was performed during the seven day look back period and noted R155 found it very important to choose between a bath, shower, or bed bath. R155 had one fall prior to entry into facility requiring surgery to her leg. Review of R155's ADL Function/Rehabilitation Care Area Assessment (CAA) dated 04/27/21 lacked documentation concerning bathing. Review of R155's Baseline Care plan dated 04/21/21 documented R155 required extensive assistance of one staff for bathing. Facility could not produce any Skin Monitoring CNA/Nurse Shower Review Sheets for R155, when requested on 05/03/21 at 01:39 PM. During an interview on 04/28/21 at 03:48 PM R155 revealed she would like to bathe at least twice a week and she understood currently she would have to settle for a bed bath. R155 stated when she had requested her baths, the staff would bring her a warm tub of water, wash cloths and towels and let her have at it. R155 revealed that her socks had not been changed, her feet had not been washed, and her back had not been washed since she arrived on 04/20/21 (eight days ago). During an interview on 05/04/21 at 10:35 AM Certified Nurse Aide (CNA) G revealed the staff were expected to fill out the shower sheets each time the staff provided/assisted with a shower, even if refused, and the nurse would come and do a skin assessment each time. The staff then filed the sheets in a binder under the resident's room number. During an interview on 05/04/21 at 10:40 AM CNA N revealed showers were documented on paper with each bed bath, shower, or washing. The nurse did the skin check and then either they would take the sheet, or the aide would take it to file it. During an interview on 04/29/21 at 01:14 PM Licensed Nurse (LN) K revealed showers were to be completed by the CNAs assigned to each hall. The showers were scheduled by the resident's preference either on days or in the evenings and which two days of the week they had chosen. The CNAs would complete them as assigned and call the LN to come complete the skin assessment with each encounter. Those were documented on paper together and kept in a binder, by room number, at the nurses' station. During an interview on 05/04/21 at 11:09 AM LN M revealed shower sheets were to be filled out at each bath, and the nurse would complete the skin assessment on the same sheet. LN M said the sheets were kept at the nurses' station in a binder, under room number, or in the resident's chart under the assessment tab. During an interview on 05/03/21 at 01:39 PM Administrative Staff P revealed LN staff were expected to complete skin assessments on the residents for first three days following admission and then with each bathing encounter. Administrative Staff P looked in R155's chart and the residents hallway shower book and verified both lacked any shower sheets or skin assessments for R155. Electronic Interview on 05/06/21 at 11:21 AM with Administrative Staff A revealed baths/showers were documented on the Skin Monitoring CNA/Nurse Shower Review Sheets. Administrative Staff A reported baths/showers were given per resident preference of frequency, day of the week and time (morning or evening), as discussed with the resident/resident representative upon admission and placed on the CNA report sheets. Administrative Staff A expected staff to follow the resident preferences when providing care and expected staff to honor the resident's preference to refuse. Review of the facility Skin Check policy dated 05/14/20 documented staff were to complete a skin check on shift of admission, every night for three nights from admission, and no less than weekly thereafter with bath/shower. The facility failed to provide necessary services to maintain good grooming for personal hygiene for R155 to ensure her comfort.

Based on observation, interview, and record review, the facility failed to ensure that Dietary staff (D1) sanitized her hands upon entering and exiting multiple resident rooms in one of three resident halls. The facility failed to ensure staff were thoroughly screened for COVID-19 prior to entering the facility to work. The facility reported no residents with COVID-19 currently or in the past. The facility census was 62. Findings include: 1. Observations on 6/4/20 revealed the following: At 10:10am, D1 exited R1's room without performing hand hygiene, held a cell phone to her right ear, then placed the phone in her pocket as she approached R2's room. At 10:11am, D1 held the meal tray ticket she had picked up in R1's room, entered R2's room, without performing hand hygiene, touched the door, then touched the resident's knee while getting the tray ticket, and then exited the room without performing hand hygiene. At 10:13am, D1 entered R3's room without performing hand hygiene, held the tray tickets from R1 and R2 in her hand, picked up the tray ticket for R3 from the over-bed table and exited the room without performing hand hygiene. At 10:16am, D1 entered R4's room without performing hand hygiene, immediately exited the room without performing hand hygiene, entered R2's room, without performing hand hygiene, spoke to a coworker then exited R2's room without performing hand hygiene, then re-entered R4's room without performing hand hygiene with the tray tickets from R1, R2, and R3 in her hand. At 10:20am, D1 exited R4's room, without performing hand hygiene and placed all four tray tickets on her cart and proceeded to the kitchen. On 6/4/20 at 10:25am, D1 indicated she received education on infection control practices and standard precautions that included when to perform hand hygiene and the dietary managers educated staff at least every week. D1 indicated that hand hygiene should have been performed upon entry and exit of each resident's room that included either washing her hands with soap and water, or use alcohol based foam rub to sanitize her hands or following contact with any resident. D1 indicated she did not know why she failed to perform hand hygiene but did not think it was that big a deal, including the use of her cell phone while working and she didn't think about it carrying germs. During an interview on 6/4/20 at 11:25am, the Assistant Dietary Manager (ADM) indicated that all dietary staff had been educated on infection control practices, standard precautions, and hand hygiene that included hand hygiene upon entry and exit of a resident room. The ADM expected that once a tray ticket was picked up from a resident's room it was to be placed on the cart and not carried into another room and all staff were expected to foam in and foam out every time they enter a resident room. During an interview on 6/4/20 at 11:50am, the Registered Dietician (RD) indicated that all dietary staff had been educated on appropriate infection control practices and appropriate hand hygiene, especially upon entering and exiting a resident's room. The RD expected all dietary staff to follow the policies put in place to decrease the risk of transmission of infections. The RD indicated it would not be appropriate for staff to enter and exit multiple resident rooms without performing hand hygiene upon entering and exiting. The RD indicated that by staff failing to perform hand hygiene when entering and exiting resident rooms, it could increase the risk of infection by cross contamination and carrying tray tickets from one resident's room to another resident's room could increase the risk of transmission of infection. The 4/2020 Covid Infection Control Policy recorded the following: Level One (Current)-CDC (Centers for Disease and Prevention) or other governing body has issued shelter-in-place orders, but no active cases of virus are present in the facility. Handwashing done after each potential cross-contamination exposure and handwashing log is in place. The COVID-19: Resources and Information for Food and Nutrition Services Webinar and corresponding power point presentation recorded the following: Wash your hands thoroughly with soap and water and use an alcohol based sanitizer if unable to hand wash. Follow handwashing guidelines. Use hand sanitizer between residents. Avoid touching your face to prevent the spread of viruses to your hands. Food handlers must wash their hands after touching anything else that may contaminate hands, such as un-sanitized equipment or work surfaces. 2. Record review of the facility's Primary Respiratory Illness Screening Tool revealed the following: On 4/2/20 five out of 35 employees did not have a temperature recorded upon entry to the facility and one out of 35 employees was identified on the screening tool by his/her first name only. On 4/4/20 two out of 18 employees did not have a temperature recorded upon entry to the facility and one out of 18 employees was identified by his/her first name only. On 4/5/20 one out of 18 employees did not have a temperature recorded upon entry to the facility and one unnamed employee was screened upon entry to the facility. On 4/6/20 six out of 34 employees did not have a temperature recorded upon entry to the facility and two out of 34 employees were identified by first name only. On 4/10/20 two out of 18 individuals signed in to the facility did not have any screening or temperature recorded upon entry to the facility. It is unknown if these individuals were visitors or facility employees due to the lack of identifying information. On 4/13/20 13 of 39 employees did not have a temperature recorded upon entry to the facility. A notation on screening form showed no one taking temp. Five of 39 employees were identified by first name only. On 5/10/20 one of 15 individuals, identified by first name only, did not have any screening or temperature recorded upon entry to the facility. On 5/25/20 16 of 18 employees did not have a temperature recorded upon entry to the facility. On 5/30/20 five of 18 employees did not have a temperature recorded upon entry to the facility and three of 18 employees had no screening conducted at all. One of 18 employees was listed by initials only and did not have any screening or temperature recorded upon entry to the facility. On 5/31/20 13 of 15 employees did not have a temperature recorded upon entry to the facility. On 6/04/20 one of five employees did not have any screening or temperature recorded upon entry to the facility. One undated page showed two individuals, identified by first name only, and one identified by first initial and last name only, with no screening if the individual had traveled in the past fourteen days, had been in contact with a confirmed Covid-19, having any signs or symptoms of illness, worked in another healthcare facility, or had completed the hand washing and infection control education. One undated page showed one individual who was identified by one name only, and one individual who was identified by first name and last initial only. During an interview on 6/4/20 at 12:29pm, the Infection Control Preventionist (ICP) nurse indicated that there were no known or suspected cases of COVID-19 in the facility and expected staff to perform hand hygiene upon entering and exiting a resident's room. The ICP indicated that all employees and visitors were screened upon entry to the facility before proceeding to a resident unit. The ICP indicated that Human Resources (HR) was responsible for looking at the COVID-19 screening logs to ensure they