Every finding on record at Lexington Court Care Center

Based on record review, review of the facility Self-Reported Incident (SRI), facility investigation review, police report review, interviews, review of the facility assessment, training review and policy review, the facility failed to ensure Resident #44 was provided appropriate and dignified dementia care to meet Resident #44's total care needs. This resulted in actual harm on 08/24/25 when Resident #44, who was identified with severe cognitive impairment with a diagnosis of dementia and required one staff assistance with activities of daily living (ADLs), received bruising to her bilateral wrists and lower forearms after her hands and wrists were held while she was combative with personal care provided by Certified Nursing Assistants (CNA) #204, #233 and #251. The staff failed to follow facility procedure related to care of a resident with dementia and failed to respect her right to refuse care during times of combativeness, agitation and duress resulting in bruising that measured four centimeters by four centimeters to her wrists and lower forearms. Subsequently, Resident #44 received X-rays of her bilateral wrists and hands due to complaints of pain. This affected one (Resident #44) of three residents reviewed for dementia care. The facility census was 69. Findings include: Review of Resident #44's medical record revealed an admission date of 03/27/17 with diagnoses including Alzheimer's disease, unspecified dementia without behavioral disturbances, diabetes, hypothyroidism, depression, and a history of urinary tract infections.Review of Resident #44's care plan, dated 06/26/18, revealed the resident had care plans in place for verbal behaviors and resisting care. Approaches included accepting the resident's right to refuse and show respect for the resident's decision, maintaining a calm environment and calm approach to the resident, and when the resident begins to resist care, stop and try tasks later. Do not force the resident to do a task.Further review of the care plan revealed Resident #44 had a care plan dated 02/18/21 for severe cognitive impairment related to diagnosis of Alzheimer's disease with approaches including to allow the resident time to absorb and respond to information and to explain all procedures and treatments to the resident prior to initiating them. Resident #44 also had a care plan dated 02/18/21 to monitor the resident for bruising and bleeding related to receiving aspirin daily as a blood thinning medication. Approaches included attempting to protect the resident from injury or trauma.Review of Resident #44's five-day minimum data set (MDS), dated [DATE], revealed a brief interview for mental status (BIMS) score of five (out of a possible score of 15) indicating the resident had severe cognitive impairment. Further review of the MDS revealed Resident #44 was dependent on the facility staff for toileting hygiene and bathing or showering needs and the resident was occasionally incontinent of bladder and frequently incontinent of her bowels. No behaviors were documented on the MDS.Review of current physician orders revealed Resident #44 was ordered aspirin 81 milligrams daily.Review of the resident's progress notes, dated 08/24/25 at 11:26 A.M. and written by Registered Nurse (RN) #164, revealed Resident #44 was alert and oriented times two. The resident was pleasant and cooperative with care. Resident #44 required the assistance of one staff with activities of daily living (ADL), bed mobility, and with stand and pivot transfer from bed to wheelchair using bed rails to transfer. Resident #44 was incontinent of bowel and bladder and required check and change every two hours and required the assistance of one staff with transferring to toilet, using the grab bars in the bathroom. The resident was able to self-propel in a wheelchair. Resident #44 was in her wheelchair in the dining room and denied any needs at this time. Review of Resident #44's nurse progress notes, dated 08/24/25 at 5:36 P.M. and written by Licensed Practical Nurse (LPN) #250, revealed LPN #250 had received a phone call from Resident #44's daughter requesting an update because her brother had visited earlier (that date) and Resident #44 had hit him. Resident #44's daughter requested the resident's urine be tested for a urinary tract infection (UTI).Review of the behavior monitoring log revealed no evidence of resident behaviors prior to 08/24/25 at 8:00 P.M.Review of Resident #44's behavior log flow sheet revealed on 08/24/25 at 8:00 P.M. Resident #44 displayed behaviors of refusing care, frustration/escalation of behavior, being argumentative, scratching, biting, kicking, hitting and pinching. Prior to the behaviors being displayed, the resident was incontinent of her bladder. The behaviors took place in the resident's room and bathroom. The staff attempted the following interventions: approaching the resident calmly and quietly from the front, offering food/drink, assessing her for pain and treating it if indicated, offering or assisting her to the bathroom, offering rest, repositioning, redirecting to a quiet area, approaching 1:1, offering care later, having a different caregiver approach her, and using two caregivers. The interventions were not effective in calming the resident. Further review of the log revealed the nurse was notified of the resident's behavior. There was no progress note to explain this behavioral incident on 08/24/25 at 8:00 P.M. in further detail or any interventions implemented by staff to allow care to be completed.Review of Resident #44's nurse progress notes dated 08/24/25 at 9:42 P.M. and written by LPN #250, revealed the resident was resting in bed and was alert and cooperative with taking her bedtime medications.Review of Resident #44's nurse progress notes dated 08/25/25 at 3:20 A.M. and written by LPN #250, revealed the resident's urine was dipped and was positive for leukocytes, protein, ketones, and specific gravity off from normal. Medical Doctor (MD) made aware.Review of Resident #44's nurse progress notes, dated 08/25/25 at 5:14 A.M. and written by LPN #250, revealed the second shift Certified Nursing Assistants (CNAs) informed this nurse of the resident demonstrating combative behavior with personal care. Night shift CNAs informed the nurse that Resident #44 did not have combative behavior this shift.Review of Resident #44's nurses progress notes, dated 08/25/25 at 12:37 P.M., revealed an interdisciplinary team note written by the Director of Nursing (DON) that stated the resident had an allegation of abuse. Further review revealed LPN #222 and CNA #156 reported Resident #44 had bruising to her bilateral wrists and forearms. Upon bringing this information to this nurse's attention, an investigation was started. Resident #44 was combative with care on 08/24/25, resulting in bruising to (her) bilateral wrists and forearms. The resident was combative with toilet assistance and was combative during visit with son. Resident's son noted behaviors and nursing reached out to the MD for urinalysis due to change in mental status. Skin and pain assessments were completed and revealed bruising was noted to the resident's bilateral wrists and forearms. No signs or symptoms of pain were observed. Resident #44 was pleasant during the investigation and assessments and stated I fell when asked how the bruises were obtained. Resident #44 was cooperative this morning with care and with staff. The local police, MD, and the responsible party were notified. A behavior care plan was in place. Resident #44's care plan was reviewed and updated.Review of Resident #44's skin incident event dated 08/25/25 at 12:30 P.M., and completed by RN #180, revealed the resident had a bruise on her right wrist/arm that measured 4.5 centimeters (cm) in length and 4 cm in width. The skin incident event indicated that the bruise occurred while the resident was receiving ADL care and having a behavioral outburst.Review of Resident #44's nurses progress notes dated 08/25/25 at 1:59 P.M. an interdisciplinary team note, written by RN Nursing Administration #180, revealed the resident acquired a wound. The location of the wound was bilateral wrists/forearms, and the type of wound was a bruise. An order was placed to monitor the bruised areas. Interventions included staff education and Geri-sleeves (arm protectors) to be worn as tolerated. The root cause of the wound was combative with care. Resident #44 would be followed by the wound team weekly. MD and the responsible party were notified. Resident #44's care plan was updated (This was written as a late entry note on 08/29/25 at 11:01 A.M.).Review of Resident #44's skin incident event, dated 08/25/25 at 3:47 P.M. and completed by RN #180, revealed the resident had a bruise on her left wrist/arm that measured 3.8 cm in length and 4 cm in width. The skin incident event indicated that the bruise occurred while the resident was receiving ADL care and having a behavioral outburst.Review of Resident #44's nurses progress notes, dated 08/26/25 at 4:13 P.M. and written by the DON, revealed the resident went out to an appointment (unrelated to the incident). Per MD, new orders for bilateral wrists, forearms and bilateral hands (X-rays). This nurse put in STAT (immediate) X-ray orders and updated the resident's daughter. Per the resident's daughter, the resident is returning with paperwork for laboratory tests and a follow-up appointment.Review of Resident #44's physician's orders revealed an order dated 08/26/25 for x-rays of the resident's right and left forearms, wrists and hands to be completed STAT for the resident having pain reported by the resident's daughter and bruising. There was no pain assessment or documentation of the resident's pain other than the physician orders for the X-ray.Review of Resident #44's nurses progress notes, dated 08/26/25 at 9:14 P.M. and written by LPN #215, revealed x-ray results were received at the facility that revealed no acute fracture or dislocation to the resident's left and right hands and wrists.Review of a SRI Form, Tracking Number 264469 dated 08/25/25, revealed the DON was notified by LPN #222 that Resident #44 had bruising to her bilateral wrists and an investigation regarding physical abuse was initiated.The DON and medical records/Certified Nursing Assistant (CNA) #230 assessed Resident #44 and the resident was found safe and comfortable in (her) environment. The resident stated she received bruising from a fall. Bruising to bilateral wrists and forearms were noted to be inconsistent with a fall. The resident did not voice any care complaints or any needs at this time. Skin and pain assessments were completed with no adverse findings.Further review revealed Resident #44 was noted with combative behaviors on the evening prior. Interviews with staff and residents completed. In interviews with staff, CNA #251 reported in an effort to de-escalate behaviors during incontinence care, he moved the resident's bilateral wrists to redirect the resident during combative behaviors. This was witnessed by CNA #204 and #233, who were all three present for incontinence care provided to the resident. All three CNAs report the appropriate redirections took place during incontinence care.Prior to incontinence care, multiple comfort measures were attempted for redirection of combative behaviors. All CNAs noted to speak in a calm tone and slowly. Resident offered reassurance and bedtime snack. After incontinence care, the resident did not display further combative behaviors.Upon notification the next morning, CNA #251 was suspended. Skin assessments and resident interviews conducted with no adverse findings.All notifications completed including the MD, Power of Attorney, and local police department. Psychosocial follow-ups were completed without any adverse findings. The Administrator interviewed Resident #44 who reported the bruising was from a fall. Abuse education provided to all staff; X-rays were completed in-house with no adverse findings.An allegation of abuse was reported to the local law enforcement. Report number 25-11470 was completed by two (unidentified) officers.The allegation was unsubstantiated as the evidence was inconclusive. Education was provided on dealing with residents who have dementia, and combative behavior. Resident care plans updated to reflect combative behaviors and behavior logs in place to monitor.Review of the local police department report number 25-11470 dated 08/25/25 revealed the facility nurse manager was made aware of bruising on the arms of a resident and confirmed them describing the marks as in the shape of fingerprints. The resident, who was [AGE] years old and diagnosed with dementia, was asked if she remembered how she sustained the bruising and was unable to recall. The nurse manager stated that after speaking with the staff from the previous night it was learned that the resident became very combative and staff advised they had to restrain the resident's arms to safely perform their duties.Review of CNA #204's statement, from the facility investigation, revealed CNA #204 stated she was asked to assist CNA #233 and CNA #251 with getting Resident #44 from the toilet and into bed as the resident was very combative and irritated. Resident #44 continued to bite, pinch, hit and yell after she was assisted to bed. CNA #204 stated CNA #251 placed his hand on Resident #44's wrist to deflect a hit while CNA #233 was doing her care.Review of CNA #233's statement, from the facility investigation, revealed CNA #233 went and got CNA #251 to help her provide incontinence care for Resident #44 who was kicking and hitting her. CNA #233 stated that CNA #251 placed his hands on Resident #44's wrist to redirect her from hitting them.Review of CNA #251's statement, from the facility investigation, revealed he was asked by CNA #233 to assist with changing Resident #44 because she was kicking, hitting, and scratching. CNA #251stated they attempted to assist the resident to the toilet six to eight times before they placed her in the bed and changed her. Resident #44 continued to attempt to bite and hit and CNA #251 stated that he placed his hands on her wrists and redirected her arms to the trunk of her body whenever she would swing or grab.Further review of the facility investigation, date of event 08/25/25, revealed the root cause of the bruises to be CNA #251 attempted to grab the resident's wrists to calm the resident and get the resident to stop hitting at staff. As a result of grabbing the resident's wrists, bruises formed this morning and were noted by CNA and LPN.Review of the employee file for CNA #251 revealed a hire date of 01/02/25 with completed training for abuse prevention, recognizing and reporting on 06/14/25, abuse and neglect: resident abuse on 08/18/25 and challenging behaviors in dementia care on 06/25/25. Further review of CNA #251's employee file revealed he was placed on suspension pending investigation on 08/25/25. After the investigation was completed, CNA #251 was discharged , effective 08/28/25, for a customer service violation. This document was signed by previous Administrator #500.Review of the resident's medical record and facility investigation, including the SRI did not indicate the resident was unsafe or why care had to be provided at that time and the resident's wrists held to prevent her from hitting three staff who were in the room providing care when she typically required one staff assistance with ADLs. There was no evidence that the three CNAs notified the nurse, LPN #250, of the resident's behavior and the resident's wrists being held to provide care.In an interview on 10/21/25 at 4:15 P.M., the DON stated Resident #44 had one bruise on each wrist and the bruises did not look like fingerprints as stated in the police report and she did not know where they got that or that Resident #44 was restrained. The resident had stated that the bruises were from a fall; however, the resident needed assistance to transfer and would not have been able to get herself up off the floor if she fell. The DON stated she knew the resident had not fallen recently and she started the investigation. The DON stated the staff made multiple attempts to change Resident #44 prior to this attempt but were unsuccessful. She stated the facility staff are trained to step away but she felt the staff needed to complete incontinence care for this resident, even though she was refusing the care and was combative. The DON stated CNA #251 was terminated for not coming to work or calling off on 08/30/25 and 08/31/25.In an interview on 10/21/25 at 4:30 P.M. Business Office Manager (BOM) #177 stated she was not on the 08/28/25 phone call made to CNA #251 and was not sure who was present; however, she was aware that he did not answer his phone. BOM #177 verified there was no paperwork to confirm CNA #251 did not call or not show up for work on 08/30/25 or 08/31/25 in CNA #251's employee file and the paperwork in the file stated that he was terminated on 08/28/25 for a customer service violation.In an interview on 10/22/25 at 12:24 P.M., CNA #233 stated that on 08/24/25 she attempted to change Resident #44, who became combative, so she walked away and then came back after about 10 minutes. On her second attempt, the resident hit her in the face. She then went to ask CNA #251 for help, and he and CNA #204 went with her to change the resident about 10 minutes later. While they were changing Resident #44, CNA #251 redirected the resident's arms away from them so they could change her. Resident #44 continued to try to hit, kick and bite them. CNA #233 stated she could not remember how CNA #251 redirected the resident or her hands. CNA #233 stated this occurred around 9:00 to 9:30 P.M. as they were attempting to do last checks before shift change. The nurse was aware that the resident was being combative. When asked how this situation would have made her feel if someone did the same to her, the CNA stated it would have upset her and made her angrier than she already was.A follow-up phone interview with the DON on 10/24/25 at 2:22 P.M. with the Administrator present, confirmed the resident did have a diagnosis of Alzheimer's Disease and dementia and staff received annual training on care of residents with dementia. The DON shared staff were trained to step away from residents who refused care and give them time and re-approach the resident later, but in this situation with Resident #44, she had refused care all day and no one had changed her (due to incontinence), and they wanted to ensure the resident had received incontinence care. The DON confirmed the medical record contained a progress note dated 08/24/25 at 11:26 A.M. that indicated the resident was cooperative with ADLs provided by one staff and would stand pivot to transfer using grab bars to the toilet and did not indicate the resident had refused care on the date of the incident. The DON further stated around 3:00 to 4:00 P.M. the resident started getting more combative with care and the resident was obviously not very happy. The DON stated the nurse working would have been administering medications at the time of the incident and would have been available to assist the staff if needed and there were not any safety issues for other residents. The DON was unaware if the staff had requested assistance from the nurse (LPN #250), but she remembered talking with the nurse, but she could not remember if the nurse provided her with a statement (as it was not part of the investigation provided). The DON stated she was not the manager who discharged CNA #251. Lastly, the DON verified the staff needed to provide care to the resident; however, her expectation would be for staff not to lay their hands on a resident in order to provide care and the nurse should have been aware of what was happening so care could have been provided to the resident the safest way possible and not by causing bruises to the resident's wrists and arms. The DON shared she was informed CNA #251 was terminated for failure to report to work. The DON stated the CNA was terminated while she was on vacation and she could only provide the information that was told to her which was he was a no call, no show on 08/30/25 and 08/31/25. The DON acknowledged this was after the aide was terminated but had no additional information to provide.A phone interview on 10/26/25 at 2:42 P.M. with LPN #250 revealed she no longer worked at the facility (she was from a sister facility, and she was no longer needed). The LPN verified she was the nurse working the night of 08/24/25 and Resident #44's daughter reported the resident struck her (the resident's) son while he visited that afternoon. Further interview with LPN #250 revealed she was unaware of any concerns related to the resident's care and evening shift staff reported Resident #44 was combative, but they were eventually able to assist the resident to bed and get her changed. The staff did not report CNA #251 held/guided/redirected the resident's hands at her sides while the other staff provided care as this would not have been appropriate and she would have contacted the DON to report an allegation of physical abuse. Further interview revealed if she had been aware the resident was combative or resistant to care, she would have told them to give her space, offer the resident a snack, provide a diversional activity but to never continue with care. The LPN stated the resident had spurts of being grouchy but staff knew that and it was not unusual but since she struck out at her son, LPN #250 and another nurse did check her urine and notified the physician (later in the shift). Lastly, LPN #250 stated she felt bad for Resident #44 being forced to receive care and it would have upset her and made her angry if she received care she clearly did not want and held her down against her will.An additional interview on 10/28/25 at 9:38 A.M. with the DON verified CNA #204 and CNA #233 were still employed and received no disciplinary action related to the incident with Resident #44. The DON stated CNA #204 and CNA #233 reported to the nurse that Resident #44 was striking out but CNA #204 and CNA #233 did not feel Resident #44 had been abused. The DON stated staff received abuse and dementia training through Relias (a cloud-based learning management system (LMS) designed to deliver, manage, and track online training primarily for the healthcare, human services, and long-term care sectors). The DON verified there was no additional training or in person training because of the incident that occurred on 08/24/25 with Resident #44. The DON was not sure what time the incident was reported to the nurse but believed the care for Resident #44 occurred around 6:00 P.M. The DON stated all the staff were trained to report any suspicions of abuse even if they were unsure if actual abuse occurred.An interview on 10/28/25 at 10:35 A.M. with former interim Administrator #500 revealed she was the facility administrator from approximately July through the end of August 2025 and said the DON typed the SRI which was an injury of unknown origin. Resident #44 reported she had fallen but the DON did not believe the resident fell. Administrator #500 stated CNA #251 was not terminated due to the investigation. She stated no one could contact CNA #251 so she completed the termination form and indicated the reason was a customer service violation which was a blanket reason for many terminations.An interview on 10/28/25 at 10:58 A.M. with CNA #204 revealed Resident #44 was irritated on 08/24/25. CNA #204 verified she had not been assigned to provide care for Resident #44 that day, but she assisted CNA #233 and CNA #251 with getting Resident #44 off the toilet. Resident #44 had not been changed and really needed changed. Resident #44 was hitting and biting staff. CNA #204 stated she believed the nurse was aware because Resident #44 was yelling and everyone could hear the resident. CNA #204 could not remember what Resident #44 was yelling. CNA #204 verified Resident #44 did not want staff to provide incontinent care. When asked if Resident #44 had behaviors, CNA #204 stated Resident #44 would say she wanted to go home, like multiple other residents did. CNA #204 stated CNA #251 acted as a barrier and placed his hands out across Resident #44. CNA #251 took more of the hits from Resident #44 than CNA #204 and CNA #233. CNA #204 went back to provide care to the residents she was assigned to after incontinence care was done. CNA #204 thought the nurse checked Resident #44 after care was done and she believed the incident occurred around 8:30 P.M. or 9:00 P.M. because last checks on residents were being done.Review of the facility assessment updated on 09/04/25 revealed the facility would supply training/education on abuse, neglect and exploitation, person centered care and dementia management care. The assessment revealed the facility accepted residents with psychiatric/mood disorders such as impaired cognition, mental disorder, bipolar disorder, post-traumatic stress disorder, anxiety disorder, behavior that needs interventions, and schizophrenia. The facility also accepted residents with neurological system disorders which included Parkinson's disease, Alzheimer's disease, and non-Alzheimer's dementia. Services provided by the facility included managing the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, and care of someone with cognitive impairment. The staff training/education and competencies to provide the level and types of support and care needed for the resident population included: resident rights to ensure that staff members are educated on the rights of the resident and the responsibility of a facility to properly care for its residents. Training also included identification of resident changes in condition, including how to identify medical issues appropriately and how to determine if symptoms represent problems in need of intervention. Abuse, neglect, and exploitation training included activities that constitute abuse, procedures for reporting incidents of abuse, and care/management for persons with dementia and resident abuse prevention. Competencies included caring for person with Alzheimer's or other dementia.Review of the policy titled Abuse Prevention Program Policy and Procedure, reviewed 01/2025, revealed each resident had the right to be free from abuse, neglect and corporal punishment of any type by staff or anyone. The facility will provide a safe resident environment and protect residents from abuse. Abuse, is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation of an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psycho-social well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. All staff are expected to be in control of their own behavior, are to behave professionally, and should appropriately understand how to work with the nursing home population.Atrium Center facilities care for diverse populations including, among others, residents with dementia, mental disorders, intellectual disabilities, ethnic/cultural differences, speech/language challenges, and generational differences. The facility assumes the responsibility of ensuring the safety and well-being of each resident they admit.Staff are held accountable to their actions to meet the Medicare and Medicaid requirements for participation by providing care in a safe environment. Atrium will not consider striking a combative resident an appropriate response in any situation. It is also not acceptable for any staff member to claim his/her action was reflexive or a knee-jerk reaction and was not intended to cause harm. Retaliation by staff is abuse, regardless of whether harm was intended, is unacceptable and must be cited.Characteristics of Increased Risk of Abuse include but are not limited to verbally aggressive behavior, such as screaming or cursing, insulting or intimidating; physically aggressive behavior such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, throwing objects; resistive to care and services.Review of the Dementia Care: Challenging Behaviors and Direct Care Staff training, dated 2023 and provided to facility staff as the required dementia care training revealed Dementia is a common chronic condition affecting older adults. Some individuals with dementia experience behaviors such as restlessness, wandering, agitation, physical aggression, and shouting. This course discusses how to prevent and manage these types of behaviors. It also discusses factors affecting the behaviors of individuals with dementia. Without knowledge of dementia and management of dementia-related behaviors, the quality of life of individuals with dementia declines.The goal of this course is to educate direct care workers in post-acute care settings on identifying and managing challenging behaviors in older adults with dementia.Memory loss and cognitive changes are the most common symptoms of dementia. Individuals with dementia may feel angry, confused, and sad. Older adults may show behaviors that create challenges for caregivers. Not every person with dementia will experience every behavior discussed in this course. Dementia-related behaviors may include (but not limited to): Delusions, hallucinations, physical or verbal aggression, yelling.Individuals with dementia can experience episodes of aggression which can be physical or verbal. This type of behavior can occur suddenly for no known reason or result from a situation that has become frustrating to the older adult with dementia.The best strategy for managing dementia-related behaviors caused by physical health factors is notifying your immediate supervisor of these issues. By doing this, you will help identify and treat the problem that is causing the behavior. This deficiency is an incidental finding discovered during the complaint investigation.