were complete. During an interview on 6/4/20 at 1:32pm, HR1 indicated that she was responsible for scheduling the staff responsible for completed screening of employees and visitors, to ensure there was a screener available at the staff screening table. She indicated that staff screeners were trained by either HR, ICP, or the Director of Nursing (DON) and the training included how to use the thermometer and understanding the importance of completing the screening form appropriately. HR1 indicated that the screeners know they are to text, call, or email her if they have any concerns, are going to send someone home, or if someone is reporting symptoms. She reviewed the screening logs every day and scans the temperatures to make sure if someone reported an elevated temperature that it was followed up on and she only reviewed the screening logs that are computerized. She indicated that the ICP nurse was responsible for reviewing the paper screening logs completed by the night shift. HR1 indicated that it was the responsibility of the night shift charge nurse to take the temperatures of night shift staff as they came on duty because screeners were scheduled for the day and evening shift but not for the night shift. She was unaware of any missing temperatures on the paper screening logs as she only reviewed the computerized logs. During an interview on 6/4/20 at 1:57pm, the ICP nurse indicated that she monitored the daily symptom screening logs, expected the night shift staff to complete the screening log as they came to work prior to going to the unit. Staff were to find the night shift charge nurse to have their temperature taken and the charge nurse recorded the temperature on the screening log. The ICP nurse thought they forget to go back and write their temperature down because she verifies with the night shift charge nurse that everyone was screened and no one was displaying symptoms. The ICP indicated that sometimes it's several days before she obtains the paper screening logs to review and follow up on but that staff would call her right away if there were any issues. During an interview on 6/12/20 at 6:38am, Registered Nurse (RN1) worked on the night shift. He indicated the night shift staff were screened at the table before coming onto the unit then came directly to the nurses' station to have their temperatures checked. RN1 indicated it was the responsibility of the nursing staff to record the temperatures on the screening sheet. During an interview on 6/12/20 at 3:41pm, Licensed Practical Nurse (LPN1) indicated she worked the evening shift. LPN1 indicated the evening shift nurse screened the night shift staff at the screening table. LPN1 indicated that if a staff member came to work late and no one was at the table, then they were to report directly to the 300 hall nurses' station for their screening which included checking their temperatures and completing the screening questions prior to starting the shift. LPN1 indicated the 300 hall was a direct path to the nurses' station from the screening station. The undated COVID-19 Response Plan recorded under the title Occupational Health, 3. Employees are screened at the door for symptoms, and temperature is taken before they report to work. The following questions are asked of each employee: -Did you use proper hygiene when arriving? - Have you traveled in the last 14 days? -Have you been I contact with confirmed COVID-19? -Are you experiencing symptoms of illness-fever, cough, congestion, shortness of air, sore throat, nausea, vomiting, fatigue? -Do you work any other place?

The facility had a census of 71 residents. Based on observation and interview the facility failed to have a system in place to prevent the transmission of communicable diseases/infections when staff kneeled on the floor next to the bed while completing a resident treatment and when staff took a medication/treatment cart inside a resident room and situated the cart in the resident's restroom while he provided a treatment. Findings included: - During an observation on 11/25/19 at 01:15 PM, Licensed Nurse (LN) G prepared to complete a treatment to Resident (R) 3's buttocks while the resident lay in bed. LN G kneeled on the floor next to the bed in order to complete the treatment rather than raising the bed higher. LN G remained in the kneeling position throughout the treatment. During this same observation, LN G moved a rolling medication/treatment cart which contained supplies for multiple residents into R3's bathroom and left the cart parked in the bathroom while he completed the treatment. During an interview on 11/25/19 at 03:30 PM Administrative Nurse D reported staff should not take medication/treatment carts into resident rooms and especially not into resident bathrooms. Administrative Nurse D also reported staff should not kneel directly on the floor in order to provide care or treatments. Although requested, the facility failed to provide an infection control policy. The facility failed to have a system in place to prevent the transmission of communicable diseases/infections when staff kneeled on the floor next to the bed while completing a resident treatment and when staff took a medication/treatment cart inside a resident room and situated the cart in the resident's restroom while he provided a treatment.

The facility had a census of 71 residents, with four residents selected for sample. All four sampled residents required assistance with transfers. Based on observation, interview, and record review, the facility failed to provide two of four sampled residents with the necessary supervision and services to accomplish safe/comfortable transfers via mechanical lifts. (Resident (R) 3, R4) Findings included: - R3's 10/14/19 Admission Minimum Data Set (MDS) identified the resident with severe cognitive impairment (Brief Interview for Mental Status score of two), an inability to ambulate, and the need for extensive assistance of two staff for transfers. The 10/15/19 Care Area Assessment (CAA) for Activities of Daily Living (ADLs) noted R3's need for assistance of one to two staff for all ADLs. The undated Care Plan directed staff to transfer R3 via a full body lift with assistance of two staff. During an observation on 11/25/19 at 12:50 PM, Certified Nurse Aide (CNA) M and CNA N prepared to transfer R3 from the wheelchair to the toilet via a total mechanical lift. Staff placed the toileting sling beneath the resident appropriately and raised the resident to an appropriate height and then lowered her onto the toilet. The resident exhibited no signs of discomfort during the transfer to the toilet. After R3 sat on the toilet for 8 minutes, CNA M and CNA N raised the resident up off the toilet with the lift. With the resident suspended above the toilet, CNA M provided perineal care, applied a clean brief, and pulled the resident's slacks back up into an appropriate position. Throughout this 4 minute process, R3 winced, attempted to reposition her body by pulling up on the metal bars of the lift, and demonstrated physical signs of discomfort. CNA M and CNA N repeatedly told the resident, We're almost finished. Hang on. or It will just be another minute. Im hurrying. Once staff completed pericare and redressed R3, they kept her suspended in the lift and moved her from the bathroom to the bed via the mechanical lift. R3 continued to show physical signs of discomfort during the transfer. The straps of the toileting sling were bunched up directly behind R3's knees and that area appeared to be the point of discomfort. The total time staff maintained R3 suspended in the lift following toileting until the time they lowered her onto the bed was 11 minutes. During an interview on 11/27/19 at 10:10 AM, Registered Physical Therapist (RPT) GG reported staff should maintain residents in a suspended position for the minimal time required to accomplish a transfer. According to RPT GG, staff should have used the full lift to move R3 on and off the toilet, lowered her into the wheelchair following pericare, and then transported her from the bathroom to the bed in the wheelchair rather than in the lift. Although requested, the facility failed to provide an policy related to safe use of mechanical lifts. The facility failed to provide R3 with the necessary supervision and services to accomplish a safe/comfortable transfer via a full mechanical lift. - Resident (R) 4's clinical record included an 09/04/19 quarterly Minimum Data Set which identified the resident with severe cognitive impairment (Brief Interview for Mental Status score of four), an inability to ambulate, and the need for extensive assistance of one staff for transfers. The undated Care Plan noted R4's need for assistance of one for most activities of daily living. The Care Plan lacked specific interventions related to transfers. During an observation on 11/25/19 at 01:30 PM, Certified Nurse Aides (CNAs) O and CNA P prepared to transfer R4 from the wheelchair placed near his bed into the bathroom via a sit to stand mechanical lift. CNAs O and P placed the straps for the lift appropriately and then started the raise R4 upwards from the chair. After only raising R4 a few inches from the wheelchair, CNA O stopped raising the resident and began to move the lift in the direction of the bathroom. At the time, R4 stood with both feet on the lift platform, his knees bent at a 90 degree angle, his hip/buttocks extended behind him, and the torso sling raised up under both armpits which caused the shoulders to rise to the level of his ear lobes. In this position, R4 did not have the ability to bear his weight on his feet. Once in the bathroom, staff lowered R4 onto the toilet. Following toileting, CNA O and CNA P raised R4 from the toilet via the sit to stand lift, provided pericare, and pulled up the resident's slacks. Then, with R4 in the same position with his knees bent at a 90 degree angle and with the torso sling raised up under his arms, staff used the lift to take R4 from the bathroom back to his wheelchair which was located next to his bed. During the lift transfers to the toilet and from the toilet, R4 appeared to hang by his upper arms from the sling and the position of his bent knees afforded him no opportunity to bear weight as required for use of a sit to stand lift. During an interview on 11/25/19 at 02:50 PM, Administrative Nurse D reported R4 would not be able to bear weight on his feet is his knees remained bent at a 90 degree angle. Administrative Nurse D also reported staff should not use the lift to move residents about in their rooms, but should place the wheelchair as close as possible to the bathroom and then raise residents from the wheelchair and move them directly to the toilet. During an interview on 11/27/19 at 10:10 AM, Registered Physical Therapist (RPT) GG reported staff should raise residents high enough in a sit to stand lift for them to be able to bear weight on their feet. RPT GG also reported staff should transport residents suspended in lifts for the shortest possible distance for comfort and safety. Although requested, the facility failed to provide an policy related to safe use of mechanical lifts The facility failed to provide R4 with the necessary supervision and services to accomplish a safe/comfortable transfer via a sit to stand mechanical lift.

The facility has a census of 74 residents. The sample included 18 residents, with five reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to adequately monitor blood sugars as ordered by the physician for one of five residents reviewed for unnecessary medications. Resident (R) 15 received insulin and had blood sugars out of the physician ordered parameters. Findings included: - R15's quarterly Minimum Data Set (MDS) assessment, dated 07/15/19, recorded the resident had a Brief Interview for Mental Status (BIMS) score of 10 (moderately impaired cognition) and no behaviors. The MDS recorded R15 required extensive staff assistance with Activities of Daily Living (ADLs), had a [DIAGNOSES REDACTED]. The 07/16/19 care plan directed staff to monitor R15's blood sugar, administer insulin and diabetic medication as ordered by the physician. The 03/26/19 physician's orders [REDACTED]. The 05/20/19 physician's orders [REDACTED]. The 06/25/10 physician's orders [REDACTED]. R15's Blood Sugar Report, Interdisciplinary Notes, and (MONTH) 2019 Medication Administration Record [REDACTED] 07/29/19 at 11:04 AM - 349 mg/dl 07/28/19 at 02:59 PM - 366 mg/dl 07/27/19 at 07:38 PM - 366 mg/dl 07/27/19 at 03:29 PM - 313 mg/dl 07/25/19 at 11:38 AM - 360 mg/dl 07/25/19 at 05:00 AM - 332 mg/dl 07/19/19 at 09:25 PM - 374 mg/dl 07/19/19 at 06:19 PM - 367 mg/dl 07/18/19 at 11:46 AM - 332 mg/dl 07/15/19 at 10:19 AM - 305 mg/dl R15's (MONTH) 2019 Medication Administration Record [REDACTED] 07/27/19 at 08:00 AM - 109 mg/dl 7/24/19 at 05:31 AM - 112 mg/dl 07/20/19 at 05:35 AM - 89 mg/dl 07/17/19 at 05:51 AM - 62 mg/dl 07/16/19 at 03:10 PM - 104 mg/dl 07/16/19 at 05:43 AM - 107 mg/dl 07/14/19 at 05:45 AM - 113 mg/dl On 07/30/19 at 07:48 AM, observation revealed R15 rested in bed, and Licensed Nurse (LN) G administered 15 units of [MEDICATION NAME]to R15. On 07/31/19 at 02:03 PM, LN G stated nursing staff checked R15's blood sugar before meals and at bedtime, assess R15, and notify the physician when R15 had elevated blood sugars greater than 300 mg/dl. On 08/01/19 at 02:26 PM, Administrative Nurse D stated staff should assess R15 when blood sugars were elevated, recheck the blood sugars after insulin administration and notify the physician as ordered. Upon request the facility had no policy to check or monitor blood sugars. The facility failed to adequately monitor elevated blood sugars to ensure appropriate care and treatment for [REDACTED].

The facility has a census of 74 residents. The sample included 18 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to notify the physician about elevated blood sugars for one of five sampled residents (Resident (R) 15). Specifically, the staff failed to notify R15's physician for blood sugars outside physician ordered parameters. Findings included: - R15's quarterly Minimum Data Set (MDS) assessment, dated 07/15/19, recorded the resident had a Brief Interview for Mental Status (BIMS) score of 10 (moderately impaired cognition) and no behaviors. The MDS recorded R15 required extensive staff assistance with Activities of Daily Living (ADLs), had a [DIAGNOSES REDACTED]. The 07/16/19 care plan directed staff to monitor R15's blood sugar, administer insulin and diabetic medication as ordered by the physician. The 03/26/19 physician's orders [REDACTED]. The 05/20/19 physician's orders [REDACTED]. R15's Blood Sugar Report and Interdisciplinary Notes recorded the following elevated blood sugars without physician notification: 07/29/19 at 11:04 AM - 349 mg/dl 07/28/19 at 02:59 PM - 366 mg/dl 07/27/19 at 07:38 PM - 366 mg/dl 07/27/19 at 03:29 PM - 313 mg/dl 07/25/19 at 11:38 AM - 360 mg/dl 07/25/19 at 05:00 AM - 332 mg/dl 07/19/19 at 09:25 PM - 374 mg/dl 07/19/19 at 06:19 PM - 367 mg/dl 07/18/19 at 11:46 AM - 332 mg/dl 07/15/19 at 10:19 AM - 305 mg/dl On 07/30/19 at 07:48 AM, observation revealed R15 rested in bed, and Licensed Nurse (LN) G administered 15 units of [MEDICATION NAME]to R15. On 07/31/19 at 02:03 PM, LN G stated nursing staff checked R15's blood sugar before meals and at bedtime, nursing staff should assess R15, and notify the physician when R15 had elevated blood sugars greater than 300 mg/dl. On 08/01/19 at 02:26 PM, Administrative Nurse D stated staff should assess R15 when blood sugars were elevated, and notify the physician as ordered. The facility's Physician Notification Guideline policy, dated 01/17/18, directed staff to report abnormal or elevated blood sugars as ordered by the physician. The facility failed to notify the physician about elevated blood sugars for R15, placing R15 at risk for adverse side effects.