Based on observation, interview, and facility policy, the facility failed to ensure a clean and sanitary kitchen as well as hair restraints were worn by kitchen staff while in the kitchen. This had the potential to affect 69 residents out of 69 who received meals from the facility kitchen. The census was 69. Findings include: Observation on 03/25/25 at 10:27 A.M. revealed Interim Dietary Manager (IDM) #300 was not wearing a hair restraint. IDM #300 stated he did not know it was a regulation to wear a hair restraint in Ohio. Further observation of the kitchen revealed there was grease running down the front of the stove. IDM #300 verified the grease and stated that he would get it cleaned up. Observation on 03/26/25 at 11:45 A.M. [NAME] #302 was serving garlic bread with her gloved hand after touching other utensils and plates. She stated that she knew better and then got a pair of tongs. Observation on 03/26/25 at 11:58 A.M. revealed grease started to run down the front of the stove again. Looking at the stove, there was a grease tray that was overflowing, so when someone bumped the stove, it started to run down the front of the oven door. The shelf above the stove was greasy with dust on top of the grease. IDM #300 verified the grease and stated that he would get it cleaned up. Review of the facility policy from the diet manual dated 01/2025 titled, Sanitation Standards of Practice, revealed that it is policy to ensure food service areas are clean, sanitary and in compliance.

Based on medical record review, resident and staff interviews, and policy review, the facility failed to ensure a care plan reflected a resident's current status. This affected one (#61) of one reviewed for care plans. The facility census was 69. Findings include: Review of the medical record for Resident #61 revealed an admitted [DATE]. Diagnoses included myelofibrosis, muscle weakness, migraines, and infection of surgical site. The resident was cognitively intact. Review of Resident #61's care plan updated 02/28/25 revealed it did not include goals and interventions in place for Activities of Daily Living (ADLs). Interview with Resident #61 on 03/25/25 at 10:00 A.M. confirmed she uses a wheelchair and requires assistance from staff to complete ADLs. Interview on 03/25/25 at 1:35 P.M. with the Director of Nursing (DON) verified Resident #61's care plan did not address the resident's ADL needs. Review of the facility's policy titled, Resident Assessment Accuracy of Assessment, dated 11/28/27 revealed the facility must conduct initially and periodically a comprehensive and accurate assessment of each resident's functional capacity. The assessment must accurately reflect the residents' status.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure resident food preferences were honored. This affected one resident (#42) of one resident reviewed for food preferences. The census was 69. Findings include: Review of the medical record for Resident #42 revealed an admitted [DATE] with diagnoses included but not limited to Alzheimer's disease, heart failure, and thyrotoxicosis. Review of the most recent completed Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #42 was severely cognitively impaired and was dependent for activities of daily living. Review of the care plan dated 03/03/22 revealed Resident #42 was at nutritional risk related to diagnoses. Interventions included but not limited to honoring preferences. Review of Resident #42's diet ticket revealed Resident #42 disliked chicken. Observation of lunch tray line on 03/26/25 at 12:10 P.M. revealed Resident # 42's tray was portioned up with pureed chicken alfredo and pureed broccoli. Resident #42's diet ticket stated Resident #42 disliked chicken. [NAME] #302 stated Resident #42 has gotten chicken already and eats it, so she did not need a substitute. Observation and interview on 03/26/25 at 12:40 P.M. revealed Resident #42's was served pureed chicken alfredo. An interview with daughter of Resident # 42 revealed her mother does not like chicken and would like a substitution. Regional Clinical Director #301 called the kitchen for an alternative. Interview on 03/26/25 at 5:18 P.M. with Registered Diet Technician #310 revealed she does a tray audit monthly but does not have access to the diet ticket system to audit the diet tickets and/or update preferences. Review of the facility policy dated 01/2025 titled, Resident Interviewing/Obtaining Nutritional History, revealed preferences will be obtained by the resident or resident representative.

Based on observation, resident interview, staff interview, record review, and review of facility policy, the facility failed to ensure smoking materials were stored in a safe manner. This affected one (Resident #50) of one resident reviewed for storage of smoking materials. The facility census was 69. Findings include: Review of the medical record for Resident #50 revealed an admitted [DATE]. Diagnoses included hypokalemia, absence of right leg below knee, disorders of plasma-protein metabolism, Peripheral vascular disease, unspecified sequelae of cerebral infarction and depression. She required limited assistance with activities of daily living and she was cognitively intact. Review of Resident #50's smoking assessment dated [DATE] revealed she is to be supervised when smoking and all smoking materials are to be given to staff members to be kept in a locked location. Observation on 03/26/25 at 9:47 A.M. with Maintenance Man (MM) #473 revealed Resident #50 had four packs of cigarettes in the refrigerator in her room. Interview on 03/26/25 at 10:52 A.M. with Housekeeper Supervisor (HS) #472 revealed Resident #50 did not go out to smoke on 03/26/25 at 7:00 A.M. HS #472 confirmed she was not aware Resident #50 had cigarettes in her room but had a supply of cigarettes locked up behind the nurse's station. Interview on 03/26/25 at 11:00 A.M. with Medical Records Coordinator (MRC) #462 revealed Resident #50 went out to smoke on 03/26/25 at 10:00 A.M. She was given cigarettes to smoke that were kept behind the nurse's station locked up. She denied knowing Resident #50 had cigarettes in her room. Interview on 03/26/25 at 11:11 A.M. with Resident #50 revealed last night, she was short on cigarettes and a staff member in the afternoon shift was going to the store. Resident #50 gave the staff member money to buy her cigarettes. When she received her cigarettes, she put them in the refrigerator. She forgot they were in there until MM #473 and Surveyor found them in her refrigerator. Review of the facility's policy, Smoking Policy last updated 09/2022, revealed residents are not permitted to have lighters or other smoking paraphernalia on their person during non-smoking times. This includes both safe and unsafe smokers .Residents will be given their cigarettes and E-cigarettes, upon arrival to designated smoking areas. All cigarettes that are unsmoked will be returned to facility staff for storage. Smoking material will be labeled and kept in a central location lock and key and available by staff members or family.

Based on observation and staff interview, the facility failed to ensure medical records were available to nursing staff to administer medications and treatments to residents residing in the facility. This affected all 60 residents. The facility census was 60. Findings include: Observation on 06/14/22 at 7:06 A.M., revealed the facility's electric power failed. The facility's generator was functioning. Observation on 06/14/22 at 7:40 A.M., with Registered Nurse (RN) #530 revealed the facility used an Electronical Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #530 was unable to log into the EMAR system. Interview on 06/14/22 between 7:41 A.M. and 8:05 A.M., with RN #530, Licensed Practical Nurse (LPN) #531 and #566, verified they were unable to administer medications for their residents due to the internet was down related to the power failure. RN #530, LPN #531 and #566 verified they had no paper MAR's, Treatment Administration Record (TAR) or physician monthly order reconciliation records in residents files to verify residents orders to administer medications or treatments to the residents. Interview on 06/14/22 at 8:10 A.M., with the Director of Nursing (DON) verified there were no resident records available for any residents in the facility for nurses to use for residents medication or treatment administration. DON revealed the facility had an emergency back up system for residents medication and treatment administration records, that would be used in case of a power outage. DON revealed the emergency back up system would allow the facility to print residents medication and treatment administration records in case of a power outage to allow nurses to administer the medications and treatments for residents using paper medication and treatment administration records. DON revealed the emergency back up system was not functioning. DON confirmed she never reviewed or ran the emergency back up system before and confirmed she did not know how to use it. DON revealed the monthly physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . DON confirmed if a resident had a medical emergency and needed sent to the hospital, the facility would have no medical records, including diagnosis, medications, and treatments to send with the resident. DON confirmed residents were unable to receive any medications or treatments. Observation on 06/14/22 at 8:20 A.M., revealed Regional Nurse #589 was attempting to receive instructions on the phone to run the emergency back up system for the EMARS and ETARS. Regional Nurse #589 revealed the back up system was not connected to a red outlet which was ran by the generator. Interview on 06/14/22 between 9:56 A.M. and 10:00 A.M., with RN #530, LPN #531 and #566 verified they continued to be unable to pass medications or administer treatments to residents due to power failure. Interview on 06/14/22 at 11:15 A.M., with DON confirmed the facility continued to have an electrical failure, the generator was no longer working and residents would be evacuated to sister facilities from the facility. DON confirmed the emergency back up system did not work and the facility had not been able to administer medications or complete treatments for residents. DON confirmed this affected all residents residing at the facility.

Based on observation, resident interviews, and staff interviews, the facility failed to serve attractive foods at appropriate temperatures. This affected nine (Resident #9, #15, #17, #26, #27, #28, #34, #40, and #47) residents and had the potential to affect all 60 residents residing in the facility. The facility census was 60. Findings include: Interview on 06/07/22 at 1:44 P.M., during the resident meeting portion of the annual survey, with Residents #9, #15, #17, #26, #27, #28, #34, #40, and #47, revealed several concerns being mentioned regarding the lack of flavor and temperature of food and beverages served to residents. Observation on 06/13/22 at 12:40 P.M., of the lunch meal revealed residents were served a chili mac that appeared mushy and watery, and noodles were broken down into small pieces. Interview on 06/13/22 at 12:45 P.M., with Dietary Cook #569 revealed the staff member used egg noodles because there was no elbow macaroni available as indicated by the recipe. Observation and interview on 06/13/22 at 12:46 P.M., with Dietary Manager #532 verified the chili mac looked mushy and did not look appetizing. Dietary Manager #532 reported she always ordered enough supplies for the following week's menu but that dietary cooks went off the grid and changed the menu so the elbow macaroni was likely used for something else. Observation on 06/27/22 at 12:32 P.M., of a facility test tray, with Dietary Manager #532 revealed the milk being served to residents was 51 degrees Fahrenheit, and nectar-thick milk being served to residents was 59.7 degrees. Dietary Manager #532 verified the milk was way too warm.

Based on observation, record review, resident interview, staff interview, and policy review, the facility failed to ensure the menu was followed and proper portion sizes were served to residents. This had the potential to affect 60 of 60 residents residing in the facility. The facility census was 60. Findings include: Observation of tray line on 06/13/22 at 12:00 P.M., revealed Dietary Cook #558 served chili mac with one number (#) 8 scoop instead of one #5 scoop, served pureed green beans with one #12 scoop instead of one #16 scoop, and served pureed cornbread with one #20 scoop instead of one #10 scoop. Review of the lunch meal spreadsheet for 06/13/22 revealed that chili mac should be served using one #5 scoop, pureed green beans should be served using one #16 scoop, and pureed cornbread should be served using one #10 scoop. Interview on 06/13/22 at 12:30 P.M., with Dietary Cook, #558 verified at the time of observation that incorrect portion sizes were served to residents. Dietary Cook #558 verified she did not check the spreadsheet to see what scoop sizes were necessary. Interview on 06/13/22 at 12:39 P.M., with Dietary Manager #532 stated staff should know to empty out a little or use a scoop and a half to ensure proper portion sizes. Dietary Manager #532 reported the facility did not have all the scoop sizes available. Observation on 06/14/22 at 8:46 A.M., of the breakfast meal revealed residents received French toast sticks, cold cereal, and a banana for breakfast. Review of the menu for 06/14/22 revealed residents should have also received turkey links. Interview on 06/14/22 at 9:01 A.M. with Dietary Cook #536 verified residents did not receive turkey links and no substitute was made. Interview on 06/14/22 at 9:04 A.M., with Dietary Manager #532 revealed the facility had been having difficulty getting turkey links and the turkey links should have been replaced with regular sausage links which the facility had in stock. Observation of tray line on 06/27/22 at 12:18 P.M., revealed mashed potatoes were served with one #12 scoop instead of one #8 scoop, shredded pork was served with one #12 scoop instead of one #8 scoop, vegetables were served using one #8 scoop instead of one four-ounce spoodle, pureed pork was served using one #12 scoop instead of one #8 scoop, and residents did not receive a choice of roll as indicated on the menu. Review of the lunch meal spreadsheet for 06/27/22 revealed that mashed potatoes should be served using one #8 scoop, shredded pork should be served using one #8 scoop, vegetables should be served using one four-ounce spoodle, pureed pork should be served using one #8 scoop, residents should receive one choice of roll, and residents receiving pureed diets should receive two-thirds slice pureed bread. Interview on 06/27/22 at 12:34 P.M., with Dietary Manager #532 verified improper serving sizes as indicated in the aforementioned findings were used for the lunch meal. Dietary Manager #532 also verified there was no replacement made for the rolls or the pureed bread. Dietary Manager #532 reported the facility had difficulty getting rolls in and stated the dietary cook normally made replacements and must not have seen the roll on the menu to replace it. When asked if substitutions had to be preapproved, Dietary Manager #532 then stated she was actually the one who made replacements and that the dietary cook was supposed to give all residents a slice of bread in place of the roll. Dietary Manager #532 then furnished documentation which showed biscuits were ordered to replace the rolls. Observation on 06/27/22 at 1:08 P.M., of Dietary Manager #532 and Dietitian #587 revealed the staff members were seen quickly exiting a resident's room while laughing and carrying a container of what appeared to be rolls. During the resident council portion of the annual survey conducted on 06/27/22 at 1:44 P.M., with Resident #9, #15, #17, #26, #27, #28, #34, #40, and #47, revealed one resident reported receiving half of a hotdog bun as a snack prior to the resident council meeting. Numerous other residents reported they did not receive half of a hotdog bun or any other type of bread or snack. Review of the policy titled Portion Control, revised April 2021, revealed portion control would be achieved through adherence to the therapeutic menus and standardized recipes, and use of standardized serving utensils. The policy stated portions would be served according to the serving sizes listed on the therapeutic menus and portion control equipment would be used to assure appropriate portions.