The facility had a census of 60 residents. Based on observation, interview and record review the facility failed to maintain a clean and sanitary environment for residents when staff failed to disinfect hand rails, door knobs and other areas of the resident's room and failed to follow the manufacturer's recommendations for wet times (the amount of time the manufacturer recommends that surfaces be wet with disinfectant to be effective) of 10 minutes for disinfecting room surfaces. This had the potential to affect all residents on 1 of 6 halls Findings included: - During an observation on 8/18/16 at 8:12 AM housekeeping staff J brought chemicals into a resident's room, put on gloves and then squirted Emeral Cream (stain remover) into the toilet and the sink. At 8:14 AM staff J sprayed Triad lll all over the sink and on the toilet. Staff J explained that he/she left the spray on and cleaned the rest of the resident's room. Staff J stated the Triad lll had to be on for 5-10 minutes. Staff J sprayed a rag with Triad lll and wiped the over bed table at 8:15 AM. At 8:17 AM staff J used the rag he/she sprayed the Triad lll on, to wipe down the resident's recliner and wiped the outside of the trash can. Two minutes after wiping the surface at 8:17 AM the surfaces of the over bed table started to dry. At 8:18 AM staff took a sponge and scrubbed down the sink, ran the water and rinsed off the sink, 4 minutes after applying the Triad lll. Staff J then took the rag he/she had sprayed with Triad lll and dried off the sink at 8:19 AM, 5 minutes after spraying it. At 8:20 AM, 5 minutes after staff J wiped the over bed table with the disinfectant rag the table was dry. Observation at 8:22 AM revealed no visible moisture on the sink and it felt dry to touch. During an interview on 8/18/16 at 8:43 AM Housekeeping staff N stated he/she expected staff to disinfect all the door knobs, rails in the bathroom, recliners, over bed tables, the table legs, telephones, light switches, areas around the sink and do the tiles in the bathrooms daily. Administrative housekeeping staff N stated the surfaces for the Triad lll needed to be wet for 10 minutes. During an interview on 8/22/16 at 12:15 PM administrative staff O reported the housekeeping staff generally cleaned specific areas of the facility they were assigned to and only covered another area when needed. Review of the product information used during the observation revealed the following: Instructions for the Triad lll Disinfectant Cleaner revealed all surfaces must remain wet for 10 minutes and then can be wiped or let air dry. The facility failed to ensure staff followed the directions for a 10 minute wet time to ensure disinfection of surfaces in a resident's room.

The facility had a census of 69 residents and a sample of 16 residents. Three residents were sampled for falls. The facility identified 8 cognitively impaired and independently mobile residents with access to the unlocked therapy room. Based on observation, interview, and record review the facility failed to maintain a safe environment by the failure to implement interventions to prevent further falls for 1 of 3 residents reviewed for falls (#24), and by the failure to secure a hydrocollator from 8 cognitively impaired and independently mobile residents. Findings included: - Review of resident #24's signed physician orders [REDACTED]. with fluid), and chronic kidney disease (inability of the kidneys to excrete wastes, concentrate urine and conserve electrolytes). Review of the admission MDS (minimum data set) dated 9/5/13 revealed a BIMS (brief interview for mental status) score of 11 indicating moderate cognitive impairment. The resident had depression and delusions. The resident required minimum assistance of one with transfers and ambulation and extensive assistance of one with dressing, toileting, personal hygiene and bathing. The resident had a history of [REDACTED]. Medications included an antipsychotic, antianxiety, antidepressant and a diuretic. Review of the CAA (care area assessment) dated 9/5/13 revealed the following: ADL (activities of daily living) CAA- The resident had a history of [REDACTED]. The resident required assistance with daily care needs and mobility. Referral made for skilled rehabilitation services for improved strength, ADL, and functional mobility training. Falls CAA- Will proceed to the care plan to minimize risk of further falls with serious complications or injury. Visual checks in place, floor mat to alert staff to be initiated, and referral to skilled rehab services for improved strength, endurance, mobility and safety. Review of the interim care plan with a date of 8/26/13 revealed a problem fall/potential for injury related to weakness and impaired mobility. An update on 10/20/13 following fall included floor alarm while in bed, and initiation of 30 minute safety checks and neurochecks initiated. The interim care plan stated "only to be used for 21 days from admission" The resident admitted to the facility on [DATE]. Review of the comprehensive care plan dated 9/5/13 revealed no fall prevention or interventions on the comprehensive care plan. Licensed nurse A reviewed the care plan and acknowledged no potential for falls listed on the care plan. Review of the post fall nursing report dated 10/20/13 at 10:25 p.m. revealed no new interventions. The fall investigation not provided due to being a part of the QAA (quality assurance) program. Review of the nurse's progress notes dated 10/20/13 at 11:00 p.m. revealed the resident had fallen. Staff found the resident in a supine position with his/her walker under his/her head next to the wall. The resident had a large bruise on his/her left hand with a puncture mark and skin tear to the left thumb. Neuro's (neurological checks) within normal limits, ROM (range of motion)normal to all extremities, and resident was alert and oriented. The resident stated he/she tried to walk with the walker to reach the call light attached to his/her bed from his/her recliner and fell . The resident had shoe slippers with soles on and was fully dressed. The nurse cleansed puncture and skin tear on hand and applied band aid. Two staff helped the resident up to the wheelchair. The nurse noted a small knot found on the left side of the head with neuros and vitals continued. The nurse then notified the physician and the supervisor of the fall. Review of the nurse's progress notes dated 10/21/13 for fall follow-up had no mention of a floor alarm being in place at the time of the follow-up. Review of the nurse ' s progress notes on 10/22/13 fall follow-up made no mention of the floor alarm in place. Review of the nurse ' s progress notes on 10/23/13 follow-up made no mention of a bed alarm in place. Review of the fall risk assessment dated [DATE] (prior to fall) had a score of 24 indicating the resident was high risk for falls. A score of 18 or higher was a high fall risk. Review of the fall risk assessment dated [DATE] (after fall) had a score of 35, high risk for falls. A score of 18 or higher was a high fall risk. Review of the CNA (certified nursing assistant) care sheet for the resident indicated the resident needed focused supervision with activities in the room and was to have a floor alarm while in bed. Observation on 10/29/13 at 9:10 a.m. revealed the resident in bed sleeping. The call light was attached to the sheet next to the resident and no floor alarm in place. Observation on 10/30/13 at 5:25 a.m. revealed the resident slept in bed with the foot of the bed elevated with the call light clipped to the bed sheet beside the resident. No floor alarm found by the bed as per the interim careplan. The walker was kept out of reach at the foot of the bed. On 10/29/13 at 2:35 p.m. the resident stated he/she had fallen while walking in his/her room landing on the left side. The resident stated he/she had bruising on the left knee, hip, elbow and shoulder, but no other injuries. The resident stated he/she just lost balance. On 10/30/13 at 5:30 a.m. direct care staff B reported the resident was on 30 minute safety checks by him/her and the nurse on duty. The resident was good at using his/her call light for assistance as needed and transferred with the use of a gait belt. During an interview on 10/30/13 at 10:30 a.m. direct care staff C reported the resident was on 30 minute checks but that was all to prevent another fall. The staff stated the resident had no alarms being used. During an interview on 10/20/13 at 2:30 p.m. direct care staff D reported the only intervention the staff did for the residents falls was 30 minute safety checks. The staff reported they used to have an alarm on the floor by the bed but not anymore and did not know when it stopped. During an interview on 10/30/13 at 8:30 a.m. licensed nurse E reported that when a resident had a fall it was the nurse on duty's responsibility to update the care plan with new interventions. During an interview on 10/31/13 at 8:50 a.m. administrative nurses F and G reported that when a resident had a fall an intervention was to put in place by the supervisor on duty and the intervention written on the care plan. That new intervention was then placed on the CNA care sheet hanging in the resident's bathroom. That day or the next if the fall was at night, the director of nursing reviewed the fall report took the fall investigation to the fall risk meeting. At that meeting interventions and the cause of the fall are reviewed and changes made to the care plan by the fall committee. Administrative nurse F stated somehow staff failed to update the care plan after the resident's fall on 10/20/13. Review of the undated policy named Fall Prevention revealed: The facility will have an interdisciplinary team used for identification of specific fall risk factors, discuss and document strategies initialized for each resident and attempt to minimize the risk factors without compromising mobility and functional independence whenever possible, report and record falls and near falls so that new risk factors are identified, decrease risks and prevent falls to the degree possible, trend and track causes of falls by review of the fall risk assessment score of 18 or higher, determine causative factors and develop interventions to prevent further falls. Multiple falls are defined as two falls with a 30 day or three falls within 60 days. Assess the risk potential by the nurse to complete the fall risk assessment upon admission, with each fall occurring quarterly and according to the RAI (resident assessment)process. Assessment, care plan and monitoring of the residents related to fall issues initiated by nurse staff on admission. A review of resident medications completed for possible effects related to falls. Notify physician of each fall. If repeated falls occur, request: Lab work and/or UA and/or x-ray, PT/OT (physical therapy/ occupational therapy) screen/evaluation, medication dosage change, restraint or alternative orders if necessary. Assess for vision/hearing problems, encourage proper footwear, assess orthostatic hypotension (blood pressure changes when changing positions) assess environment where fall occurred. The interdisciplinary team would discuss and initiate appropriate interventions for identified risk factors. Interventions will be designed in relation to [DIAGNOSES REDACTED]. Documentation would include a " potential for injury " problem added to the care plan, document specific products, services and interventions undertaken to reduce the risk of falls. The facility failed to provide a safe environment for resident #24 by the failure to plan and implement interventions to prevent further falls. - On 10/29/13 at 5:17 PM observation revealed the hydrocollator (a liquid heating device used in physical therapy to heat and store hot packs for therapeutic uses) in an unlocked and unsupervised therapy room accessible to residents. The outside metal surface of the hydrocollator was 127.5 degrees, and felt hot to the touch. The hydrocollator was padlocked with a strap around it to prevent it from opening. No residents in area at this time. On 10/30/13 at 5:10 AM observation in the unlocked and unsupervised therapy room revealed the hydrocollator metal surface had a temp of 140 degrees. Lights were not on and no residents in observed in area. On 10/30/13 at 2:25 PM observation revealed therapy staff I lifted the padlocked lid. Staff I reported staff had gotten lax about making sure to tighten the strap used to prevent the lid from opening. Staff I tightened it before securing the padlock. Staff I also reported that the metal surface felt hot to touch. The temperature of the outside metal surface of the hydrocollator registered 118 degrees Fahrenheit. When asked about the sign on the door to the therapy room that stated "Leave Open" , therapy staff I reported they used to lock the room, but during construction the staff had to leave door unlocked. On 10/31/13 at 2:20 PM Administrative staff H reported the staff used to lock the therapy room when unsupervised, but due to construction they needed to use the therapy room exit door. Staff H reported after completion of the construction staff would lock the room when they left for the day. The facility did not have a written policy for the safe storage of hydrocollator's. The facility failed to have the hot hydrocollator secured and in a locked room when unsupervised.

The facility census totaled 77 residents, with 3 residents reviewed for weight loss. Based on observation, interview, and record review, the facility failed to provide nutritional care and services consistent with the planned care to avoid a significant weight loss for 1 of 3 sampled residents. (#73) Findings included: - Review of resident #73's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 2/10/11 identified the resident with moderately impaired cognition, decisions poor, and cues/supervision required, needed limited physical assistance of one person with bed mobility, and the assessment also identified the resident needed supervision with set-up help only for transfers, walking, and eating. The assessment noted no/unknown weight loss, and the resident received a therapeutic diet. Review of the Change of Diet form dated 6/26/09 revealed the resident needed to have a Dementia Diet. At 8:41 A.M. on 3/31/11 Staff H reported the Dementia Diet included high calorie, high protein foods, whole milk, and Super Cereal (oatmeal with dry milk and carnation milk added to increase protein and calories). Review of the Dietary Breakout revealed the residents on a Dementia Diet received 6 ounces of Super Cereal and 8 ounces of whole milk with each brunch, and received 4 ounces of whole milk with the dinner meal, as planned. Review of a psychiatry progress note dated 1/20/11 revealed, " staff notice patient continues to 'cycle' having 24 hour periods of being awake, friendlier, pacing and walking and not sleepy. Then, has 1-2 days of isolating to room, staying in bed with poor motivation. In the evenings, (gender) is more irritable and trying to leave/go home. " Review of the Weight Record revealed the resident weighed 163.5 pounds on 9/18/10. On 3/26/11 the resident weighed 142.8 pounds, displaying a loss of 20.7 pounds in 6 months. (12.8% of their total body weight) On 4/4/11 before the brunch meal, Nurse Z weighed the resident, which amounted to 142.8lbs Review of the care plan signed on 2/17/11 identified the resident with cognitive loss as evidenced by short and long term memory problems with impaired decision making. It also identified the resident with altered nutritional status related to dementia. " (Gender ' s) nutritional status shall be maintained to the highest level possible related to disease process. " It directed staff to provide the resident with a dementia diet, to remind daily of scheduled meals, and assist out to meals as needed. It notified staff that the resident ate independently, but directed staff to provide set-up help as needed, and they monitored weight weekly. On 3/28/11 at 11:25 A.M., observation revealed a staff member took a room tray into the resident ' s room, set it on a bedside table to the resident ' s right side, and then exited the room. In the room, the resident laid in bed with their eyes closed, and slouched over to their left side. An uncovered plate presented with French toast, bacon, peaches and pineapple. The resident ' s water pitcher sat next to the food. The facility failed to provide the resident with whole milk or Super Cereal. At 11:37 A.M., the resident continued to lie in the same position with their eyes closed, and the food remained uneaten. During the evening meal on 3/29/11 at 4:30 P.M., observation revealed staff served the resident a piece of chicken covered with cheese and mushrooms, stuffing, carrots, and a buttered roll, water and a cup of coffee. They then served the resident cheesecake, but failed to ever provide the resident with 4 ounces of whole milk as planned. A family member of the resident came in and sat next to the resident at the dining table. The family member encouraged the resident to drink more of their water and eat more of their food. After the encouragement, the resident ate and drank more. As the two spoke, the family member ate the resident ' s carrots, their roll, and half of their cheesecake. In total the resident ate their chicken and ? of their cheesecake, 1-2 bites of carrots, approximately 50% of their meal. Review of the Intake Log for the 3/29/11 dinner meal revealed staff reported the resident ate 75%-100%. Observation of the brunch meal on 3/30/11 at 11:39 A.M. revealed staff served the resident scrambled eggs, toast, bacon, apricots, a pear slice, and a cup of hot chocolate. Again, staff failed to serve the resident Super Cereal or milk as planned in the Dementia Diet. On 3/31/11 at 8:20 A.M. Nurse K reported they didn ' t know if the resident had lost weight. The resident had " good days and bad days, " and ate less on the bad days. Nurse K looked at the weight log record, and reported they thought it looked like the resident had a weight loss. Nurse K noted they weren ' t sure if anyone had identified it. At 11:49 A.M. that same day, Nurse K reported they didn ' t know why the resident had lost weight, but confirmed the resident needed encouragement to eat their meals. At 3:57 P.M. on 3/31/11 Nurse N reported the resident needed a lot of encouragement to eat at meals. On 3/31/11 at 8:41 A.M., Administrative Dietary Staff H reported they reviewed the Weight Log for weight loss. They considered a weight loss significant if the resident lost 5% in 30 days, or 10% in 180 days. They had not identified the resident for weight loss. Staff H also reported they didn't use some of the weights in the chart because they felt the weights were inaccurate at times. Staff H reported they didn't plan to do anything until the resident hit a 10% weight loss. On 3/31/11 at 9:19 A.M. Administrative Dietary Staff AA reported they didn't identify the resident with a weight loss prior to that day, but confirmed the resident had lost weight according to the weight log. Again, after speaking with Administrative Dietary Staff H, at 12:17 P.M. on 3/31/11 the resident received pancakes with syrup, sausage links, pears, a peach slice and a glass of water in their room. The resident lay in bed, with the food next to them on a bedside table. Observation revealed no Super Cereal or milk on the tray as planned in the Dementia Diet. The facility failed to consistently implement the planned services to avoid an unplanned, significant weight loss of 12.8% for resident #73.