Based on observation, staff interview and policy review, the facility failed to ensure food items were stored properly with a labeled and dated to prevent food borne illness. This had the potential to affect 60 of 60 residents residing in the facility. The facility census was 60. Findings include: Observation on 06/13/22 at 7:58 A.M., during an initial kitchen tour revealed the freezer contained one bag of undated and unlabeled breadsticks, one clear plastic package of undated and unlabeled egg patties, one clear plastic bag of undated and unlabeled cookie dough, and one clear plastic package of undated and unlabeled chicken breasts. Interview on 06/13/22 at 8:12 A.M., with Dietary Cook #569 verified the undated and unlabeled items found during the tour. Review of the facility policy titled Storage Procedures, revised April 2021, revealed food items in the freezer were to be labeled and dated.

Based on record review, staff interview, and policy review, the facility failed to accurately code the minimum data set (MDS) assessments to reflect the status of the resident. This affected three (#63, #55, and #7) of 28 residents records reviewed. for assessments. The total facility census was 60. Findings include: 1. Review of Resident #63's medical record revealed the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of progress note dated [DATE] at 9:37 A.M., revealed the resident had an acute respiratory change and the facility called the physician and obtained orders to send the resident to the emergency room (ER). The staff called 911 and provided the resident an aerosol medication nebulizer treatment while waiting for the squad to arrive. Review of progress note dated [DATE] at 9:45 A.M., revealed the the squad arrived at 9:45 A.M. and the staff was still providing the resident the medication nebulizer treatment. The note documented the squad left the facility with the resident to the ER. Review of the progress note dated [DATE] at 12:42 P.M., revealed the ER called at 12:42 P.M. to say the resident had expired. Review of the MDS assessment dated [DATE], revealed the type of MDS was coded as death in the facility. Interview on [DATE] at 4:14 P.M., with the Director of Nursing (DON), confirmed the resident did not expire at the facility but was taken via squad alive to the emergency room and expired at the hospital. The DON verified the MDS was coded inaccurately as the resident did not expire in the facility but at the hospital. 2. Review of Resident #55's medical record revealed the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the [DATE] admission MDS and [DATE] 5-day assessment MDS revealed the resident is cognitively impaired, requires extensive assist for bed mobility transfers, dressing, toileting, hygiene and is independent in eating. The resident was coded for receiving seven days of insulin, injections, antipsychotic, antibiotic, and anti coagulant medications. Review of Resident #55's medication orders revealed the resident received the following medications daily, insulin (antidiabetic), [MEDICATION(S)] (antipsychotic), [MEDICATION(S)] (anticoagulant) and [MEDICATION(S)] (antidepressant) in her care at the facility. Review of medical record revealed the resident had [MEDICATION(S)] (anti depressant) 37.5 milligram extended release every 24 hours used in her care at the facility with an order date of [DATE]. Interview on [DATE] at 11:40 A.M., with the MDS Nurse #540, verified the [MEDICATION(S)] was not coded on the MDS as being used when the resident in fact had received the medication on during the look back period. 3. Review of the medical record for Resident #7 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE] revealed Resident #7 had a weight of 204 pounds. Review of the quarterly MDS assessment dated [DATE] revealed Resident #7 had a weight of 158 pounds. Weight loss of more than 5 percent in the last month or loss of 10% or more in last 6 months was marked No or unknown. Interview on [DATE] at 12:14 P.M., with MDS Nurse #540 verified Resident #7's weight loss of 22.5% was not accurately reflected on the MDS Assessment. Review of the policy titled Automated Data Processing Requirement, dated [DATE], revealed encoded MDS data accurately reflects the resident's status.

Based on observations, record reviews, resident interviews, staff interviews and policy review, the facility failed to develop comprehensive plan of care to meet the needs of the resident. This affected seven (#3 #24, #27, #2, #43, #61 and #19) of 28 resident records reviewed for care plans. The total facility census was 60. Findings include: 1. Review of of Resident #3's medical record revealed the resident was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of 03/26/22, quarterly Minimum Data Set (MDS) assessment revealed the resident is cognitively intact. The resident is coded as receiving [CONDITION(S)] services. Review of Resident #3's care plans revealed there was no care plan in place for to address her [CONDITION(S)] treatment, use of central catheter for [CONDITION(S)], or what the staff should monitor the resident for relating to her [CONDITION(S)] treatments. The care plans did include plans to address her skin ulcers, pain management, and nutrition and hydration needs. Interview on 06/28/22 at 11:03 A.M., with Resident #3, confirmed she has had [CONDITION(S)] treatment three times weekly since prior to her admission to the facility. Resident #3 stated she has a [CONDITION(S)] catheter for her treatment and her veins were not large enough for a arteriovenous shunt and she would need to have a cow artery transplant to have a shunt in her arm. Resident #3 stated she did not want a cow part in her body and had decided to have her treatment through the central [CONDITION(S)] catheter. Interview on 06/28/22 at 4:40 P.M., with the Director of Nursing, confirmed the resident has had [CONDITION(S)] services during her entire stay at the facility and there was no [CONDITION(S)] care plan present for the resident to reflect the resident goals and interventions related to her [CONDITION(S)] services. 2. Review of Resident #24's closed medical record revealed the resident was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the critical admission assessment dated [DATE] revealed the resident had a hemodialysis port in place at the time of admission. Review of the resident's assessments revealed there was a [CONDITION(S)] communication forms completed and part of the medical record starting on 01/11/22 and continuing until discharge. Review of the 06/14/22, return no anticipated MDS assessment revealed the resident was cognitively intact. The resident was coded as having [CONDITION(S)] services. Review of Resident #24's care plan revealed there was no care plan in place for to address her [CONDITION(S)] treatment, use of central catheter for [CONDITION(S)], or what the staff should monitor the resident for relating to her [CONDITION(S)] treatments. Interview on 06/30/22 at 8:30 A.M., with Licensed Practical Nurse (LPN) #561 it was confirmed the resident had a [CONDITION(S)] catheter used for her [CONDITION(S)] treatment. Interview on 06/30/22 at 1:35 P.M., with the DON verified the resident care plan was not reflective of the resident as it did not have a [CONDITION(S)] care plan in place. 3. Review of Resident #27's medical record revealed the resident was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the quarterly MDS assessment dated [DATE], revealed the resident has mild cognitive impairment, and no behaviors. The MDS coded the resident as receiving seven days of antipsychotic and antidepressant medications. Review of the resident Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Ability (antipsychotic) 15 milligram (mg) daily by mouth, ordered on 01/14/22; [MEDICATION(S)] (antidepressant) 30 mg daily at bedtime by mouth, ordered on 01/14/22; and [MEDICATION(S)] (antidepressant) extended release 24 hours ,150 mg daily ordered on 01/14/22. Review of resident care plans revealed there was no care plan in place related to the use of the [CONDITION(S)] medications used in the care of the resident. Interview on 06/28/22 at 4:30 P.M., with the DON confirmed the resident care plans did not include a care plan for the use of [CONDITION(S)] medications. 4. Record review for Resident #19 revealed an admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the quarterly MDS assessment dated [DATE] revealed Resident #19 had an indwelling catheter and was always incontinent of bowel. Record review of the Critical Admission assessment dated [DATE] at 1:32 A.M., completed by Registered Nurse (RN) #529, revealed the resident was admitted with a 16 french indwelling catheter. Record review revealed Resident #19 had no care plan for the indwelling catheter. Observation on 06/13/22 at 10:16 A.M., of Resident #19 revealed Resident #19 had an indwelling urinary catheter. Interview on 06/27/22 at 5:00 P.M. , with MDS Nurse #540 confirmed she was responsible to complete residents comprehensive care plans. MDS Nurse #540 verified Resident #19 had no care plan for the indwelling catheter. 5. Record review for Resident #43 revealed an admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the quarterly MDS assessment dated [DATE] revealed Resident #43 had moderately impaired cognition. Resident #43 was totally dependant for transfers, locomotion, dressing, personal hygiene, and bathing. Resident #43 used a wheel chair for locomotion. Observation on 06/13/22 at 11:25 A.M., revealed Resident #43 was sitting in the activity room, in a tilt and space chair, slightly declined with no foot pedals. Resident #43's feet were dangling in the air while sitting declined in the chair. Resident #43's scalp, forehead and bridge of her nose was covered with dry, flaking skin. The bridge of her nose was also red. Record review of the care plan for Resident #43 revealed there was no care plan developed for the use of the tilt and space chair nor was there a care plan for the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the physician orders for June 2022 revealed Resident #43 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 06/14/22 at 10:06 A.M., revealed Resident #43 was sitting in the activity room, in a tilt and space chair, slightly declined with no foot pedals. Resident #43's feet were dangling in the air while sitting declined in the chair. Resident #43's scalp, forehead and bridge of her nose was covered with dry, flaking skin. The bridge of her nose was also red. Interview on 06/14/22 at 10:11 A.M., with Activities Coordinator #558 confirmed Resident #43 was sitting in the activity room, in a tilt and space chair, slightly declined with no foot pedals. Resident #43's feet were dangling in the air while sitting declined in the chair. Resident #43's scalp, forehead and bridge of her nose was covered with dry, flaking skin. The bridge of her nose was also red. Activities Coordinator #558 revealed Resident #43 normally does not wear foot pedals. Interview on 06/14/22 at 10:12 A.M., with Certified Nursing Assistant (CNA) #539 revealed she washed Resident #43's face three to four times a day and puts a baby lotion or bath and body lotion on her face. Interview on 06/14/22 at 10:15 A.M., with Licensed Practical Nurse (LPN) #566 revealed the girls use over the counter lotions when they notice her skin dry and flaky. LPN #566 revealed she was not sure how long Resident #43 used the tilt and space chair for or how long she had dry flake skin for. Interview on 06/27/22 at 5:00 P.M., MDS Nurse #540 verified Resident #43 had no care plan for the tilt and space chair or treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 06/27/22 at 11:01 A.M., with LPN #503 she was not sure how long Resident #43 has been in the chair or had dry flake skin to her face/forehead and scalp, but its been as long as she can remember. Interview on 06/27/22 at 11:13 A.M., with CNA #539 revealed she washed Resident #43's face and scalp with soap and water and put bath and body works lotion on her face and scalp. CNA #539 revealed a small bottle of bath and body coconut body lotion. CNA #539 confirmed this is what she used when caring for Resident #43, on her face and scalp for her dry fakery skin. CNA #539 revealed she was not sure how long Resident #43 had dry flake skin on her scalp, forehead and nose and revealed it was as long as she knew Resident #43. Interview on 06/27/22 at 2:39 P.M., with Rehab Director #590 revealed Resident #43 was receiving therapy in January 2022 Resident #43 was discharged from therapy in January 2022 and at that time Resident #43 was in a standard wheel chair. Rehab Director #590 revealed Resident #43 was picked back up in April 2022 for therapy and at that time she was in the tilt and space chair. Interview on 06/27/22 at 2:12 P.M., with LPN #503 revealed the staff normally tilt the chair back for Resident #43 when she was not eating. LPN #503 revealed she was not sure how far the chair should be tilted back. Interview on 06/27/22 at 2:30 P.M., with CNA #513 revealed she always tilted Resident #43's chair so she didn't slide. CNA #513 revealed one of the other CNA's told her Resident #43 was supposed to be tilted in the chair. CNA #513 confirmed she was not sure how far back she was to be tilted in the chair. Interview on 06/27/22 at 2:33 P.M., with CNA #518 stated she adjusted Resident #43's tilt and space chair according to the care plan. CNA #518 verified Resident #43 had no care plan for the tilt and space chair. CNA #518 then stated, Oh well, I just know when, I do it every two hours. Interview on 06/27/22 at 4:00 P.M., with the DON, confirmed Resident #43 did not have a care plan for the tilt and space chair or treatment to Resident #43 dry flaking skin. DON confirmed the care plans should have been completed for Resident #43. 6. Record review for Resident #61 revealed an admitted [DATE]. Resident #61 was admitted to the hospital on 05/06/22 and returned 05/11/22. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the scheduled five day MDS assessment completed 05/15/22 revealed Resident #61 had an indwelling catheter and was always incontinent of bowel. Record review of the Critical Admission assessment dated [DATE] completed by LPN #503 revealed Resident #61 had a indwelling catheter draining yellow urine. Record review of the care plans for Resident #61 revealed Resident #61 did not have a care plan for an indwelling catheter. Review of the physician orders for Resident #61 revealed an order dated 06/03/22 to remove Resident #61's indwelling catheter and monitor for urine retention. Interview on 06/29/22 at 2:43 P.M., with DON confirmed resident had the indwelling catheter since she returned from the hospital on 05/11/22. DON confirmed the catheter was discontinued 06/03/22. DON confirmed there was no physician order or care plan for the catheter. 7. Record review for Resident #2 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the quarterly MDS assessment dated [DATE] revealed Resident #2 had severe cognitive impairment. Resident #2 have severely impaired vision. Resident was totally dependent for bed mobility, transfers, and toileting. Resident required limited assistance with meals. Record review of the care plan revealed Resident #2 had no care plan for assistance required for activities of daily living and no care plan for [CONDITION(S)] in one eye and low vision in the other. Interview on 06/27/22 at 5:00 P.M., with MDS Nurse #540 confirmed Resident #2 had no care plan for activities of daily living or [CONDITION(S)] in one eye and low vision in the other. Review of the policy titled Resident Assessment comprehensive Care Plan updated 11/28/17, revealed the facility must develop an implement a comprehensive person centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3) that includes measurable objectives and timeframe's to meet a resident's medical nursing and mental and psychosocial needs that are identified in the comprehensive assessment. Each resident will have a person -centered comprehensive care plan developed and implemented to meet his other preferences and goals and address the resident's medical, physical, mental and psychosocial needs.

Based on medical record review, resident interview, staff interview, and policy review the facility failed to revise comprehensive care plans according to resident needs. This affected five (#3, #4, #7, #15, and #27) of 23 residents reviewed for comprehensive care plans. The facility census was 60. Findings include: 1. Review of the medical record for Resident #7 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively impaired and was totally dependent on staff for bed mobility, transfers, dressing, toileting, and personal hygiene. The resident had minimal difficulty with hearing and was noted to have hearing aid(s). Review of the plan of care for Resident #7, dated 04/14/22, revealed the resident had hearing loss. Interventions included hearing aid as ordered, removing hearing aid at night and keeping in medication cart, and referral to audiology as needed. Review of the provider documentation dated 04/25/22 revealed Resident #7's hearing aids had been lost and the resident would begin trying new hearing aids once receiving necessary paperwork from the facility. Review of the missing item report dated 06/01/22 revealed Resident #7's hearing aids had been missing since before COVID. Review of Resident #7's comprehensive care plan revealed the plan was not updated to include addressing the resident's hearing loss while she was without hearing aids. Interview on 06/13/22 at 11:36 A.M., with Resident #7 revealed the resident's hearing aids were lost at the facility. Interview on 06/30/22 at 12:03 P.M., with the Assistant Director of Nursing (ADON) #504 verified Resident #7's care plan had not been revised to include alternative hearing needs once the resident's hearing aids were lost. 2. Review of of Resident #3 medical record revealed the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of 03/26/22 quarterly Minimum data set revealed the resident is cognitively intact, had no behaviors, requires extensive assist with toileting, transfers, dressing, hygiene, bed mobility and is independent with eating. The resident is coded as receiving [CONDITION(S)] services. Review of the resident Medication and Treatment Administration Records revealed the resident had Doxycline [MEDICATION(S)] 100 milligrams (mg) twice daily for left foot wound dated 06/18/22 and [MEDICATION(S)] 125 mg four times daily for [CONDITION(S)] difficle dated 06/07/22. Resident #3's current treatment to left foot wound of cleanse with normal saline pat dry apply prismal pad with 4x4 gauze and wrap with Kerlix and cover with stockinet dated 06/27/22. Interview on 06/28/22 at 8:20 A.M., with Resident #3 confirmed she admitted to the facility with her wounds. The resident stated at one time she had a wound vac in place to her left foot wound to assist with wound healing and stated the wound vac dressing was changed at the wound doctors office. The resident could not remember when the wound vac was discontinued but she stated the facility changes her dressings regularly and she has no complaints at the facility. Observation of a conversation between Resident #3 and the Wound Physician #1 on 06/28/22 at 11:04 A.M., revealed Wound Physician #1 stated to Resident #3 I know you like to lay on you back, and that in the past you have refused an air mattress, Resident #3 interrupted the physician and stated yes I am non compliant. Resident #3 continued to state I do not lay on my side and I do not want an air mattress. The physician asked if she would consider using pillows to assist in relieving pressure off her bottom to assist in healing the wound on her bottom and the resident stated she could try it. Observation of Registered Nurse #504 performing wound care on 06/28/22 in the afternoon revealed the dressing change was performed per standard and per the order. The wound was cleansed with normal saline, patted dry, [MEDICATION(S)] was applied covered with 4x4 and wrapped with a Kerlix. The resident tolerated the procedure with no complaints of pain or discomfort. Review of resident care plan revealed there was a care plan in place for wound vac to left foot. The care plan was additionally silent to the resident being non compliant with interventions related to skin care including trial of air mattress, and refusals of turning side to side, and the current antibiotics used in her care to treat acute illness related to her left foot wound and [CONDITION(S)] difficile. Review of medical record revealed the wound vac treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 06/28/22 at 4:40 P.M., with the Director of Nursing confirmed the care plan was not updated to reflect the current treatment used for the resident's wound care to her left foot and still reflected the use of a wound vac that was discontinued on 04/12/22. The DON also confirmed the resident was not compliant with the use of an air mattress and with off loading by turning and the care plan did not reflect her non compliance with cares. Lastly the DON confirmed the care plan did not reflect the antibiotic treatment and acute conditions the resident was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Review of Resident #4 medical record revealed the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent quarterly MDS dated [DATE] revealed the resident has mild cognitive impairment, has no behaviors, is always incontinent of bowel and bladder, requires extensive assist from staff for bed mobility, transfers, dressing, toileting, personal hygiene but is independent with eating. The resident is coded as receiving seven days of antibiotics during the look back period. Review of Resident #4 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident progress notes revealed the progress note from 06/08/22 at 8:47 A.M., stated the physician gave orders for [MEDICATION(S)] 50 mg daily at bedtime. Review of the care plan revealed the care plan was silent to the use of [MEDICATION(S)] as prophylaxis for [CONDITION(S)]. Interview on 06/28/22 at 8:34 A.M., with Resident #4, confirmed she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident stated with her short-term memory loss she cannot tell exactly how long it takes the staff to provide care for her. Interview on 06/28/22 at 4:40 P.M., with the DON confirmed the resident care plan was not updated to reflect the antibacterial medication use to prevent [CONDITION(S)]'s for this resident. 4. Review Resident #15's medical record revealed the resident was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE] revealed the resident is cognitively impaired had no behaviors, is dependent on staff for transfers, requires extensive assist for bed mobility, dressing, toileting and personal hygiene and limited assistance for eating. The resident is coded as having a mechanically altered therapeutic diet an unstageable pressure ulcer with pressure relieving device to bed and chair. Review of resident medical record revealed the resident had orders for antibiotic [MEDICATION(S)] 500 mg twice a day on 06/14/22-06/28/22 with indication of use [CONDITION(S)]. Review of care plans revealed the care plan was silent for the resident receiving treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the DON on 06/28/22 at 4:30 P.M. it was verified the resident's care plan was not up to date reflecting the antibiotic use the resident had for a [CONDITION(S)]. 5. Review of Resident #24 medical record revealed the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the discharge return not anticipated MDS dated [DATE] revealed the resident was cognitively intact, had no behaviors, was supervision for bed mobility, extensive assist with transfers, dressing, eating, toileting and personal hygiene. The resident is coded as always incontinent of bowel and bladder. Review of resident care plan revealed there was a care plan in place indicating resident is at nutritional hydration risk due to receives 100% of nutrition and hydration via tube due to nothing per oral (mouth) status cerebral infarct, [CONDITION(S)], DM, CKD, [CONDITION(S)] ulcer, electrolyte fluid imbalance [CONDITION(S)], CHF, ecoli bacteremia hypovolemia, necrotic third toe and right arm altered labs triggers for malnutrition, dated 01/25/22 initiated. The care plan was updated 02/22/22 to record changing to nocturnal tube feed Nepro at 55 milliliters/ hour (ml/hr) 6:00 P.M.-4:00 A.M., recommend discontinuing evening water flush continue day time water flush at 350 ml per percutaneous endoscopic gastrostomy (PEG) tube. Review of progress note dated 05/04/22 revealed new order to discontinue nocturnal tube feed, discontinue 350 ml flush, oral Nepro twice daily, 60 ml flush per peg to transition out of tube feed and into per oral (by mouth) diet exclusively. The resident and family are aware. Interview on 06/30/22 at 8:30 A.M., with Licensed Practical Nurse #561, confirmed the resident was not using the feeding tube for nutrition or medication, but had transitioned to taking medication by mouth and was eating a regular diet. Interview on 06/30/22 at 11:35 A.M., with the DON, verified the resident care plan was not updated when the resident transitioned from tube feeding to oral feeding on 05/04/22. Review of the policy titled Resident Assessment comprehensive Care Plan updated 11/28/17 revealed the facility must develop an implement a comprehensive person centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3) that includes measurable objectives and timeframe's to meet a resident's medical nursing and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must: Include areas assessed that indicate the resident is at risk, their strengths, or identify weakness per the MDS or the CAA's. Identify the care or services being declined, the risk the declination poses to the resident,and efforts by the interdisciplinary team to educate the resident and the representative as appropriate. Reflect changes in the residents preferences and goals as they change throughout their stay. The comprehensive care plan will be initially developed in Matrix, printed and kept either in the Resident's chart or a are Plan notebook at the nurse's station available to all staff, care givers, residents, resident representatives, physicians and physicians extenders as well as surveyors. Updates will be made to this printed comprehensive care plan as needed.

Based on medical record review, review of hospital records, resident interview, staff interview, observation, and review of facility policy, the facility failed to assess Resident #62 for a change in condition. The facility also failed to assess and obtain physician orders for dry skin condition for Resident #43. This affected two (#62, and #43) of 23 residents reviewed for quality of care. The facility census was 60. Findings include: 1. Review of Resident #62's medical record revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #62 was admitted to the hospital on 05/06/22. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/23/22, revealed the resident had impaired cognition. The resident required the extensive assistance of one staff member for bed mobility, dressing, transfers, and personal hygiene. Review of the nursing notes dated 05/06/22 and timed 5:17 A.M., revealed a State tested Nurse Aide (STNA) alerted Licensed Practical Nurse (LPN) #531 to Resident #62's room. The resident was noted to be a bit grey in color and had emesis of slight dark color and mucous consistency. The physician was notified. Review of the nursing notes dated 05/06/22 and timed 6:37 A.M., revealed the physician ordered stat labs and to start hypodermoclysis (fluids) of 0.45 sodium chloride running at 60 milliliters (ml). The Assistant Director of Nursing (ADON) started the fluids, family was updated, and the laboratory was contacted for stat labs. Review of the nursing notes dated 05/06/22 and timed 9:33 A.M., revealed the physician received and read the labs and advised to send Resident #62 to the emergency room . Review of the nursing notes dated 05/06/22 and timed 11:00 A.M., revealed emergency medical services (EMS) were contacted and transporting Resident #62 to the local emergency room . Review of the nursing notes dated 05/06/22 and timed 11:58 P.M., revealed Resident #62 was admitted to the intensive care unit (ICU) due to [CONDITION(S)], urinary tract infection ([CONDITION(S)]), hydronephrosis, and pneumonia. Review of the hospital documentation dated 05/06/22 and timed 11:35 A.M., revealed Resident #62's blood pressure was 85/62. Review of the hospital documentation dated 05/06/22 and timed 1:31 P.M., revealed Resident #62 was brought to the emergency room due to worsening confusion and low blood pressure. The resident was nonverbal and hypotensive. Review of Resident #62's medical record revealed the resident's vital signs including blood pressure were taken by a nurse in the facility on 05/02/22 at 9:07 A.M. There were no further blood pressures documented and there were no vital signs or assessments documented on 05/06/22. Interview on 06/27/22 at 3:45 P.M., with LPN #531 verified there were no vital signs or an assessment documented for Resident #62 on 05/06/22. LPN #531 reported she worked the night of 05/05/22 to 05/06/22 and the Assistant Director of Nursing (ADON) took over caring for Resident #62 on 05/06/22 at approximately 6:30 A.M. Interview on 06/27/22 at 3:48 P.M., with the Assistant Director of Nursing (ADON) revealed upon arrival to Resident #62's room on the morning of 05/06/22, Resident #62 looked like he didn't feel good and was pale pink in color. The ADON verified there was no assessment completed or any vital signs documented for Resident #62 on 05/06/22. Review of the policy titled Standards of Nursing Practices, revised May 2018, revealed residents having any change in condition would have a complete nursing assessment performed and documented which may include but is not limited to vital signs, bowel sounds, lung sounds, pulse ox, skin appearance, and mental status. 2. Record review for Resident #43 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE] revealed Resident #43 had moderately impaired cognition. Resident #43 was totally dependant for transfers, locomotion, dressing, personal hygiene, and bathing. Observation on 06/13/22 at 11:25 A.M., revealed Resident #43 was sitting in the activity room, in a tilt and space chair. Resident #43's scalp, forehead and bridge of her nose was covered with dry, flaking skin. The bridge of her nose was also red. Record review of the care plan for Resident #43 revealed there was no care plan developed for dry flaking skin. Record review of the physician orders for June 2022 revealed Resident #43 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 06/14/22 at 10:06 A.M., revealed Resident #43 was sitting in the activity room, in a tilt and space chair. Resident #43's scalp, forehead and bridge of her nose was covered with dry, flaking skin. The bridge of her nose was also red. Interview on 06/14/22 at 10:12 A.M., with Certified Nursing Assistant (CNA) #539 revealed she washed Resident #43's face three to four times a day and put baby lotion or bath and body lotion on her face. Interview on 06/14/22 at 10:15 A.M., with Licensed Practical Nurse (LPN) #566 confirmed there were no physician orders to treat and care for Resident #43's dry flaking skin to her scalp, forehead and bridge of her nose. LPN #566 revealed the girls use over the counter lotions when they notice her skin dry and flaky. LPN #566 revealed she was not sure how long Resident #43 had dry flake skin for. Interview on 06/27/22 at 5:00 P.M., MDS Nurse #540 verified Resident #43 had no care plan for the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Observation on 06/27/22 at 10:52 A.M., revealed Resident #43 was sitting up in her chair in the activity room. Resident #43's scalp, forehead and bridge of her nose was covered with dry, flaking skin. The bridge of her nose was also red. Resident #43 did not answer when asked if her skin on her face or head was uncomfortable. Interview on 06/27/22 at 11:01 A.M., with LPN #503 verified Resident #43 had dry flake skin to face/forehead and scalp. LPN #503 verified there were no orders for the treatment to the dry skin on the scalp, forehead or nose. LPN #503 revealed she would let someone know. LPN #503 revealed she was not sure how long Resident #43 had dry flake skin to her face/forehead and scalp, but its been as long as she can remember. Interview on 06/27/22 at 11:13 A.M., with CNA #539 revealed she washed Resident #43's face and scalp with soap and water and put bath and body works lotion on her face and scalp. CNA #539 revealed a small bottle of bath and body coconut body lotion. CNA #539 confirmed this is what she used when caring for Resident #43, on her face and scalp for her dry fakery skin. CNA #539 revealed she was not sure how long Resident #43 had dry flake skin on her scalp, forehead and nose and revealed it was as long as she knew Resident #43. Interview on 06/27/22 at 4:00 P.M., with DON confirmed there was no documentation or assessments regarding the dry flaking skin on Resident #43's scalp, forehead or nose. DON confirmed the physician should have been notified of the skin condition and treatments implemented with a plan of care. Review of the facility policy titled Standards of Nursing Practices, revised May 2018, revealed residents having any change in condition would have a complete nursing assessment performed and documented which may include but is not limited to vital signs, bowel sounds, lung sounds, pulse ox, skin appearance, and mental status.

Based on observation, resident and staff interviews, record review and review of the policy, the facility failed to safely store four (#66, #39, #47, and #32) residents medications. this had the potential to affect eight (#51, #23, #10, #45, #40, #31, #34, and #12) residents identified by the facility as being independently mobile and cognitively impairment. The facility census was 60 Findings include: 1. Observation on 06/13/22 at 8:45 A.M., revealed Resident #66 had two medication cups with medications inside and a cup full of water sitting on her bedside stand. Regional Registered Nurse #588 confirmed there were two medication cups of unidentified medications sitting on Resident #66's bedside stand and no nurse was in the area. Record review for Resident #66 revealed an admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 was cognitively intact. Resident required extensive assistance with bed mobility and transfers. Record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 06/13/22 at 8:56 A.M., with LPN #531 confirmed she left Resident #66's morning medications at her bedside. 2. Observation on 06/13/22 at 8:48 A.M., revealed Resident #39 had an unidentified pill sitting on her bedside stand. Resident #39 stated it was a water pill and that she had taken all the other medications. The Administrator observed and confirmed the medication was left on Resident #39's bedside stand at this time. Record review for Resident #39 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS assessment dated [DATE] revealed Resident #39 was cognitively intact. Resident #39 required extensive assistance with bed mobility and transfers. Record review of the MAR for Resident #39 revealed on 06/13/22 morning medications administered to Resident #39 by LPN #531 included medication [MEDICATION(S)] 40 mg one tablet. Interview on 06/13/22 at 8:56 A.M., with LPN #531 confirmed she left Resident #39's morning medications at her bedside. 3. Observation on 06/13/22 at 8:51 A.M., revealed the Administrator removed nasal spray and an inhaler from Resident #47's room. Administrator confirmed she was removing the nasal spray and inhaler from Resident #47's room due to the medications were unsecured. Record review revealed Resident #47 had an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS assessment dated [DATE] revealed Resident #47 was cognitively intact. Resident #47 required assistance with activities of daily living. Record review of the MAR for Resident #47 revealed on 06/13/22 morning medications administered to Resident #47 by LPN #531 included [MEDICATION(S)] 100-25 mcg one inhalation and [MEDICATION(S)] spray 50 mcg one spray in each nostril. Interview on 06/13/22 at 8:56 A.M., with LPN #531 confirmed she left Resident #47's morning medications at her bedside. 4. Observation on 06/13/22 at 9:09 A.M., revealed Resident #32 had a medication cup with unidentified medications inside sitting on her bedside table. Resident #32 stated, They do this every day, I'll take them later. Record review of the medical record for Resident #32 revealed an admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS assessment dated [DATE] revealed Resident #32 was cognitively intact. Resident required extensive assistance for bed mobility. Record review of the MAR for Resident #32 revealed on 06/13/22 morning medications administered to Resident #32 by LPN #503, included: [MEDICATION(S)] 100 mg one tab, amlodapine five mg one tab, aspirin 81 mg one tab, [MEDICATION(S)] 2,500 micrograms (mcg) one tab, [MEDICATION(S)] five mg one tab, [MEDICATION(S)] sulfate 325 mg one tab, [MEDICATION(S)] adult 50 plus 250-5-1 one capsule, potassium chloride 20 meq one tab, and vitamin D-3 50 mcg one tab. Interview on 06/13/22 at 9:34 A.M., with LPN #503 confirmed she left Resident #32'S medications at her bedside. Interview on 06/30/22 at 8:04 A.M., with Director of Nursing (DON) confirmed there were no residents residing in the facility that were to self administer their own medications and medications were to be kept secure until the nurse administered the medications to the residents. DON confirmed medications were never to be left unsecured with any resident. DON confirmed Resident #51, #23, #10, #45, #40, #31, #34, and #12 was identified as independently mobile and cognitively impairment. Review of the policy titled,General Dose Preparation and Medication Administration dated 12/01/07 revealed facility staff should not leave medications unattended. The facility was to identify the resident and observe the residents consumption of the medications.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure the call light was positioned within reach of a resident. This affected one (#5) of six residents observed for call light placement. The facility census was 60. Findings include: Review of the medical record for Resident #5 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the significant change Minimum Data Set (MDS) assessment, dated 03/23/22, revealed the resident was cognitively impaired. The resident was also totally dependent upon staff for all activities of daily living (ADLs). Review of Resident #5's plan of care, dated 04/24/22, revealed Resident #5 was at risk for falling due to a recent [CONDITION(S)] (stroke). Interventions included monitoring the resident for attempts to get up unassisted, reminding the resident to call for help when needing assistance, and keeping call light in reach at all times. Observation on 06/13/22 at 9:20 A.M., revealed Resident #5 was in bed sleeping and the call light was unable to be seen within reach of the resident. Interview and observation on 06/13/22 at 9:21 A.M., with Non-Certified Nursing Assistant (NCNA) #538 verified Resident #5's call light was not in reach and was on the floor and wrapped around the foot of the bed. NCNA #538 had to move Resident #5's bed to untangle the call light and place it within reach of the resident. Observation on 06/14/22 at 9:53 A.M., revealed Resident #5 was sleeping in bed and her call light was on the floor near the foot of the bed. Observation and interview on 06/14/22 at 10:04 A.M., with Certified Nursing Assistant (CNA) #552 verified the call light was on the floor and not within reach of Resident #5. Observation on 06/27/22 at 9:36 A.M., revealed Resident #5 was sleeping in bed and her call light was unable to be seen. Observation and interview on 06/27/22 at 9:38 A.M., with Licensed Practical Nurse (LPN) #503 verified Resident #5's call light was not within reach and was on the floor and wrapped around the foot of the bed. LPN #503 untangled the call light cord and placed it within the resident's reach. Interview on 06/30/22 at 9:25 A.M., with the Director of Nursing (DON) verified Resident #5 was able to use her call light during the aforementioned times and it should have been within reach. Review of the policy titled Standards of Nursing Practices, revised May 2018, revealed staff would respond to resident requests for assistance by answering call lights within a reasonable amount of time.

Based on record review, Resident Assessment Instrument (RAI) Manual review, policy review and staff interviews, the facility failed to complete a significant change in status assessment in the Minimum Data Assessment (MDS) when a resident displayed a significant change in health. This affected two (#61 and #7) of 25 residents reviewed. The facility census was 60. Findings include: 1. Record review for Resident #61 revealed an admitted [DATE]. Resident #61 was admitted to the hospital from the facility on 05/06/22 and returned to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #61 was cognitively intact. Resident #61 required limited assistance for bed mobility, transfers, toilet use, personal hygiene, and dressing. Resident required supervision for ambulation. Resident ambulated with a walker. Resident was independent for eating and received a regular textured diet. Resident was always continent of bowel and bladder. Record review revealed an entry MDS was completed 05/11/22 to include identification information. Record review of the scheduled five day MDS assessment completed 05/15/22 revealed Resident #61 was severely cognitively impaired. Resident required extensive assistance of one for bed mobility, dressing, and personal hygiene. Resident #61 required extensive assistance of two for transfers and toilet use. Resident #61 had an indwelling catheter and was always incontinent of bowel. Resident required a wheelchair for locomotion with extensive assistance of one. Resident #61 required limited assistance of one for eating and received a mechanical altered diet. Review of the quarterly MDS dated [DATE] revealed additionally to the MDS dated [DATE], Resident #61 required extensive assist of one with eating. Interview on 06/29/22 at 2:43 P.M., with the Director of Nursing (DON) revealed prior to Resident #61 going to the hospital on 05/06/22, Resident #61 was alert and oriented. Resident #61 was able to transfer herself, ambulate without assistance, dress and groom herself, feed herself, and was continent of bowel and bladder. Upon return from the hospital on 05/11/22, Resident #61 was severely cognitively impaired, and required assistance with all activities of daily living including eating. Resident #61 returned with an indwelling catheter and was incontinent of bowel. DON confirmed Resident #61 had a significant change in condition. Interview on 06/30/22 at 10:41 A.M., with MDS Nurse #540 confirmed a significant change in status should have been completed for Resident #61 after returning from the hospital with a significant change in condition but was not. 2. Review of the medical record for Resident #7 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had a weight of 204 pounds and required the extensive assistance of one staff member for bed mobility, transfers, dressing, toileting, and personal hygiene. Review of the quarterly MDS assessment dated [DATE] revealed Resident #7 had a weight of 158 pounds and was totally dependent on staff for bed mobility, transfers, dressing, toileting, and personal hygiene. Review of the quarterly MDS assessment dated [DATE] revealed Resident #7 had a weight loss of more than five percent in the last month or 10 percent in the last six months. Resident #7 was totally dependent on staff for bed mobility, transfers, dressing, toileting, and personal hygiene. Review of the MDS records for Resident #7 revealed no significant change assessment was completed related to Resident #7's weight loss or decline in activities of daily living (ADLs). Interview on 06/29/22 at 12:14 P.M., with MDS Coordinator #540 verified the lack of a significant change assessment. Review of the most recent version of the Resident Assessment Instrument (RAI) Manual revised October 2019 revealed a significant change in condition assessments are appropriate when a significant change in a resident's condition from their baseline has occurred as indicated by comparison of the resident's current status to the most recent comprehensive and quarterly assessments, or when there are two or more areas of decline. Review of the policy titled Resident Assessment Comprehensive Assessments Significant Change in Status, dated 11/28/17, revealed a significant change in status assessment must be completed within 14 days after a determination has been made that a significant change in the resident's status from baseline occurred.