The facility census totaled 77 residents, with 3 residents sampled for pressure ulcers. Based on observation, interview, and record review, the facility failed to prevent the development of recurrent or multiple avoidable Stage 2 pressure ulcers for 2 of 3 sampled residents. The facility failed to develop and implement the care plan, and measure and assess all pressure wounds for resident #47. The facility failed to implement pressure redistribution interventions prior to the development of avoidable pressure ulcers to each heel for resident #28. Findings included: - Resident #47's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date of 3/10/11 identified the resident with a Brief Interview of Mental Status (BIMS) score of 7. The BIMS is a brief screening tool that aids in detecting cognitive impairment (0 to 7 indicates severe impairment). The MDS also identified the resident as requiring extensive assist of one person for bed mobility, transfers, walking in room, locomotion on the unit, and toilet use. It indicated the resident had a stage 2 pressure ulcer, present on admission, and noted the resident as at risk for developing pressure ulcers. The facility's Weekly Wound Report sheet noted a Stage 1 pressure wound is defined as "inflammation or redness of the skin which does not blanch or disappear when pressure is relieved. "A Stage 2 pressure wound is defined as " a superficial skin break with redness of surrounding area, shallow crater. " Review of the resident ' s Weekly Wound Report revealed the resident had a pressure wound to the left buttock on 12/9/10. Staff noted the area again on 12/10/10 in the Weekly Skin and Pain Assessment. On 12/21/10, staff noted an open area to the right buttock, with no mention of the left. They reported the area to the right buttock appeared healed on 1/28/11. During that period of time, staff failed to measure the wound on multiple dates. The area reopened on 2/11/11, and appeared healed on 3/2/11. Review of the Weekly Skin and Pain Assessment revealed the resident had an open area to the right lower buttock on 3/15/11. Staff documented the area healed on 3/30/11. During that period of time, the staff failed to consistently assess the wound including measuring, a description of the wound and progress toward healing. Review of the Treatment Administration Record (TAR) revealed a treatment initiated on 12/14/11. It directed staff to apply [MEDICATION NAME], a brand of moisture barrier cream, to the resident ' s right and left gluteal folds, and apply [MEDICATION NAME] (a type of dressing) to help prevent breakdown. The resident's care plan, last reviewed on 3/17/11, identified the resident as at risk for skin break down as evidenced by history of pressure ulcers. The care plan directed staff to monitor the resident for position changes while in bed, and to assist the resident as necessary. The care plan lacked an intervention to direct staff to reposition the resident when the resident sat in their wheelchair even though the physician wrote an order on 12/14/10 to avoid allowing the resident to sit for more than one hour at a time. Observation on 3/29/11 at 2:30 P.M. revealed staff assisted the resident out to the activity table. Observations at 2:55 P.M. and 3:28 P.M. revealed the resident sat at the table in the same position. At that time, a staff member assisted the resident to the dining room table for supper. They received supper at 4:22 P.M., still in the same position. Staff then assisted the resident to their room at 5:15 P.M., and into a recliner. Staff failed to reposition the resident for 2 hours and 45 minutes. According to the Prevention and treatment of [REDACTED]." Observation of the resident ' s skin on 3/30/11 at 3:00 P.M. revealed darkened areas and reddened areas to both of the resident ' s lower inner buttocks. Nurse K applied small amounts of pressure to the darkened areas and to the reddened areas. Observation revealed the darkened areas blanched, but the reddened areas failed to blanch. Nurse K measured the areas, the right noted to be 2 cm (centimeters) long by 2 cm wide, and the left area as 2 cm long by 1 cm wide, and no depth to either area. On 3/31/11, review of the record revealed staff failed to document the areas they identified the previous day. On 3/31/11 at 10:33 A.M. Nurse Aide Y reported they took the resident out to activities after early breakfast (the facility served continental breakfast around 7:00 A.M. daily), and brought them back to their room after the brunch meal (brunch meal started at 11:00 A.M. daily and lasted approximately one hour) to lay down. Aide Y reported they didn't know of any certain amount of time the resident could be in their wheelchair. During an interview on 3/31/11 at 11:15 A.M., Nurse K reported staff members didn't ' chart the areas unless they had opened. Review of the Wound sheet for this resident revealed an area for staff to document reddened areas. The nurse confirmed the areas had reopened several times and staff needed to always reposition the resident every two hours while in their chair or in bed. On 3/31/11 at 3:48 P.M., Nurse Aide W reported they repositioned the resident in their bed and in their wheel chair every two hours. At 4:20 P.M. on 3/31/11, Nurse N reported the resident could physically reposition, but staff couldn't ' rely on the resident to do it in a timely manner. During an interview at 12:14 P.M. on 3/31/11, Administrative Nurse F reported the resident could reposition independently, needed to be monitored, and reported 2 hours and 45 minutes in one position as not acceptable. Nurse F confirmed the wound physician gave an order to avoid sitting for more than one hour, and also reported staff needed to follow the order. Nurse F confirmed staff should have measured each open area, but failed to do so. Nurse F confirmed the charting for the wounds to be very unclear. Also, Administrative Nurse F reported they didn't ' expect staff to chart anything if they found an unblanchable area. They needed to notify the director and physician and document only if the area opened. Review of the facility ' s undated Skin Breakdown Prevention and Wound Management Guidelines protocol revealed, " In the event a new skin abnormality is noted such as a skin tear, bruising, blister, red area which does not blanch, rash, or wound of any classification the nurse must document these findings: 1) Document assessment findings on the non-decub weekly assessment form; 2) in the nurse's notes. " The policy also noted, " For any wound, a weekly wound report must be completed, until wound has healed (use one sheet for each wound.) This would include a stage 1 pressure area (inflammation or redness of the skin which does not blanch or disappear when pressure is relieved). The facility failed to follow their policy in regards to an area which didn't ' blanch when assessed by their nurse. The facility failed to develop and implement the care plan for position changes to relieve the resident, with a history of pressure wounds, from pressure and further skin breakdown while the resident sat in a chair. The facility also failed to consistently monitor the healing, or lack thereof, by the failure to consistently measure and assess all pressure wounds. - Resident # 28's Physician order [REDACTED]. The Doctors Progress Notes dated 2/17/10 included cognitive decline, recurrent skin breakdown, and recurrent urinary tract infections [MEDICAL CONDITION]. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/10/11 recorded the resident with a BIMS (a brief screener that aids in detecting cognitive impairment) score of 5 which indicated a severe cognitive impairment. Speech, vision and the ability to express self and understand others were assessed as adequate. The MDS also revealed the resident required extensive (2 person) assistance for Activities of Daily Living (ADL's) bed mobility, transfers, toileting, dressing, personal hygiene and locomotion on the unit. The facility initiated a therapeutic diet due to a weight loss of 5% or more in the last month or 10% or more in last 6 months. The assessment recorded the resident at risk for the development of pressure ulcers with 1 or more unhealed pressure ulcers at Stage 1 or greater. The assessment recorded the resident currently had one Stage 2 pressure ulcer with the date of 1/4/11 and revealed old healed pressure ulcer areas. The Skin and Ulcer Treatment section recorded the use of a pressure reducing device for the chair and bed. Review of the Braden Scale (a tool for predicting pressure score risk) revealed on 9 /13/10, the facility scored the resident at 18, on 10/18/10 the staff scored the resident at 16, and on 1/10/11 they scored the resident at 14. (Total score of 12 or less represents High Risk, 13 - 14 represents Moderate Risk, and 15 -18 represents Mild Risk). During interview done on 3/31/11 at 7:45 a.m. with licensed nursing staff K, staff revealed the resident had a history of [REDACTED]. Staff K reported the