Based on medical record review, resident interview, staff interview and policy review, the facility failed in involve a resident and/or a resident representative in the care planning process. This affected one (#13) of 23 residents care plans reviewed. The facility census was 60. Findings include: Record review for Resident #13 revealed an admitted [DATE]. Resident transferred to the hospital on 05/23/22 and returned 05/27/22. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the five-day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #13 was cognitively intact. Resident required total dependence for bed mobility, and transfers, required extensive assistance for dressing. Resident was independent for eating. Resident was occasionally incontinent of urine and always continent of bowel. Resident was at risk for falls and had repairs of fractures. Interview on 06/13/22 at 8:44 A.M., with Resident #13 revealed he had not had any care plan meeting or discussion about a care plan meeting on admission or after. Resident#13 revealed he would like to have a care plan meeting because he had questions regarding his care and discharge plans. Interview on 06/27/22 at 2:06 P.M., with Social Service Designee (SSD) #553 revealed the DON completed the initial care plan meeting, to be completed within 48 hours of admission, and SSD #553, completed the remaining care plan meetings. SSD #553 revealed Resident #13 had a care plan meeting scheduled for 05/27/22. Resident #13 went to the hospital on 05/23/22 and returned 05/27/22. SSD #553 revealed she canceled the care plan meeting on 05/27/22 and rescheduled the meeting for 06/08/22. SSD #553 revealed she then realized she was on vacation the week of 06/08/22 and again rescheduled the care plan meeting for the next week (unable to recall the date), the next week all residents were evacuated to a sister facility on Tuesday, 06/14/22 and returned Friday, 06/17/22. SSD #553 revealed she then rescheduled the care plan meeting for 06/29/22. SSD #553 confirmed Resident #13 was admitted on [DATE] and did not have an initial care plan meeting to be completed within the first 48 hours of admission, or a comprehensive care plan meeting to be completed in the 14 days after admission. Interview on 06/27/22 at 3:58 P.M., with the DON confirmed she was to complete all residents initial care plan meetings within 48 hours of admission. DON confirmed Resident #13 did not have an initial care plan meeting completed. DON revealed he must have got missed. Review of the policy titled Resident Assessment comprehensive Care Plan updated 11/28/17, revealed the facility must develop an implement a comprehensive person centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3) that includes measurable objectives and timeframe's to meet a resident's medical nursing and mental and psychosocial needs that are identified in the comprehensive assessment. Each resident will have a person -centered comprehensive care plan developed and implemented to meet his other preferences and goals and address the resident's medical, physical, mental and psychosocial needs.

Based on medical record review, observation, resident interview, staff interview, review of shower sheets, and review of facility policy, the facility failed to ensure residents received assistance with showers and/or shaving as required. The facility failed to apply foot pedals to a wheel chair of a dependent resident. This affected two (#37 and #43) of three residents reviewed for Activities of Daily Living (ADLs). The facility census was 60. Findings include: 1. Review of Resident #37's medical record revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #37's admission Minimum Data Set (MDS) assessment, dated 05/11/22, revealed the resident had a moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of nine. The assessment revealed the resident required extensive assistance of two staff for bed mobility, transfers, and toileting, and required physical help from two staff members for bathing. The resident was not noted to refuse or resist care. Review of Resident #37's plan of care, dated 05/13/22, revealed the resident was at risk for self care deficit and needed assistance with ADLs. Goals included the resident would be well groomed, proper hygiene would be maintained, and the resident would bathe twice per week. Review of the shower schedule revealed Resident #37 was to receive assistance bathing on Tuesdays and Fridays on first shift. Review of facility bathing records for 05/11/22 through 06/17/22 revealed no evidence Resident #37 received assistance bathing between 05/24/22 through 06/01/22 or between 06/0822 through 06/17/22. The resident was noted to have received bed baths on five occasions with two shower refusals and no there was no indication the resident was offered or received assistance shaving. Two additional shower sheets were not indicative of whether the resident received a shower or bed bath. Observation on 06/13/22 at 8:47 A.M., revealed Resident #37's facial hair was grown out and unshaven. Interview on 06/13/22 at 8:47 A.M., Resident #37 stated he had only received assistance bathing twice since he had been there, that he had never been offered a shower or assistance shaving, and that staff automatically gave him bed baths which were not thorough. Observations on 06/14/22 at 9:51 A.M., on 06/27/22 at 9:42 A.M., on 06/28/22 at 11:55 A.M., and on 06/29/22 at 8:23 A.M. revealed Resident #37's facial hair remained unshaven. Interview on 06/29/22 at 2:15 P.M., with Licensed Practical Nurse (LPN) #566 revealed residents normally had a bathing preference sheet although Resident #37 did not have one. LPN #566 was unaware of Resident #37's shower and/or shaving preferences. LPN #566 stated State tested Nurse Aides (STNAs) offered showers to all residents and were required to inform the nurse on duty if a resident refused. LPN #566 reported the nurse would then attempt to encourage the resident to shower and if the resident refused they would then receive a bed bath. LPN #566 verified all shower refusals and assistance shaving was documented on resident shower sheets. Review of the policy titled Activities of Daily Living (ADLs)/Maintain Abilities, dated November 2021, revealed a resident who was unable to carry out ADLs would receive the necessary services to maintain good grooming and personal hygiene. 2. Record review for Resident #43 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE] revealed Resident #43 had moderately impaired cognition. Resident #43 was totally dependant for transfers, locomotion, dressing, personal hygiene, and bathing. Resident #43 used a wheel chair for locomotion. Observation on 06/13/22 at 11:25 A.M., revealed Resident #43 was sitting in the activity room, in a tilt and space chair, slightly declined with no foot pedals. Resident #43's feet were dangling in the air while sitting declined in the chair. Record review of the care plan for Resident #43 revealed there was no care plan developed for the use of the tilt and space chair. Observation on 06/14/22 at 10:06 A.M., revealed Resident #43 was sitting in the activity room, in a tilt and space chair, slightly declined with no foot pedals. Resident #43's feet were dangling in the air while sitting declined in the chair. Interview on 06/14/22 at 10:11 A.M. with Activities Coordinator #558 confirmed Resident #43 was sitting in the activity room, in a tilt and space chair, slightly declined with no foot pedals. Resident #43's feet were dangling in the air while sitting declined in the chair. Activities Coordinator #558 revealed Resident #43 normally does not wear foot pedals. Interview on 06/14/22 at 10:12 A.M., with Certified Nursing Assistant (CNA) #539 revealed Resident #43 refused her foot pedals foot pedals. Interview on 06/14/22 at 10:15 A.M., with Licensed Practical Nurse (LPN) #566 revealed she did not know where Resident #43's foot pedals were. Observation with LPN #566 revealed Resident #43 had one foot pedal for her chair in her closet in her room. LPN #533 revealed someone must have took the other pedal and put it somewhere else. Observation on 06/27/22 at 10:52 A.M., revealed Resident #43 was sitting up in her chair in the activity room. Resident #43 was sitting in the tilt and space chair sitting straight up. Interview on 06/27/22 at 11:01 A.M., with LPN #503 verified Resident #43 was sitting in a tilt and space chair. LPN #503 revealed she was not sure how long Resident #43 has been in the chair. Interview on 06/27/22 at 2:39 P.M., with Rehab Director #590 revealed Resident #43 was receiving therapy in January 2022 Resident #43 was discharged from therapy in January 2022 and at that time Resident #43 was in a standard wheel chair. Rehab Director #590 revealed Resident #43 was picked back up in April 2022 for therapy and at that time she was in the tilt and space chair. Interview on 06/27/22 at 2:12 P.M., with LPN #503 revealed the staff normally tilt the chair back for Resident #43 when she was not eating. LPN #503 revealed she was not sure how far the chair should be tilted back. Interview on 06/27/22 at 2:30 P.M., with CNA #513 revealed she always tilted Resident #43's chair so she didn't slide. CNA #513 revealed one of the other CNA's told her Resident #43 was supposed to be tilted in the chair. CNA #513 confirmed she was not sure how far back she was to be tilted in the chair. Interview on 06/27/22 at 2:33 P.M., with CNA #518 revealed she adjusted Resident #43's tilt and space chair according to the care plan. CNA #518 verified Resident #43 had no care plan for the tilt and space chair. CNA #518 then stated, Oh well, I just know when, I do it every two hours. Interview on 06/27/22 at 4:00 P.M., with DON confirmed Resident #43 had no physician orders or any information regarding the tilt and space chair or when or who placed Resident #43 in the chair. DON confirmed Resident #43 should have had physician orders, a care plan and a restraint assessment completed for Resident #43 and use of the specialized chair.

Based on record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure Resident #7 received audiology services in a timely manner. This affected one (#7) of one resident reviewed for hearing. The facility census was 60. Findings include: Review of the medical record for Resident #7 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively impaired and was totally dependent on staff for bed mobility, transfers, dressing, toileting, and personal hygiene. The resident had moderate difficulty with hearing and was noted to have hearing aid(s). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had minimal difficulty with hearing and was noted to have hearing aid(s). Review of the plan of care for Resident #7, dated 04/14/22, revealed the resident had hearing loss. Interventions included hearing aid as ordered, removing hearing aid at night and keeping in medication cart, and referral to audiology as needed. Review of the provider documentation dated 04/25/22 revealed Resident #7 had bilateral hearing loss and her hearing aids had been lost. The note stated the certificate of medical necessity (CMN) for hearing aids was left at the facility and needed to be signed by the resident's Primary Care Physician (PCP) prior to the hearing aids being ordered. Review of the CMN form for hearing aids, dated 04/25/22, revealed the form had not been signed or returned. Review of the missing item report dated 06/01/22 revealed Resident #7's hearing aids had been missing since before COVID. Interview on 06/13/22 at 11:36 A.M., with Resident #7 revealed the resident's hearing aids were lost at the facility and this was not being addressed. Interview on 06/30/22 at 11:18 A.M., with Social Services Director #553 revealed the CMN for hearing aids had been accidentally scanned in with other provider documents from the audiology visit on 04/25/22 and was not signed or returned until the need was identified during the survey on 06/30/22. Review of the policy titled Physician Services Ancillary, not dated, revealed arrangement of services from ancillary providers including audiologists would be arranged based on resident needs.

Based on record review and staff interview, the facility failed to obtain physician orders for the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 60. Findings include: Record review for Resident #61 revealed an admitted [DATE]. Resident #61 had a hospital stay from 05/06/22 through 05/11/22. Diagnoses included acute kidney failure and altered mental status. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 was always continent of bowel and bladder. Record review of the Critical Admission assessment dated [DATE] completed by Licensed Practical Nurse (LPN) #503 revealed Resident#61 had returned from a hospital stay. Resident #61 had a Foley (indwelling) catheter draining yellow urine. Review of the scheduled five-day MDS assessment completed 05/15/22 revealed Resident #61 had an indwelling catheter. Record review of the care plan for Resident #61 revealed there was no care plan for an indwelling catheter. Record review of the physician orders for May 2022 and June 2022 for Resident #61 revealed there was no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the nursing progress notes from 05/11/22 through 06/02/22 for Resident #61 revealed there was no nursing progress note documented regarding the use or care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders dated 06/03/22 for Resident #61 revealed an order to remove the Foley (indwelling) catheter and monitor for retention. Interview on 06/29/22 at 2:43 P.M., with the Director of Nursing (DON) confirmed Resident #61 returned from the hospital on 05/11/22 with an indwelling catheter. The indwelling catheter was removed on 06/03/22. DON confirmed Resident #61 had no order for the indwelling catheter or the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . DON confirmed the facility was responsible to obtain orders for the indwelling catheter and care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on medical record review, staff interview, physician interview, resident interview, observation, and policy review, the facility failed to properly assess a resident's skin condition and failed to ensure pressure reducing interventions were implemented for two residents (#38 and #37). This resulted in actual harm that was not immediate jeopardy for Resident #38 when she was not provided her physician ordered alternating pressure mattress and was found to have two Stage 2 (partial thickness skin loss with exposed dermis) pressure ulcers to her buttocks and one Stage 3 (full-thickness loss of the skin, in which adipose (fat) is visible in the ulcer) pressure ulcer to her coccyx. The staff providing care failed to document the presence of the area and failed to inform the nursing staff of the presence of the open areas. Additionally, the facility failed to elevate the extremity of Resident #37, who had an unstageable pressure ulcer to the left heel. This affected two (#38 and #37) of six residents reviewed for pressure ulcers. The facility identified eight residents to have pressure ulcers. The facility census was 72. Findings include: 1. Review of Resident #38's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #38's pressure sore risk assessment dated [DATE] identified the resident as being at risk to develop pressure ulcers. The pressure sore risk assessment dated [DATE] identified the resident as being a low risk to develop pressure ulcers. Review of the 60 day Minimum Data Set (MDS) 3.0 assessment, dated 02/19/18, identified the resident as being cognitively intact. The resident was dependent upon two person assist with bed mobility, transfers and toilet use: required extensive one person assist with dressing and total dependence one person assist with personal hygiene. Resident #38 was identified to have an indwelling catheter and was frequently incontinent of bowel. It identified the resident as being at risk for pressure ulcers and was identified to use a pressure reducing device for the chair and the bed. Review of Resident #38's current care plan indicated the resident was at risk for pressure ulcers related to impaired and reduced mobility, variable by mouth intake, and incontinence. Interventions included a low air loss mattress to bed dated added on 02/09/18. Interventions also indicated to report any signs of skin breakdown (sore, tender, red or broken areas). Review of the physician order dated 02/09/18 revealed an order for [REDACTED]. Review of the (MONTH) (YEAR) treatment administration record (TAR) revealed the ordered alternating pressure mattress to the bed was signed off as applied on 02/09/18. Review of the Skin Body Assessment, dated 03/27/18, identified the resident as not having any areas of skin impairment. Review of the nursing notes from 03/13/18 through 03/28/18 failed to identify the resident as having any open areas to her buttocks or coccyx. Interview on 03/27/18 at 1:14 P.M., Resident #38 voiced she has a sore area to her coccyx which has been there for about three days. Resident #38 voiced night shift has been putting cream on it, however the resident stated it was not working. Resident #38 voiced the area was painful. Observation on 03/27/18 at 1:14 P.M. revealed Resident #38 was lying in bed, on her back. The resident was observed to have a pressure reducing mattress on her bed, however, there was not an alternating pressure mattress on her bed. Interview with Licensed Practical Nurse (LPN) #300 on 03/29/18 at 7:20 A.M. voiced Resident #38 did not have any pressure areas that she was aware of. Interview with the Director of Nursing (DON) on 03/29/18 at 8:10 A.M. voiced Resident #38 did not have any pressure areas. Observation on 03/29/18 from 08:19 A.M. until 8:32 A.M. revealed Resident #38 was lying in bed, the resident was observed to be turned on her right side by LPN #300 and State tested Nurse Aide (STNA) #554. Resident #38 was observed to have open areas to the left medial buttock, coccyx and on the right medial buttock. The Assistant Director of Nursing (ADON) #316 measured the areas and indicated the left medical buttock was a Stage 2 pressure ulcer which measured 4 centimeters (cm) by 1.8 cm by less than 0.1 cm in depth. She identified the area on the coccyx as a Stage 3 pressure ulcer, measuring 1.5 cm by 0.8 cm by 0.1 cm, with slough present on the wound bed. ADON #316 identified the area on the right medical buttocks as a Stage 2 pressure ulcer measuring 3.3 cm by 0.6 cm by 0.1 cm. ADON #316 voiced she was unaware of the resident having these areas. Interview with STNA #538 on 03/29/18 at 8:36 A.M. revealed Resident #38 was incontinent of bowel. STNA #538 stated Resident #38 had an open area on her buttocks at one point, however she didn't think there were any current open areas. Interview on 03/29/18 at 8:38 A.M., STNA #501 voiced she provided care to Resident #38 on 03/28/18 and did not notice any open areas. Interview on 03/29/18 at 8:44 A.M., ADON #316 confirmed the skin assessment completed on 03/27/18 did not indicate the resident had any skin impairment. ADON #316 confirmed there was no treatment orders for the resident's skin. She stated the facility has a standing order for a skin cream, however, there was no evidence this was being applied to Resident #38. ADON #316 voiced she would have expected for these areas to have been identified on the skin assessment that was completed on 03/27/18. Interview on 03/29/18 at 9:11 A.M. with Medical Records #540 revealed she had contacted the facility supplier to see if they had ordered an alternating pressure mattress for Resident #38, and she confirmed they had not. Interview on 03/29/18 at 2:10 P.M., the DON stated voiced the order for the alternating pressure mattress was a mistake and ordered for the wrong person. She confirmed it was signed off on the TAR as being applied and was unable to explain why the nurse had signed the application of the mattress. Interview on 03/29/18 at 4:32 P.M., LPN #547 revealed she completed Resident #38's skin assessment on 03/27/18. She voiced she didn't see any open areas, however the resident's buttocks was a bright pinkish color at that time. Interview with the DON on 03/30/18 at 7:28 A.M. confirmed Resident #38's care plan indicated she was supposed to have a low air loss mattress to her bed, that was implemented on 02/09/18. The DON stated the MDS nurse didn't discontinue the order from Resident #38's plan of care. The DON voiced the order was written for another resident, however, was unable to indicate what resident this order was for. Review of the facility policy titled Pressure Ulcer Prevention Protocols/Risk Assessment, dated 01/2008, revealed a resident's level of risk for pressure ulcer development will initially be determined at the time of admission taking into consideration the nature of risk to include underlying causes. It indicated the resident's plan of care will be updated in a manner that provides interventions appropriate to the resident's risk level. Review of the undated facility policy titled Assisting with Pressure Ulcers revealed to inspect the skin every time you provide care. This includes during or after transfers, re-positioning, bathing, and elimination procedures. Report any concerns at once. 2. Review of the medical record revealed Resident #37 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of hospital discharge paperwork dated 01/26/18 identified Resident #37 had chronic lower extremity wounds. The resident had bilateral lower extremity venous stasis ulcerations with weeping wounds to the knees. The right and left heels were red and non-blanchable. The hospital notes documented an air mattress in use, heels elevated, and position change as needed. Review of the plan of care dated 01/26/18 revealed the resident had risk for impaired skin integrity due to weakness and impaired mobility. Review of weekly pressure ulcer progress note dated 01/26/18 revealed Resident #37 had an unstageable pressure ulcer to the left heel measuring 2 cm by 2 cm with thick scabbing covering the wound bed. Review of nursing notes on 01/29/2018 at 12:11 P.M. documented the resident complained of soreness to the left heel and requested it padded. Upon looking at the heel there was a thick scab noted with slight redness around it. A new physician order was received for skin prep to left heel, let dry, and pad and protect the area daily. Review of Minimum (MDS) data set [DATE] included the resident was cognitively intact and required limited assistance of one person for transfers and bed mobility. Review of treatment flow record for (MONTH) (YEAR) included an entry dated 02/26/18 to encourage the resident to elevate heels while in bed every shift. Review of weekly pressure ulcer progress report dated 03/21/18 indicated the resident's left heel had an unstageable pressure ulcer measuring 0.5 cm by 0.9 cm in size. There area was described as red and purple in color. Review of the STNA care form for Resident #37 noted to elevate bilateral heels when in bed. Observation on 03/27/18 at 11:40 A.M. the resident was lying in bed and his entire left foot was resting directly on the footboard. Observation on 03/28/18 at 8:58 A.M. revealed the resident's left heel and right foot was lying directly on a pillow. There were no dressings present on the resident's feet. The resident lifted his left foot and the scabbed area was visible to the left heel. At 6:22 P.M. the resident was observed to have socks on his bilateral feet. The pad of the left foot was resting directly on the footboard. There was no pillow under his extremity to elevate the heels. Review of weekly pressure ulcer progress report dated 03/21/18 indicated the resident's left heel had an unstageable pressure ulcer measuring 0.5 cm by 0.9 cm in size. There area was described as red and purple in color. Interview on 03/29/18 at 8:15 A.M., STNA #534 stated Resident #37 had no open areas or pressure ulcers. She stated the resident can move around in the bed at times. STNA #534 was unable to reveal if the resident had any additional interventions regarding pressure ulcers. STNA #534 did confirm Resident #37 should have his feet elevated and sometimes he will keep his feet elevated. Observation on 03/29/18 at 8:25 A.M. revealed Resident #37 had a pillow under his feet, however his feet were not elevated and his left heel was resting directly on the top edge of the footboard. Interview on 03/29/18 at 8:25 A.M., STNA #534 stated she had put a pillow under the resident's feet the last time she was in the room at 8:15 A.M. STNA #554 confirmed she left the resident with his heels not elevated and his left heel resting directly on the top of footboard. She stated she had covered him with a blanket and left the room. STNA #534 stated Resident #37 was too long for the bed. Observation and interview on 03/29/18 at 8:27 A.M., LPN#300 stated she was not aware if Resident #37 had pressure ulcers. At this time LPN #300 observed Resident #37 in the bed and confirmed the resident's feet were not elevated and his left heel should not have been resting directly on the footboard. Interview on 03/29/18 at 9:35 A.M., STNA #554 confirmed they have to reposition Resident #37 often and pull him up in bed because he is tall. STNA #554 indicated Resident #37 will allow for repositioning with education. Observation on 03/30/18 1:23 P.M. revealed Resident #37 had his feet elevated with pillows and his footboard was padded with a large blanket. ADON #316 stated the resident likes the footboard so they are padding it. Observation of the treatment to the left heel at this time revealed ADON #316 removed the old dressing. The left heel pressure ulcer was purple in color and measured 0.9 cm by 0.9 cm by less than 0.1 cm. There was no drainage or depth observed. The skin was dry and intact. Resident #37 verbalized no pain. ADON #316 described the left heel area as a deep tissue injury. She confirmed that she would expect the staff to leave the resident's feet elevated and not left lying on the foot board. Interview on 03/30/18 at 1:49 P.M., Physician #1 stated he/she would expect the facility staff to ensure the resident's feet to be elevated due to the existence of the pressure ulcer. This deficiency is a recite to the complaint survey completed 01/24/18.