resident sat in the recliner for most of the day, slept in it at night and refused to change position. Staff K reported the resident became ill and then allowed a bed to be moved in the room and during that illness the resident also permitted the staff to log roll him/her which allowed the pressure ulcers on the buttocks to heal. Review of the care plan with a starting date of 12/30/10 identified the resident at risk for skin breakdowns due to episodes of bladder incontinence related to the [DIAGNOSES REDACTED]. (Notations on the care plan recorded a blister to the right heel and a red area on the L heel on 1/4/11). Further notations recorded that the left heel healed on 1/28/11 and on 2/11/11 the right heel demonstrated a 0.5 cm x 0.5 cm scabbed area). The care plan instructed the staff to promptly toilet the resident upon awakening in the morning and after a nap, after meals, at bedtime and as needed; apply [MEDICATION NAME] Moisture Barrier with toileting to prevent skin breakdown; provide the resident with a therapeutic mattress and or place a bed cradle on the bed; use heel protectors on the residents heels while (he/she) was in bed; transfer the pressure cushion from the bed to the recliner and wheelchair with the resident; assess the resident's skin weekly (to be done by a licensed nurse); assess resident for the Braden Scale quarterly; offer and encourage fluids during and between meals- including the instructions to keep fresh water available in the room at all times unless there were swallowing precautions; and the resident's skin condition monitored daily by the Certified Nurse Aid with any redness or changes reported to the licensed nurse. On 1/28/11, additional interventions included heel float boot to both feet at bedtime (HS) or while in bed and discontinued the previous treatment for [REDACTED]. The care plan dated 12/30/10 also identified the resident with skin breakdown from a history of ulcers to the buttocks and heels, and at risk for further breakdowns related to episodes of bladder incontinence, at night, refusal to change positions, and rubbing heels back and forth when lying in bed. Staff noted at this time, skin intact to the buttocks. The care plan interventions dated 7/15/10, instructed the staff to encourage the resident to reposition every 2 hours and as needed, with the staff to assist as needed, usually giving limited assistance to turn, reposition and go from sitting to standing. Notation on the care plan instructed staff when the resident refused, remind he/she of the importance of repositioning when in bed or recliner. Addition to the care plan dated 1/4/11 instructed staff to place "off load" boots on the resident at all times until skin issues resolve to bilateral feet. Staff added an intervention dated 1/14/11 to cleanse the right heel with Normal Saline, apply Xeroform, cover with pad and wrap with Kerlix daily until resolved. Review of an Interdisciplinary Note dated 2/11/11 referenced a Significant Change Review note from 1/24/11 which recorded the Resident was alert with cognitive loss evidenced by short term memory problems. The resident needed limited to extensive assist to complete his/her ADL's due to a physical decline. The resident had a recent breakdown in the skin of the right heel related to sliding his/her feet back and forth when in bed and did not want to wear heel protectors. This caused a blister to form on the right heel and a red area on the left heel. Staff initiated the use of "off load" boots to both heels to be worn at all times. Review of the Weekly Wound Reports for the left heel dated 1/4/11 - 1/28/11 recorded when the staff identified the wound, (1/4/11), the wound was 3 x 1 cm in size without any noticeable break in the skin, red/purple in color, and the physician was notified. The facility notified the physician and the physician ordered heel float boots. On 1/17/11 no size of the wound was documented, the color remained red/purple and the treatment with heel float boots continued. 1/21/11 the record revealed the size of the wound was 2 x 1 cm, the color was purple and the current treatment was noted as Xeroform gauze with a Kerlix wrap. The entry dated on 1/28/11 recorded the area appeared healed. Review of the Weekly Wound Report for the right heel from 1/4/11 - 3/29/11 revealed on 1/4/11, the facility identified the pressure ulcer as a 7 x 5 cm sized white blister, located on the inside, back area of the right heel with NA (not applicable) written in the "Stage" area. The facility notified the doctor at 3:00 p.m. and ordered heel float boots worn at all times to keep the pressure off the heels. On 1/11/11 the facility documented the pressure ulcer as 7 x 5 cm in size, red colored with yellow discharge. Treatment was specified as heel boots at all times and a non adherent pad with Keri used for protection. On 1/17/11, the staff failed to document anything on the form. On 1/21/11 the staff recorded the size as 4 x 2 cm, the depth as superficial, and the color pink. During the month of February the size decreased to 0.25 cm. the depth described as scabbed over, and the color changed to tan. The staff recorded Aloe as the treatment. On 3/16/11 - 3/29/11 the staff recorded the size changed to a minimal scabbed area with a depth of less than 0.1 cm and the current treatment recorded to "off load" on pillows. Review of Mid Kansas Wound Specialists physician progress notes [REDACTED]. A right heel pressure ulcer developed with an onset/duration of 12/10 to 01/11. The assessment reported a decubitus ulcer to the right heel that was unstageable. The plan instructed to "off load" the right heel; keep the area dry and leave the scab alone; discontinue using the "off loading" boot as the boot itself was causing pressure - just off load with a pillow so the heel doesn't touch the bed; and apply moisture barrier to peri-wound skin. The right heel wound was described as 1 x 1 cm, scabbed over with scant drainage. The assessment recorded no debridement was done. On 3/29/11 at 2:45 p.m. observation revealed the resident in his/her room in the recliner with the chair footrest elevated. His/Her heels rested on the chair footrest, not floated on a pillow. His/her eyes were closed and his/her mouth partially opened. The resident appeared to be sleeping. Observation on 3/30/11 at 7:50 a.m. revealed resident sitting with the head of the bed elevated to 90 degrees and his/her legs straight out with the pillow underneath his/her calves, resulting in both heels resting directly on the bed. Forty-six minutes later, on 3/30/11 at 8:36 a.m. observation revealed staff S rubbed [MEDICATION NAME] cream onto the residents feet and pulled the pillow down toward his/her ankles to "off load" the heels. Staff S confirmed that "off loading" pressure boots had been discontinued because the resident complained the right boot hurt. On 3/30/11 at 4:40 p.m. during an interview, nurse aid staff FF reported the resident moved his/her legs around a lot when in bed and staff found it very difficult to keep his/her heels off loaded. Staff FF reported he/she attempted to explain to the resident the importance of keeping pressure off his/her heels while in bed or in the recliner. Staff FF revealed that due to the resident's cognitive deficits, he/she didn't know if the resident ever understood. On 4/4/11 at 8:00 a.m. during an interview, licensed nurse staff Z reported he/she wasn't aware the resident still had a pressure ulcer to the heels. Staff Z reported he/she thought the pressure ulcer healed. Staff Z reported the staff was expected to keep the resident's heels "off loaded" and he/she checked it him/ herself whenever the resident was in bed. Staff Z also reported the resident moved the pillow a lot so he/she expected the staff to check placement often. Staff Z revealed that other than the boots, which the resident hated, "off loading" with pillows was all they had done to relieve the heel pressure. He/She reported the staff reminded the resident to leave the pillow in place but the resident wasn't compliant. Staff Z reported he/she questioned if the resident could understand or just didn't want to comply. On 4/4/11 at 8:26 a.m. during an interview, administrative staff F confirmed the resident kept moving the pillow out of correct placement which required the staff to continuously go to the resident's room to check placement and replace the pillow. Staff F reported they hadn't tried any other "off loading" methods but continued use of the pillow because the wound specialist recommended it. Staff F also confirmed the facility had not attempted off loading for the resident's heels prior to the observation of the skin breakdown. As a result of the facility's failure to implement pressure redistribution prior to the development of a Stage 2 pressure ulcer on the right heel, a resident assessed as at risk for the development of pressure ulcers and with a history of recurrent pressure ulcers, developed avoidable pressure ulcers on each heel.