Based on observation, record review, resident interview, staff interview, family interview, and policy review, the facility failed to ensure the environment was kept free from hazards. This resulted in actual harm that was not immediate jeopardy for Resident #23 when staff had to step away from her in the shower room to move a large linen cart out of the pathway, the resident stepped backward, tripping over a scale and falling onto the scale sustaining a [MEDICAL CONDITION] and a lower extremity laceration that required ten sutures. Additionally the facility failed to use the appropriate number of staff during a transfer for one resident (#38), and failed to follow a physician order for [REDACTED].#23, #38, and #48) out of three residents reviewed for hazards. The facility census was 72. Findings Included: 1. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of care plan dated 11/02/17 identified the resident had impaired vision, even with the use of glasses, and [DIAGNOSES REDACTED]. Review of care plan dated 11/02/17 included the resident was at risk for falling related to impaired cognition, impaired safety awareness, weakness with recent hospitalization , unsteady gait, and fall prior to admission. Increased risk for injury related to fractures with [DIAGNOSES REDACTED]. Interventions included use caution when transferring resident, avoid bumping extremities against objects due to risk for fractures, and assist resident in all areas of activities of daily living. Intervention dated 01/22/18 included ensure use of gait belt when ambulating with resident. Intervention on 01/25/18 included use appropriate amount of staff for all mobility, transfers, ambulation and mobility as needed. Review of the Minimum Data Set (MDS) assessment, dated 12/04/17, revealed the resident was severely cognitively impaired, required extensive assistance of one person to ambulate off/on the unit, and required physical help of one person in part of bathing activity. The resident had balance issues with walking and transfers, but was able to stabilize without staff assistance. The resident used a walker and/or wheelchair for mobility. Review of Physical Therapy discharge note, dated 12/15/17, documented the resident needed stand by assistance and could ambulate 275 feet. The resident was also noted to be a moderate risk for falls. Review of nursing note dated 01/22/18 at 10:04 A.M. documented staff was walking with resident in West shower room to take a shower. The resident tripped on the weight scale and fell , hitting her head on the scale leaving a bruise and abrasion. The resident had complaints of pain to the right arm and leg. The physician was called and ordered the resident to be sent to the hospital for treatment. At 1:40 P.M. the nursing note documented the resident was admitted to the hospital with [REDACTED]. Review of safety event/ fall event documentation dated 01/22/18 at 9:57 A.M., noted the resident was walking with a staff person to the shower. The resident stepped back and tripped over a scale and fell on to the floor landing on the scale. The report indicated the environment had clutter present on the floor. Immediate interventions included to move the weight scale and keep the shower room less congested. Review of witness statement dated 01/22/18 from State tested Nurse Aide (STNA) #526 revealed the STNA was walking Resident #23 to the shower room. She opened shower room door and directed Resident #23 to stand still while the aide moved a cart. Resident moved her feet and tripped over weight scale letting go of her walker and falling on her right side across the scale, hitting her head on the bottom of scale as she fell down. STNA #526 noted she then directed the resident not to move and yelled out to nurse she needed help. Review of witness statement from STNA #501 revealed on 01/22/18 about 9:30 A.M. she was at the nurse's station filling out paperwork. She observed STNA#526 take Resident #23 in the shower room. STNA #526 came back and said she needed the nurse right away. STNA #501 went into the shower room observed Resident #23 laying on her right side on the scale. The resident said she was okay, but was in pain. STNA #501 and STNA #526 took vitals and sat with the resident. They noticed the resident had blood on her elbow of her shirt. They then noticed blood dripping on the floor under the resident's leg. The STNAs lifted the leg up just a little bit and noticed the resident had a gash on her leg. The aides were then instructed not to move the resident and take vitals again. STNA #501 sat with the resident until the ambulance came. Review of nursing note dated 01/25/18 5:50 P.M. revealed the resident returned to the facility. The resident was noticed to have facial grimacing. There was a skin tear noted to the right elbow and both hands had bruising. The right thigh had an incision with a dressing in place. The resident had a laceration to the right lower extremity with ten sutures. Interview on on 03/28/18 at 2:56 P.M. with Resident #23's family, Family Member #901, revealed the resident was admitted to the facility after a fall in the resident's apartment. The resident had cracked a rib and cracked vertebrae with the fall prior to admission to the facility. The resident was brought to the facility for rehabilitation. Family Member #901 indicated the resident was a fall risk. Interview on 03/29/18 at 9:20 A.M. with STNA #526 explained Resident #23 required one-person assistance and she could use her walker. STNA #526 stated she entered the shower room and made sure it was clear and she had all the necessary items to shower the resident. When she went to Resident #23's room the resident was already up with her alarm was going off and was anxious about a shower. She stated she did not think she needed to use a gait belt, because she was just walking with Resident #23. STNA #526 thought you only need to use a gait belt if the resident needed physical assistance while walking. She was taking the resident to the shower stall on the left side of the room and when she opened the door to the shower room the big linen cart was in front of the walkway. She stated the scale was in front of the shower stall on the right. The scale was always in the shower room, but you could get around it if you were going to the left side shower. She stated typically she would walk with the resident with one arm around her, but not touching the resident just in case she fell and the resident had her glasses on. The aide said she had to push the cart aside and when she did the resident tripped and fell over the scale. STNA #256 stated the cart should not have been there and the fall could have been avoided. She confirmed they always keep the linens carts in the shower rooms. Observation on 03/30/18 at 7:42 A.M. revealed a shower on the right side of the room and a whirlpool on the left side. There was a closed large linen cart was in the West front shower room, the cart was placed directly in front of the shower. Additionally, there was a large round trash can with linens on the lid directly in front of the toilet. Interview on 03/30/18 at 7:45 A.M., STNA #526 confirmed the clutter in the shower room. STNA #526 confirmed the aides use the shower room to bathe the residents. She explained an aide would not be able to remain hands on to assist the resident to the shower if the resident was ambulating because you would have to push the cart out of the way. She then explained with the location of the large trash can you cannot safely get someone on the toilet. Interview on 03/30/18 at 7:48 A.M., the Corporate Registered Nurse (RN) confirmed the observation of clutter in the West shower room. Interview on 03/30/18 at 8:20 A.M., Laundry/Housekeeping (L/H) Staff #506 explained when she places the linen carts in the shower rooms she tries to ensure appropriate infection control procedures are maintained. She tries to make sure the clean linen cart is not near the toilet or soiled linens. She confirmed she left the large linen cart in the shower walk way in the front West shower room this morning. She explained they spoken with her about ensuring the walkways are clear for resident's safety. She stated she was constantly trying to help clean up the shower rooms by picking up dirty towels, etc. L/H Staff #506 stated if the smaller linen carts are used the aides would run out of linens, because they have the blankets on them. Interview on 03/30/18 at 9:43 A.M., Therapy Program Manager (TPM) #610 explained Resident #23 required assistance with ambulation. At the resident's prior (to the fall) discharge the resident was able to ambulate with stand by assistance. TPM #610 explained stand by assist means you are walking beside her and you are just there if she needs you. TMP #610 stated she would expect staff to use a gait belt prior to the resident's fall as she was a moderate risk for falls. After the resident fell she required contact guard assist and she was able to ambulate 20 feet, which was a significant decline. The resident had the fracture, some minimal pain, and a laceration as a result from the fall and it limited her. Interview on 03/30/18 at 12:04 P.M., the Director of Nursing (DON) explained the facility had the weight scale in the shower room for years. The scale was to the right on the wall and it is a really big scale for weighing residents in wheelchairs. The DON confirmed there was also a large linen cart, in the shower room. The DON confirmed after the fall they removed the weight scale and uncluttered the room. DON stated she felt the fall was avoidable if the weight scale had not been in the shower room. Review of the facility policy titled Fall Prevention and Management Program Policy, dated 01/2018, indicated the DON was responsible to ensure the fall prevention and management program was in place. Each resident will have a care plan specific to their risk level and individualized preventative approaches specific to identified contributing factors to reduce and attempt to eliminate their risk for fall incidents. 2. Review of Resident #38's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment, dated 12/06/17, identified the resident as being cognitively intact. It identified the resident as requiring an extensive assistance of two persons with transfers. Review of the at risk for injury care plan related to falls, and at risk for falling, revised on 03/28/18, indicated to use two staff members when transferring the resident. This intervention was implemented on 12/06/17. Review of the hospital discharge instructions dated 11/30/17 revealed the resident was a two assist with a front wheeled walker. Review of the Incident/Accident Report dated 12/12/17 at 9:15 A.M. revealed the during the transfer in the resident's room the resident's left leg became weak and the resident was lowered to the floor. The resident had no injuries. It revealed the immediate intervention taken to prevent recurrence was for a two person assist with all transfers. Review of the witness statement dated 12/12/17 revealed at 9:15 A.M. the staff was transferring the resident from bed to the wheelchair to take her to the bathroom per her request. While standing the resident's left leg became weak and gave out. The staff lowered the resident to the floor. Interview on 03/29/18 at 2:30 P.M., RN #300 revealed Resident #38 has required two staff assistance since admission. She voiced staff should have always use two person assist with the resident because of how her participation fluctuates. She confirmed Resident #38 fell while staff were only using one assist, and she confirmed per the care plan the resident should have had a two person assist. Interview on 03/30/18 at 7:35 A.M.,the DON confirmed on 12/12/17 when Resident #38 had fallen, staff was only using a one person assist. 3. Review of Resident #48's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the 30 day MDS assessment, dated 02/28/18, identified the resident as being having moderate cognitive impairment. Review of Resident #48's care plan, revised on 02/20/18, indicated the resident has difficulty swallowing and requires medications to be crushed, mixed in food in food substance. It indicated to observe the resident closely for signs of choking and or aspiration. Review of the care plan updated 03/08/18 indicated the resident was a nutritional risk due to dysphagia. Interventions included no straws. Review of Resident #48's physician order dated 03/15/18 revealed an order for [REDACTED].>Observation on 03/28/18 at 2:41 P.M., 03/30/18 at 8:17 A.M., and 03/30/18 at 11:54 A.M. of Resident #48's room revealed there was a pink water pitcher in on his bedside table with straw in it. Interview on 03/30/18 1:06 P.M., Resident #48 revealed he uses the straw to drink water from his water pitcher. Observation on 03/30/18 at 1:06 P.M. revealed Resident #48 had a pink water pitcher sitting on his bedside table with a straw in it. Interview on 03/30/18 at 1:08 P.M., STNA #538 stated Resident #48 drinks water from his water pitcher using a straw, however, all his drinks in the dining room are consumed without a straw. STNA #538 confirmed there was currently a straw in his water pitcher. Interview on 03/30/18 at 1:10 P.M. with Licensed Practical Nurse (LPN) #300 confirmed the resident was not allowed to have straws. Interview with Speech Therapist #612 on 03/30/18 a 3:02 P.M. revealed the resident was not allowed to have straws. She voiced Resident #48 has a swallowing delay and using a straw could increase his risk of aspiration.