The facility reported a census of 77 residents with 17 selected for review. Based on observation, interview, and record review, the facility failed to provide necessary care and services for 1 resident, #18, with constipation, who experienced severe pain and discomfort, when staff manually removed a large amount of stool from the resident's rectum on two separate occasions, on two consecutive days. The facility also failed to ensure the coordination of care for 1 of 1 sampled resident (#12) reviewed for Hospice services. Findings included: - The facility readmitted resident #18, on 10/31/04, with [DIAGNOSES REDACTED]. The 10/31/04, admission physician's orders [REDACTED].O.(by mouth) daily, PRN (as needed) for constipation, and Senna 8.6 mg tablet, one po as needed if 3 days without bowel movement". The 3/3/10, physician's orders [REDACTED]. Start Senna S by mouth twice daily for constipation, inform doctor if abdominal cramping or diarrhea. Dementia diet, encourage salty foods." Other physician's orders [REDACTED].O. daily", and 6/28/10, "Change Senna plus to one P.O. daily and one PRN if 3 days without a bowel movement". The physician progress notes [REDACTED]. The 12/13/10, physician's orders [REDACTED]. The quarterly MDS (minimum data set) dated 1/27/11, revealed short and long term memory problem, with moderately impaired decision making skills. The assessment recorded the need for extensive assist of 2, with all activities of daily living (ADL's), transfer, dressing, toileting, personal hygiene. The assessment indicated no pain observed or documented. The 11/18/10, care plan instructed staff, "Prompt toileting upon awakening and after meals, check and assist as needed, every 2 hours and prn at night. The resident does continue to take self at times. Provide constipation medication as ordered, prune juice every morning, offer and encourage fluid intake during meals." The 2/2/11, dietary profile indicated, "Dementia diet with prune juice and health shakes twice daily, encourage salty foods." Review of the medication administration records for January, February, and March, 2011, revealed, Milk of magnesia given five times in January, on the 5th,11th,17th, 30th, and 31st, one time in February, on the 17th, and one time in March, on the 29 th. Senna PRN, given only one time in January on the 16 th and two times in February, on the 1st, and the 12th. On 3/30/11, an order was obtained and read, "[MEDICATION NAME], 10 mg rectally, daily, as needed for constipation". This entry noted an extra large result after administration. Review of the bowel monitoring, indicated the resident had no bowel movements for 3 or more days on: 1/1-5/11, 1/8-11/11, 1/13-17/11, 1/19-21/11, 1/27-31/11, 2/2-4/11, 2/14-17/11, 3/3-5/11, 3/9-12/11, 3/14-17/11, 3/19-22/11, 3/24-26/11, A nursing note dated 3/29/11, at 5:30 pm, recorded "...Alert with confusion noted. Constipation noted with milk of magnesia given per PRN orders." Review of the nurse's notes for January, February, and March, 2011, lacked documentation of any problems related to bowel movements or constipation. The facility's bowel monitoring policy dated December 2007 recorded: "Residents bowel movement shall be reviewed each day. 1. The 3-11 nurse for each neighborhood will review the "No BM in last 9 shifts Report" from Care Tracker each day. 2. Any resident on the report will be assessed to determine if laxative is required. 3. A PRN laxative will be required if resident has not had a bowel movement in 3 consecutive days. 4. If a laxative is necessary it will be administered as directed by physician order [REDACTED]." 5. The completed "No BM in last 9 shifts report" will be forwarded to the Director of Nursing for review. 6. Nursing staff will consult the resident's attending physician to review the resident's bowel regimen if an order is not present for a laxative or the resident requires PRN laxative more than 4 times in a month." On 3/29/11, at 4:45 pm, certified nursing staff L assisted the resident to eat the evening meal, which included only 6 ounces of water for liquids, of which the resident consumed less than 25%. Certified nursing staff L then ambulated with the resident, to the toilet. Observation revealed the resident crying and bearing down as if needing to have a bowel movement. The certified nursing staff began verbally encouraging the resident to "Push and bear down". After approximately 5 minutes, the certified nursing staff called the nurse to the room. Licensed staff, N entered the room, and offered " Let me help you", put on a glove, kneeled down in front of the resident, reaching in front of the resident, through the toilet seat opening, underneath of the resident, and attempted to manually remove a partially expelled bowel movement. At this time, the resident cried out loudly, telling staff to stop. The nurse stopped immediately, and began talking with the resident. Observation revealed the resident crying, with tears dripping down the cheek, and facial grimacing. The nurse offered again to "Help", and the resident nodded yes. The nurse again gloved and approached the resident from the front, through the toilet seat, and as the nurse touched the resident, the resident screamed out again to "Stop". The nurse at this time, stopped, ungloved, washed his/her hands and went to see if the resident had a suppository to assist with constipation. The nurse then provided the resident an oral dose of milk of magnesia. The certified nursing staff L stated, at 4:55 pm, when asked if this was a common occurrence for this resident, "Yes, we have to help him/her frequently. He/She doesn't understand due to the [MEDICAL CONDITION], so he/she can't evacuate himself/herself." Further questioning related to fluid intake, revealed, "The resident usually only drinks a little. The resident gets water for supper, but doesn't usually finish one glass. We provide an evening juice or water; usually we sit it on the bedside table in the room, where it can be reached. I am not sure how much the resident drinks. We just leave it sit there for him/her." On 3/30/11, at 7:00 am, observation revealed the bedside table, close to the bed, contained one four ounce plastic cup of water about half full. On 3/30/11, at 9:50 am, this resident was observed sitting on the toilet moaning, not crying, positioned with the left arm, behind his/her back, holding onto the right side of the base of toilet seat. The certified nursing staff M stated, "We are supposed to chart on the care tracker to notify the nurse to offer a medicine for constipation, if the resident has not had anything in three days. He/She can't remember and it is hard for him/her to have a bowel movement, so we have to help him/her a lot." On 3/30/11, at 10:13 am, continuous observation revealed certified nursing staff M called another staff member to get the nurse. Licensed staff K entered the room at this time. The nurse then gloved his/her hands, applied lubricating jelly to the fingers, and as the certified nursing staff held the resident up, the nurse attempted to remove the hard, fecal matter, that the resident had partially expelled. Observation revealed the resident crying, bending the knees, trying to sit and pull away from the staff. The nurse removed some well formed bowel movement, more dropped onto the toilet surface. The nurse then added more lubricant to the dirty glove, and digitally removed more fecal matter from the resident ' s rectal vault. The resident continued to cry, and began to yell, "Stop that. I need help, stop." and continued crying out, loudly, moaning, sobbing, and dribbling urine down the legs onto his/her clothes and the floor. The nurse removed a moderate amount of formed stool. On 3/30/11, at 10:25 am, licensed staff K, called the resident's doctor, got a new order, and stated, "I called the doctor. I got a new order for a suppository, but I will let him/her rest until after lunch, then we will do the suppository". On 3/31/11, at 10:55 am, licensed staff K, stated, "No, I can't think of any reason why he/she doesn't have a water pitcher. I don't know of anything that would stop us from giving him/her one. We give the PRN medications, but we don't do it until after the care tracker report is reviewed and a problem identified. He/She is having a better day today. I think he/she feels better now, after having a large bowel movement. I don't think he/she drinks juice. I haven't given him/her any." On 3/31/11, at 11:30 am, dietary staff P, stated, "The dementia diet is just the same as the regular diet." Dietary staff verified at this time, that this resident was not offered prune juice on any date to his/her recollection. Stated, "I think they get him/her orange juice sometimes, and Hawaiian punch, but no prune juice. He/She drinks water, and that's about all." The facility failed to follow their bowel monitoring policy, failed to encourage adequate fluids, failed to administer adequate stool softeners and medications to prevent constipation on a routine basis. The facility licensed nursing staff manually removed stool twice, causing the resident harm, as evidenced by the resident's crying out loudly, moaning, sobbing and dribbling urine in pain. - Review of a significant change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/21/11 identified resident #12 with short and long-term memory problems, severely impaired cognition, required limited assistance from one staff with bed mobility, transfers, eating, toilet use, personal hygiene, and extensive assistance from staff with bathing. It also identified the resident received hospice care. The care plan, dated 3/11/11 identified the resident received hospice services, but lacked specific interventions for staff that included the responsibilities for the facility staff or for the Hospice staff to ensure the resident received the expected care. The care plan did identify the resident received a "sitter" 24 hours a day, provided by the family. On 3/29/11 at 2:00 p.m., interview with Personal Sitter J identified the resident received Hospice services "for about a month." Staff J identified that now that the resident received hospice, "they (hospice) do the baths for (the resident)." Review of the hospice notes revealed the resident refused a bath on 3/4, 7, 14, and 18/11. The notes further showed hospice provided a bed bath to the resident on 3/21, 24, 25 and 28/11. Review of the computerized documentation showed the facility staff provided a shower to the resident on 3/3, 7, 21 and 24/11. The documentation lacked any further attempts by the staff or corresponding refusals to bathe by the resident. On 4/4/11 at 9:20 a.m., Administrative Nurse A identified the facility staff were expected to continue providing care for the resident. Any care provided by the hospice staff was intended to be in addition to the routine care the facility staff provided to the resident. Nurse A stated the intent for the resident included a bath twice a week by the facility staff, but that the resident may choose only one, or may choose for hospice to provide the bath. The care plan lacked any specific individualization by the facility in regards to bathing. The facility failed to coordinate the baths with hospice staff to ensure a resident received both their routine baths provided by the facility and the additional baths provided by hospice staff.