Based on record review, resident interview, family interview, staff interview, physician interview, and review of facility policy for pain and change of condition, the facility failed to ensure a resident experiencing pain was provided care and/or treatment in a timely manner. This resulted in actual harm that was not immediate jeopardy when Resident #59 was experiencing excruciating pain after dislocating her hip and the nursing staff did not notify the physician and/or emergency services until after an assessment in person by the Director of Nursing. This affected one (#59) of 25 residents sampled during the survey. The facility census was 72. Findings Included: Review of the medical record revealed Resident #59 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Minimum Data Set (MDS) assessment, dated 02/24/18, revealed the resident required supervision for personal hygiene. Review of care plan dated 02/07/18 included potential for discomfort and impaired mobility related to recent [MEDICAL CONDITION] with repair. It was updated on 02/28/18 and noted dislocation of hip with need for brace. Review of pain care plan dated 02/07/18 included the resident is at risk for pain related to [MEDICAL CONDITION]. Interventions included administer medications as ordered, monitor and record effectiveness, evaluate effectiveness of pain management interventions, adjust if ineffective, monitor and record complains of pain; location, duration, quantity, quality, alleviating factors, and aggravating factors. Review of Medication Administration Record [REDACTED]. The MAR indicated [REDACTED].M. with a plus sign for effect. Review of nursing notes on 02/28/18 at 4:00 A.M., revealed Licensed Practical Nurse (LPN) #547 documented the resident complained of pain to the left leg below the incision site with as needed medication given. At 5:30 A.M. the resident's daughter called the facility stating the resident was crying and in pain. LPN #547 documented the resident's daughter was informed the resident had received a pain pill at 4:00 A.M. The nurse informed the resident's daughter she would go assess the resident and keep her informed. At 6:15 A.M. it was noted the nurse checked on Resident #59's area of pain and noted slight bruising below the incision site, with a slight puffy area noted as well. The Director of Nursing (DON) was notified and stated she would be in to look at the resident. Review of nursing notes on 02/28/18 at 6:30 A.M. the DON documented she had assessed the resident's leg with the daughter due to complaints of pain. There was noted a small area of [MEDICAL CONDITION] below the incision and the left leg was at an abnormal abduction position. At 6:45 A.M. the resident was being transported to the emergency room . Review of radiology report dated 02/28/18 at 11:20 A.M. noted the resident had a left hip dislocation which had been reduced. Interview on 03/28/18 at 9:35 A.M., Resident #59 stated one day at about 4:00 A.M. her hip came out of the socket. The resident stated she had never had pain that bad in her life. The resident stated childbirth pain was not even that bad. The resident stated the nurses were doing absolutely nothing and she was begging them to call for help as the pain was excruciating. The resident had to contact her daughters because the nurses kept saying there was nothing they could do. Resident #59 stated she was in so much pain and was upset she could not get the help she needed with her pain. Interview on 03/29/18 at 4:06 P.M., LPN #547 explained that prior to 02/28/18 the resident would occasionally complain of pain right before bed. She stated the resident's pain ranged from a five to a nine on a scale of one to ten. Usually the resident's pain was in her lower back and rarely in her hip. The night in question the resident reported to LPN #547 that her hip hurt worse than the day she broke it. LPN #547 confirmed she gave the resident medication earlier in the shift. LPN #547 confirmed she asked the resident about her pain level prior to and after administering the pain medication, but she did not document the assessment. She explained she did document a plus sign on the MAR indicated [REDACTED]. LPN #547 stated she remembered the resident stated she was feeling better and the pain was bearable. LPN #547 could not remember the resident's pain level on a numeric scale before or after the medication and confirmed she did not document this information. LPN #547 confirmed the resident had stated her hip hurt really, really bad and the resident could not remember ever being in that much pain. LPN #547 stated typically the resident will fall asleep after the pain pill, but that night the resident did not. LPN# 547 stated she did notice the resident's leg was turned but thought that was typical for the resident. LPN #547 confirmed she received a call from one of the resident's daughters letting her know the resident was in pain. Shortly thereafter, LPN #547 stated an unknown aide also reported Resident #59 was experiencing pain. By 6:15 A.M. a daughter of Resident #59 was at the facility. LPN #547 explained they were trying to calm the resident down and she did not know why she was in pain. She explained LPN #300 was also in the room examining the resident and LPN #300 called the DON, who was on her way into the facility, so they waited for the DON. Additional interview at 4:49 P.M. LPN #547 confirmed the daughter who arrived on site wanted them to call the physician but she did not call the physician as the facility's policy is she was expected to call the DON prior to notifying the physician. Interview on 03/29/18 at 4:49 P.M., LPN #300 stated she got to the facility about 5:20 A.M. and about 5:30 A.M. Resident #59's daughter arrived. They noticed Resident #59's leg was rotated inward and the resident could not move her leg. At that point LPN #300 called the DON, who was already on the way in to the facility. Resident #59's daughter had asked if we were going to call the physician, but the DON was on her way. The resident said she was in pain, she could not lift her leg, and was not sure what happened. LPN #300 stated the resident did state she had crossed her legs. Resident #59 said her pain level was a nine out of ten and it hurt worse than when she originally had broken her hip. After the DON assessed the resident the DON called the physician while LPN #300 was calling the emergency squad. LPN #300 stated she did not call the physician as she was waiting on the DON to arrive. Interview on 03/30/18 at 11:47 A.M., the DON stated LPN #300 called the DON explaining LPN #547 had given the resident a pain pill earlier. The family had called into the facility to report the resident was in pain and both LPNs had assessed the resident. The DON stated she arrived about 15 minutes after they called her and when she assessed the resident she could tell her hip was out of alignment. The resident stated she was in a lot of pain. The DON confirmed she was aware the resident was in excruciating pain, but she was in route to the facility. The DON stated she wanted to look at the resident and complete an assessment before the nursing staff called the physician or emergency services. The DON explained the facility's policy is for the nurses contact her prior to notifying the physician. She explained the reason was because the facility was trying to cut down on rehospitalization s and also so the nurses don't call the physician for stupid stuff. Interview on 03/30/18 12:43 P.M., Daughter #2, Resident #59's daughter, explained her sister (Daughter #1) had called the facility to report Resident #59's pain. Daughter #2 explained when she arrived about 5:30 A.M. she found her mother screaming in pain. She told the nurses they needed to come take a look at the resident. The nurses came down with her and it was clearly obvious something was wrong with the resident's leg. It was horizontal to the left. Resident #59 had called Daughter #2 and said she wanted to go to the emergency room and the facility would not do anything. Daughter #2 explained she did not ask the facility to wait to send her to the hospital. The nurses said they could not call the physician because they had to call the DON first. Daughter #2 stated it was at least a half hour after she arrived, and after the DON arrived ,before the nurses contacted the rescue squad. Interview on 03/30/18 01:45 P.M., Physician #1 revealed if a nurse has identified an acute concern and/or the resident requests, the nurses can send a resident right away for treatment. Physician #1 indicated this was especially true if the resident's leg was out of alignment and the resident was experiencing extreme pain. Physician #1 stated he thinks it is the facility policy for the DON to screen all calls made to the physician, but the nurses do not have to call the DON first. Review of facility policy titled Pain Management, dated 11/2016, revealed all staff during general orientation will be introduced to the facility's pain management program and the importance of recognizing signs of pain and reporting to the charge nurse. This can be accomplished through the Stop and Watch Program. It is the responsibility of all direct care staff to be vigilant for sign and symptoms suggesting pain during the resident daily activities. Periodic interviewing and observations will also be conducted throughout the resident's day to identify any new onset of pain or effectiveness from implemented pain interventions. Review of the facility policy titled Change of Condition Policy, dated 07/2017, revealed the resident's physician must be notified when an event involving the resident occurs or when the resident experiences a change of condition. Assessment to be should include pain level and any resident complaints. In all capital letters it noted to call the physician immediately if the resident requires immediate attention and call 911 in emergency situations.

Based on observation, medical record review, staff interview, physician interviews, review of incident report, and review of facility investigation, the facility failed to perform circulation checks and monitor a resident's skin condition after the application of a right lower extremity brace. This resulted in actual harm for Resident #22 when the resident was found to have an , unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar (dead tissue) to such an extent that the full depth of the wound cannot be appreciated) pressure ulcer to the top of the right foot measuring 2 centimeters (cm) in length by 2 cm in width with the presence of eschar. Resident #22 also developed a Stage 2 pressure ulcer to the right ankle measuring 3 cm in length by 2 cm in length. This affected one (#22) of three residents reviewed for pressure ulcers. The facility identified four current residents with pressure ulcers. The facility census was 61. Findings include: Review of Resident #22's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the plan of care developed 03/21/13 identified Resident #22 to be at risk for skin breakdown related to cognitive impairment, history of skin issues, and [MEDICAL CONDITION] at times. Interventions included: any noted changes with skin status, assess, and report findings to physician, assess resident for presence of risk factors, and conduct weekly skin inspections, Pay particular attention to the bony prominences. Review of the quarterly Minimum Data Set assessment dated [DATE] identified Resident #22 to be at risk for pressure ulcers. and a written plan of care was developed. The progress notes dated 12/21/17 revealed Resident #22 was getting up from the toilet, fell and suffered a fractured right ankle. Resident #22 went to the hospital on [DATE] and returned on 12/22/17 with a brace on the right lower leg. The record revealed Resident #22 was not a surgical candidate and the family made the decision for a non-surgical approach. The record lacked any evidence of discharge orders from the hospital for the care needed for the leg brace to Resident #22's right lower extremity. Review of a physician note dated 12/22/17, written by Physician #400, revealed Resident #22 had a fallen and fractured her ankle. The physician did not identify any new orders for Resident #22. Review of the plan of care revealed on 12/22/17 the care plan was updated to identify Resident #22 had a fracture to the ankle with the presence of a splint to the right lower leg with the potential for skin breakdown. Interventions included: monitor color, temperature, and presence of pulses every shift and observe pressure points for signs and symptoms of skin breakdown, monitor to assure splint on the extremity is not too tight by keeping enough room for at least two fingers. Review of Resident #22's Treatment Administration Records (TAR) and progress notes from 12/22/17 through 01/14/18 identified no orders related to the care or monitoring of Resident #22's right lower extremity brace. The notes lacked evidence of skin and or circulation checks to the right lower extremity having been completed. Review of a progress note dated 01/14/18 at 8:45 A.M. revealed Registered Nurse (RN) #300 was checking Resident #22's skin and noticed a foul smelling odor. RN #300 identified the presence of pressure ulcers on the right foot. These pressure ulcer to the top of the right foot measured 3 cm by 2 cm. The note did not include any further description of the appearance of the pressure ulcer. The noted documented the resident's right foot and calf were red and weak pulses were located in the area. RN #300 contacted Physician #400 and an order was received to transport Resident #22 to the hospital for an evaluation. Review of the Incident Report New Discovery of Pressure Wound form, dated 01/14/18, documented the nurse discovered two wound areas to the residents right ankle. The right medial wound was identified to be 3 cm in length by 2 cm in width. The right dorsal wound (top of the foot) was identified to be 2 cm in length by 2 cm in width. Review of the hospital records dated 01/14/18 at 10:21 A.M. identified Resident #22 arrived for evaluation of a foot infection. Review of an x-ray obtained at the hospital revealed the resident had dislocated right bimalleolar (both lower leg bones) ankle fractures. The note identified a boot was placed on the right lower extremity on 12/22/17 following the original fracture. Wounds had developed under the boot. The hospital records lacked specific documentation regarding the wound appearance. Review of the progress notes dated 01/14/18 at 4:11 P.M. documented RN #300 called the hospital regarding Resident #22. The hospital revealed Resident #22 was going to return to the facility with an immobilizer device and orthopedic appointment. Review of the 01/14/18 hospital discharge orders included circulation and skin checks every shift (eight hours), clean wounds daily, and cover the wounds with a dry dressing. Review of the progress notes dated 01/14/18 at 5:44 P.M. documented Resident #22 returned from the hospital and had a scab measuring 2 cm by 2 cm to the upper surface of the right foot. The area was covered with a splint that was to be left in place until follow up with Orthopedic Surgeon #450 on 01/17/18. The note documented the hospital ordered circulation checks to be completed every shift (three times a day) and leave the splint in place until 01/17/18 when an appointment with Orthopedic Surgeon #450 was to occur. The notes identified Resident #22 was going to have a open reduction internal fixation surgery (ORIF) surgery on the right ankle to repair the fracture. Observation of Resident #22's right foot and ankle on 01/24/18 at 10:16 A.M. with RN #330 revealed the top of the right foot had an unstageable pressure ulcer with brown slough/eschar tissue present. The pressure ulcer was approximately the size of a half dollar. The approximate depth of the wound could not be determined because the wound bed was covered with the eschar tissue. An additional wound was observed to the bony prominence of the right medial ankle bone which appeared as a Stage 2 Pressure Ulcer. This area was approximately the size of a nickel. Review of the facility investigation into the development of Resident #22's pressure ulcers to the right foot revealed the presence of RN #300 wrote a statement dated 01/14/18. The statement revealed upon Resident #22's return from the hospital, she received a verbal report from the hospital that Resident #22's fracture had to be set because it had moved. This caused increase pressure to the ankle bones against the brace, which led to the development of the pressure ulcers. Statements from Licensed Practical Nurse (LPN) #500, LPN #510, and LPN #520 revealed from 12/22/17 through 01/14/18 some of the nurses would open the boot for inspection of the skin and others were told not to open the boot. Review of the statements from State tested Nurse Aide (STNA) #700, STNA #710, and STNA #720 identified some were told not to open the boot during care, while other STNAs did open the boot. Interview on 01/24/18 at 2:50 P.M., the Director of Nursing (DON) confirmed on 12/22/17 Resident #22 was returned from the hospital with no written discharge orders for care provided. The DON stated RN #300 was working on 12/22/17 and received a verbal report from the hospital instructing the facility staff not to remove the brace to the right ankle. The DON stated Resident #22's son also reported the orthopedic physician had told him the brace needed to stay on when the resident returned from the hospital on [DATE]. The DON confirmed there was no documented follow up regarding the lack of physician orders related to the care of Resident #22's brace and monitoring of the skin underneath it. Additionally, during the interview on 01/24/18 at 2:50 P.M., the DON verified she would have expected the nursing staff to have completed and documented circulation checks on Resident #22's brace from 12/22/17 through 01/14/18. The DON confirmed there was no written evidence the circulation checks or skin checks by the nurses occurred. The interview confirmed the facility had obtained no physician orders for monitoring the resident's skin, circulation checks, or care of the orthopedic boot. Telephone interview on 01/24/18 at 3:35 P.M., Physician #400 confirmed the facility should have gotten orders on 12/22/17 from Orthopedic Surgeon #450 regarding the care of Resident #22's ankle brace. The physician further identified circulation checks should have been completed and documented when she was identified to have a fractured ankle and a brace in place. This deficiency substantiates Complaint Number OH 769.

Based on clinical record review, review of the Self-Reported Incidents, review of incident/accident reports, staff interviews, and family interviews, the facility failed to provide a safe two person transfer for one (#80) resident of three sampled for accidents. This resulted in actual harm when Resident #80 received a left proximal tibial plateau fracture (the shin bone affecting the knee joint) after a State tested Nursing Assistant (STNA) transferred the resident from the chair to the bed without a second staff member assisting. In addition, the facility failed to provide supervision and ensure functioning fall prevention equipment was in place to prevent a fall for one (#62) of three residents sampled for accidents. This resulted in harm when Resident #62 was left alone in her room, with a non functioning chair alarm in place, suffered a fall, and received a fractured pelvis. The facility census was 71 Findings include: 1. Review of the clinical record for Resident #80 revealed the resident was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had severely impaired cognition, did not ambulate, and was totally dependent on two staff for transfers. The MDS indicated Resident #80 had no history of falls or fractures. Review of fall risk assessment dated [DATE] identified Resident #80 to be at high risk for falls. Review of current care plan identified the resident was at risk for injury due to osteoporosis. Review of the Self-Reported Incident (SRI) dated 11/12/2014 revealed at 2:00 P.M. Resident #80 complained of pain in the left knee, with edema present, following a transfer from the wheelchair to the bed. This transfer was completed by STNA #10 without a second staff member to assist. The SRI identified Resident #80 to be confused and required two staff for all transfers. The investigation revealed the resident had no specific complaints of pain and had completed therapy earlier in the day. Following the one assist transfer by STNA #10, Resident #80 began complaining of pain. The nurse assessed Resident #80 and found the left knee to be edematous and painful to the touch. The physician was informed and ordered portable X-ray. The X-ray results stated "there was a 20 by 8 millimeter fracture fragment seen in the knee joint and was most likely a recent fracture." The investigation revealed the physician was again notified and ordered the resident to be evaluated at the hospital that evening. Resident #80's nephew, who was the power of attorney, was notified. Review of the X-ray of the knee obtained on 11/12/14 at the hospital, revealed there was an avulsion of the tibial tubercle 13 millimeters, with joint effusion noted. The bones appear osteoporotic. There may be possible fracture of the lateral tibial plateau below the knee joint. The SRI investigation revealed the resident probably experienced this trauma to the left knee during an inappropriate transfer the morning of the noted injury, or possibly trauma to the knee while being placed at a table for a meal when she was not in her specialty wheelchair. Review of the orthopedic physician's note dated 11/14/14 revealed the resident had a new left proximal tibial plateau (knee) fracture and was non-weight bearing. Interview with Director of Nursing (DON) on 12/02/14 at 9:00 A.M. revealed Resident #80 required two staff to assist with transfers, with this information listed in the resident's care guide. STNA #10 reported to the nurse the resident was complaining of knee pain on 11/12/14. The resident's left knee was swollen. The nurse called the physician, an X ray was ordered, and the resident was sent to the hospital. Further X ray was completed at the hospital on [DATE], which indicated a possible fracture of the knee. The DON stated it was discovered STNA #10 had transferred the resident from her wheelchair to her bed without a second staff assisting. The DON verified STNA #10 should have asked for assistance with the transfer. STNA #10 received a written warning on 11/13/14 for failing to follow the care guide and provide a two person transfer. The DON stated no further staff training was provided. The DON indicated Resident #80 returned to the facility for a few days and discharged to a different facility last week. Interview with Registered Nurse (RN) #6 on 12/02/14 at 11:10 A.M. revealed she was in the hall after lunch on 11/12/14 when Resident #80 was yelling out from her bed. RN #6 stated she went into the resident's room to see if Resident #80 needed assistance and observed the resident's left knee was slightly larger than the other knee. RN #6 stated she immediately alerted Unit Manager #5 to Resident #80's swollen knee. Interview with Unit Manager #5 on 12/02/14 at 11:15 A.M. revealed she recalled RN #6 alerting her to Resident #80's swollen left knee on 11/12/14 at 1:30 P.M. She contacted the resident's physician immediately and an X-ray was ordered. Resident #80 was sent to the hospital later that afternoon, after the X-ray results showed a possible fracture. Unit Manager #5 stated STNAs should always keep a copy of the care guides in their pockets because the DON updated the care guides frequently as needed. Interview with STNA #10 on 12/02/14 at 11:30 A.M. stated she transferred Resident #80 from her wheelchair to the bed after the resident completed therapy, but before lunch, on 11/12/14. STNA #10 stated she completed a pivot transfer with the resident standing on her tip toes. The STNA was holding the gait belt the resident was wearing around her waist, and lifted up on it during the transfer. STNA #10 stated she had completed the one person transfer with the resident many times before 11/12/14. STNA #10 verified she knew Resident #80 was a two person transfer on 11/12/14 when she did the transfer by herself. 2. Review of the clinical record for Resident #62 revealed an admission to the facility on [DATE]. [DIAGNOSES REDACTED]. The resident was receiving hospice care since 11/24/14. The resident was assessed at admission on 09/19/14 to be at high risk for falls and a pad alarm was placed on the bed and chair due to decreased safety awareness. Review of an Incident/Accident Report dated 09/21/14 at 11:30 P.M. revealed Resident #62 was alone in the activities room when she fell to the floor from her wheelchair with the alarm sounding. As a result of this fall the resident fractured her left hip. After this fall staff were to place the resident at the nurses station when she was awake and restless. Review of fall risk assessments dated 09/26/14 and 11/17/14 identified the resident to be at high risk for falls. Review of the 10/03/14 plan of care included a low bed with a mat on the floor, to observe the resident frequently, and place her in a supervised area when she was out of bed. Review of the Minimum Data Set assessment dated [DATE], revealed the resident had both short and long term memory impairment with moderately impaired decision making skills. The resident was totally dependent on the staff for locomotion and was frequently incontinent. Review of an incident/accident report dated 11/17/14 at 1:40 P.M. revealed the resident was sitting in her wheelchair, in her bedroom without supervision and fell out of her wheelchair to the floor on her right side. The resident was stating "I want to go back to bed" at the time of the fall. The report indicated the alarm pad was not turned on at the time of the fall, and the alarm cord was identified to have a loose connection. Review of the radiology reported from the hospital dated 11/17/14 for this resident revealed she had a minimally displaced fractures of the right and left sacral ala as a result of this fall. There was a non-displaced fracture of the posterior proximal shaft of the left femur. The plan of care was updated after this fall to include replacing the malfunctioning alarm, staff were to offer to assist the resident back to bed after lunch, staff to use a sliding board for the resident transfers in and out of bed, and to provide pain management. There was documentation the staff was educated regarding the new interventions. Interview with the DON and Administrator on 12/03/14 at 3:45 A.M. verified the care plan was not followed when the resident fell on [DATE] and fractured her pelvis due to the resident sitting in her wheelchair, unsupervised in her room. The DON verified there was no documentation of staff checking the safety of resident while she was unsupervised. Observation of Resident #62 on 12/03/14 at 8:10 A.M. revealed she was in a low bed with a mat on the floor and pad alarm on the bed which was "on" and no concerns were noted during the investigation. Interview on 12/03/14 at 12:00 P.M. with Resident #62's daughter revealed she visited daily, but did not know if staff checked on her mother frequently enough. She stated her mother could not use the call light due to her advanced dementia. This deficiency substantiates Master Complaint Control Number OH 060 and Complaint Control Number OH 049.

Based on medical record review, observations, review of the facility's incident report, staff interviews, review of the emergency squad report, review of manufacturer's guidelines for the use of bed rails, review of the U.S. Food and Drug Administration's (FDA) bed rail entrapment guidelines, and review of facility policy regarding restraints and bed rail use, the facility failed to ensure the residents environment remained free of accident hazards for residents who utilized half bed rails and a low air loss mattress. This resulted in Immediate Jeopardy for one (Resident #1) of 14 residents reviewed who were identified by the facility as using half bed rails and a low air loss mattress. The facility census was 84 residents. On 06/26/14 at 12:00 P.M., the Administrator and Director of Nursing (DON) were notified that Immediate Jeopardy began on 06/19/14 at 12:30 A.M. when Resident #1 was found with her head entrapped in the half bed rail gasping for air. The right side of her face was swollen and her entire face was becoming cyanotic (blue in color). Licensed Practical Nurse (LPN) #2, with the assistance of State tested Nursing Assistant (STNA) #7, removed Resident #1's head from the bed rail and assisted the resident to the floor. A faint rapid pulse was observed, the resident's eyes were fixed and staring forward. Resident #1's pulse oxygen level was very low at 49%. The resident had an indentation of the bed rail from the back of her right ear to the middle of her throat. Emergency medical services (911) was called and the resident was transferred to the local hospital's emergency department. The Immediate Jeopardy was removed on 06/20/14 after the facility implemented the following corrective actions: ? On 06/19/14, Resident #1 was sent to the hospital for evaluation and returned to the facility on [DATE] at 7:54 A.M. The half bed rails were removed and replaced with grab bars on both sides of the bed. The mattress was replaced with a parameter mattress until a new air mattress was delivered on 06/19/20 at 9:00 P.M. A tab alarm was also added to the resident's bed. ? On 06/19/14 the facility checked all 14 beds with air loss mattresses and bed rails, ensuring proper fit of the mattresses. ? On 06/19/14 the facility assessed the continued need for bed rails used on all 14 beds with air loss mattresses. ? On 06/19/14, the administrator and DON began inservicing nurses and STNAs on all shifts regarding walking rounds every two hours and visually checking the residents. By 06/27/14, all 21 nurses and all 46 STNAs were inserviced by the administrator and DON regarding walking rounds every two hours and visually checking the residents, as well as the prevention of bed rail entrapment. Nurses were to be informed by the STNAs if a resident did not use/need their bed rail so a determination could be made as to the continued need for the bed rail. ? On 06/19/14, a facility Action Plan was implemented which indicated all air mattresses were assessed for safety and slippery type cover surfaces. Six mattresses that had slippery surfaces were replaced on 06/19/14. ? On 06/19/14 and 06/20/14, the facility began auditing bed rail placement for all 36 residents that utilized bed rails and/or grab bars on their beds, including the 14 beds using air mattresses, ensuring no gaps existed between the beds and the bed rails/grab bars. One resident had bed rails removed and Resident #1 had the bed rails replaced with grab bars. Effective 07/01/14, the auditing for all residents with side rails and grab bars will continue weekly as part of the facility standards of care weekly meeting. ? On 06/26/14 at 11:40 A.M. and 06/27/14 at 1:00 P.M., Resident #1 was observed in a low bed with grab bars, with a pressure reducing mattress and bolsters at the head and foot of bed. A pillow to the outside of her bed and mat by her bed were also in place. ? On 06/26/14 interviews with Registered Nurse (RN) #1, LPN #2 , LPN #3, STNA #4, STNA #5, and STNA #6 revealed knowledge of safe bed rail and mattress placement. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm but potential for more than minimal harm that is not immediate jeopardy), as the facility is in the process of implementing a new addendum to their physical restraint policy, effective 06/29/14 and 07/01/14, regarding hazards that may occur with bed rail usage in order to prevent falls and entrapment as well as completing the weekly audits. Findings include: Record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Minimum Data Set (MDS) assessments, dated 03/05/14 and 06/25/14, revealed significant changes and the resident was placed with Hospice on 06/25/14 due to significant weight loss and a decline in health status. Resident #1 was assessed as a high risk for falls upon admission to the facility on [DATE] due to impaired cognition, decline in health, dependence with activities of daily living, use of psychotropic medication and a history of falls. On the 11/19/13 and subsequent quarterly assessments, dated 02/14/14 and 03/26/14, she was assessed to benefit from the use of bilateral upper half bed rails to enable increased independence in bed mobility and positioning for comfort with staff assistance. The nursing care plan for fall risk, effective 11/29/13, included interventions of half bed rails on both sides of the bed; the bed in the lowest position with brakes locked; and grippy socks at all times. A pad alarm to her bed was added on 12/24/13. An incident report completed by LPN #2 on 06/19/14 revealed Resident #1 was found by STNA #7 around 12:30 A.M. on the floor with her head trapped inside the bed rail. The resident's body was slumped forward with her legs bent to the right. The statement written by STNA #7 revealed she heard moaning coming from Resident #1's room and she checked on the resident about 12:30 A.M. The resident was on the floor with her neck in the side rail. The bed was in the lowest position. Her body weight was still on the alarm. STNA #7 called for help and LPN #2 came in and disengaged her from the bed rail, and they lowered her to the floor. LPN #2 noted that the resident's head was trapped in the bed rail causing the right side of her face to swell, the entire face to become cyanotic and she was gasping for air. The nurse removed Resident #1's head from the bed rail and assisted STNA #7 in positioning Resident #1 on the floor. A faint rapid pulse was observed with the resident's eyes fixed and staring forward. Oxygen was applied as Resident #1's pulse oxygen level registered very low at 49 percent (%). The resident presented with an indentation of the bed rail from the back of her right ear to the middle of her throat. She became responsive as her oxygen level increased. Emergency medical services (EMS) was called and her oxygen level had risen to 99% upon the emergency medical squad's arrival. The resident was evaluated and treated at the emergency department and returned to the facility hours later in no apparent distress. According to the EMS report dated 06/19/14, they arrived at the facility at 1:14 A.M. in response to a call that Resident #1 was found on the floor. There were no specific details provided with the EMS report to describe the resident's condition at the time of their arrival to the facility on [DATE]. During a telephone interview with LPN #2 06/25/14 at 2:38 P.M., she revealed that STNA #7 called her to Resident #1's room on 06/19/14 at 12:30 A.M. Upon entering the room, the resident was found with her head caught in the bed rail. She assisted STNA #7 in removing her head from the bed rail. The resident ' s face was swollen on the right side and her face was cyanotic. She was gasping for air with her eyes fixed and staring. Her oxygen saturation level was 49% and oxygen was applied. She called for further assistance and 911 was also called. The resident became responsive as her oxygen level increased to 99% upon the emergency medical squad's arrival. The resident was transported to the hospital and returned to the facility hours later. Interview with STNA #7 by phone on 07/01/14 at 12:00 P.M. revealed she heard Resident #1 moaning and she entered the room finding the resident positioned with her body still on the pressure alarm, her legs were on the floor, but her head was below the half bed rail and her neck was caught between the bed and the bed rail. The resident was gasping for air, and she said if she didn't go in the room to check on her the resident could have choked. She called for the nurse who came into the room immediately to help her lower the resident to the floor and remove her neck from the bed rail. She added that the resident was not able to position herself in bed without the assistance of a STNA. Resident #1 returned to the facility after evaluation at the hospital on [DATE] at 7:54 A.M. The half bed rails were removed from the resident's bed and replaced with grab bars on both sides of the bed. The air mattress was replaced with a parameter mattress until a new air mattress was delivered on 06/19/20 at 9:00 P.M. The pressure alarm was discontinued, and a tab alarm was added to the resident's bed. After the resident's return from the hospital on [DATE], she continued to be assessed as a high risk for falls. Care plan interventions implemented after the resident returned from the hospital on [DATE] included removing the bed rails and adding grab/mobility bars for mobility; a parameter mattress; a mat and pillow beside her bed; and a tab alarm, which replaced the pad alarm that was discontinued. These interventions were observed in place on 06/25/14 at 10:00 A.M., 06/26/14 at 11:40 A.M., 06/27/14 at 1:30 P.M., 06/30/14 at 6:00 P.M., and 07/01/14 at 12:30 P.M. On 06/26/14 at 11:40 A.M. and 06/27/14 at 1:00 P.M., Resident #1 was observed in a low bed with bilateral grab bars, and a pressure reducing mattress with bilateral bolsters at head and foot of bed. A tab alarm was observed in use on the bed, which was ordered on [DATE] (the pressure alarm was discontinued on 06/20/14). A pillow to the outside of her bed and mat on the floor by her bed ordered by the physician on 06/20/14 were also observed on these dates. On 06/19/14, the facility's administrator and DON began inservicing all nurses and STNAs regarding walking rounds every two hours and visually checking the residents, and prevention of bed rail entrapment. All nurses and STNAs were inserviced by 06/27/14. The STNAs were to inform the nurses if a resident did not use/need their bed rail so a determination could be made as to the continued need for the bed rail. Interviews with staff including LPN #2 on 06/25/14 at 2:38 P.M.; Registered Nurse (RN) #1 on 06/26/14 at 11:40 A.M.; STNA #4 on 06/26/14 at 11:45 A.M.; STNA #5 on 06/26/14 at 3:00 P.M.; STNA #6 on 06/26/14 at 5:00 P.M.; and LPN #3 on 06/27/14 at 2:00 P.M. revealed knowledge of safe bed rail and mattress placement . On 06/19/14 and 06/20/14, the facility began auditing bed rail placement for all 34 residents who had bed rails on their beds, two residents with grab bars, and one resident who had a grab bar and a bed rail in use. This included the 14 residents who had air loss mattresses on their beds. The audit was to ensure there were no gaps between the bed rails or grab bars and the mattresses. One resident had bed rails removed and Resident #1 had the bed rails removed and replaced with grab bars. Review of weekly audit reports made by the administrator/designee revealed audit dates of 06/19/14, 06/20/14, 06/23/14, 06/24/14, 06/25/14, 06/26/14, and 06/27/14 involving residents with bed rail usage and air loss mattresses, for 14 residents. No negative findings were documented on the audit reports. During an interview with the DON on 06/26/14, he revealed that no negative findings related to bed rail use have been reported since the 06/19/14 incident. During an interview with the DON on 06/27/14 at 4:00 P.M., he revealed the facility had developed and implemented an action plan. This plan included inservicing of all nurses and STNAs regarding bed rail and mattress safety, which facility documented began on 06/19/14 until 06/17/14. Auditing of the residents' bed rails and mattresses was also included in the action plan. Documentation was presented of the auditing of bed rails and mattresses completed on 06/19/14, 06/20/14, 06/23/14, 06/24/14, 06/25/14, 06/26/14, and 06/27/14. There were no negative findings discovered during these audits. Review of the facility policy "Physical Restraint Overview", dated June 2008, revealed this policy did not specifically address bed rail use, and assessment of use for safety purposes to prevent entrapment. This was confirmed through interview with the administrator on 06/30/14 at 1:15 P.M. The administrator provided additional information, which was two pages from a book that she said the facility uses as their policy. Review of this information revealed no specific policy or procedure that addresses the assessment of bed side rail use for safety purposes to prevent entrapment. This information included the need to review the manufacturer's guidelines for the use of bed rails, with precautions given to use a properly sized mattress in order to minimize the gap between the side of the mattress and the bed rail. The precaution stated, "This gap must be small enough to prevent a resident from getting his/her head or neck caught in this location." The manufacturer's guidelines also referenced bed system entrapment information provided by the U.S. Food and Drug Administration (FDA) to reduce the risk of entrapment, which considered dimensional limits for critical gaps and spaces between bed system components. On 06/30/14 at 6:00 P.M., the DON provided an addendum to the facility "Physical Restraint Overview" policy, which addressed "Side Rail Usage." This addendum included the risk of falls and entrapment with the use of bed rails, and the assessment of the resident for bed rail usage and safety. Items identified in the addendum included evaluating the distance between the slats of the bed rails, the space between the bed rail and the mattress, and the space between the mattress and the headboard/footboard. On 07/01/14 at 9:50 A.M., the DON provided a second addendum (effective 07/01/14) to this policy which added that during the team standards of care weekly meeting, bed rails will be reviewed and discussed for safety, continued necessity, and meeting safety standards with the facility weekly audit. Interview with the DON on 07/01/14 at 12:50 P.M. revealed the facility had implemented the audits on 06/19/14 and is following through with implementation of the policy addendums. According to the FDA guidelines for bed rail entrapment prevention between the bed rail and the mattress (the space between the inside surface of the rail and the mattress compressed by the weight of a patient's head), the space should be small enough to prevent head entrapment when taking into account the mattress compressibility, any lateral shift of the mattress or rail, and degree of play from loosened rails. A dimension of less than 4 ? inches was recommended because the head is presumed to enter the space before the neck. FDA recommended a dimensional limit of less than 120 millimeters (4 ? inches for the area between the inside surface of the bed rail and the compressed mattress. This deficiency substantiates Complaint Control Number OH 261.

Based on surveyor observation, medical record review, staff interview, and facility policy review, it was determined the facility failed to maintain the weight status of a resident on enteral feedings. This affected one (#27) of two sampled residents of four in the facility who receive enteral feedings. Actual harm occurred when Resident #27, who is totally dependent on enteral feeding to meet her nutritional needs, experienced a 14% severe weight loss over a six month period of time. Findings include: Review of the medical record of Resident #27 revealed she was originally admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment completed on 04/06/10 revealed Resident #27 had short and long term memory loss and severely impaired decision making abilities. She was documented to have had a deterioration in her communication abilities within a three month period prior to her admission to the facility. She was noted to require extensive assist of one staff for bed mobility, was totally dependent on two staff for transfers and bathing, and totally dependent upon one staff for dressing, eating and hygiene needs. Her documented height on admission was 62 inches and weight was 142 pounds. The MDS indicated she had had no significant weight gains or losses in the previous 180 days. The document also noted at item K5b that she had a feeding tube in place and at item Ka her caloric intake for the previous seven days was provided by the feeding tube. Review of the most recent quarterly MDS completed on 08/28/10 revealed no changes in her cognitive status, communication abilities or activities of daily living support except she now required extensive assistance of two staff for bed mobility. She continued to be dependent upon staff for eating. Section K2 indicated her weight was 136 pounds and section K3 documented no significant weight loss or gain in the previous 180 days and she still received her calories and fluid intake by means of the feeding tube. Review of the plan of care for Resident #27 revealed she was identified at nutrition and hydration risk related to her [DIAGNOSES REDACTED]. The goal was that Resident #27 would tolerate the feeding tube with no signs or symptoms of nausea, vomiting, diarrhea, abdominal pain or distention; would maintain her weight at greater than 140 pounds without any significant weight change and would have no evidence of skin breakdown. Interventions included administering the tube feeding and flushes as ordered, monitoring her weight and notifying the physician of any significant changes, elevate the head of the bed at least 30 degrees and monitor laboratory values. Review of the medical record revealed Resident #27 had a hospital stay from 06/16/10 to 06/21/10 for treatment of [REDACTED]. Review of physician orders on admission indicated the resident received [MEDICATION NAME] 1.5 at 100 milliliters (ml) per hour between the hours of 7:00 P.M. and 7:00 A.M. with a 240 ml additional ([MEDICATION NAME]) feeding at lunch. On 04/06/10 the order was changed to [MEDICATION NAME] 1.5 at 100 ml per hour from 7:00 P.M. to 7:00 A.M. as recommended by the registered dietetic technician (DTR). On 04/29/10 the order was changed to [MEDICATION NAME] 1.5 at 75 ml per hour to be administered over 16 hours due to Resident #27 experiencing difficulty tolerating the previous tube feeding rate. On 06/10/10 an order was received to change the formula to [MEDICATION NAME] 1.2 and to increase the administration to 20 hours of infusion time. On 06/17/10 the order was again changed due to tolerance issues to administer [MEDICATION NAME] 1.2 at 60 ml per hour continuously 24 hours per day. Upon return from the hospital on [DATE], Resident #27 was ordered to receive [MEDICATION NAME] 1.2 at 50 ml per hour. On her visit of 08/26/10 the DTR recommended and the physician ordered, an increase in the infusion rate to 55 ml per hour, which was still less than the 60 ml per hour she was receiving prior to her hospitalization . The current physician order, last signed by the physician on the monthly orders 10/02/10, remains as [MEDICATION NAME] 1.2 at 55 ml per hour continuously. Review of the nurses notes revealed the resident demonstrated behaviors where she would become restless and agitated, pull at her feeding tube, and successfully tip the pole with the feeding pump over, as well as scoot down in the bed causing aspiration concerns. Nurses notes revealed the tube feeding was stopped for an indefinite time period at 8:00 P.M. on 06/24/10; for an unspecified period beginning at 11:00 P.M. on 07/04/10; from 1:23 A.M. to 5:00 A.M. on 07/09/10; from 8:00 P.M. to 9:00 P.M. on 07/15/10 and then turned off again at 10:00 P.M. for an unspecified time; for an unspecified period of time beginning at 8:00 P.M. on 07/17/10; from 6:00 P.M. on 07/18/10 for an unspecified time period with behaviors charted at 8:00 P.M.; for an unspecified amount of time on 07/24/10 beginning at 2:48 A.M.; for an unspecified period of time beginning at 2:50 A.M. on 07/29/10; for an unspecified length of time beginning at 6:30 P.M. (nurses note at 2:45 A.M. states tube feeding now back on); and for an unspecified length of time on 07/30/10. Nurses notes of 08/01/10 at 6:29 A.M. noted the "Resident squirmed all through the night. Attached tube feed x 2 and resident pulled tube machine over x 1." Nurses notes entry of 08/08/10 at 5:26 A.M. stated, "Turned tube feed off for awhile..." and the entry at 7:00 P.M. on 08/11/10 stated tube feed was stopped and stated would "continue when resident resting." The entry at 10:00 P.M. stated the tube feeding was then running. On 08/12/10 the feeding was stopped for an indefinite period beginning at 7:30 P.M.; on 08/15/10 it was noted the tube feed was currently off, but the entry at 10:45 P.M. noted that it was again on and running. On 08/16/10 at 10:00 P.M. it was noted the tube feeding was off for an indefinite period. The entry at 10:00 P.M. on 08/18/10 noted the tube feeding was off and the entry at 6:00 A.M. the following morning noted the tube feeding remained off due to increased agitation. Nurses notes of 09/11/10 at 8:00 P.M. noted the tube feeding was being held due to risk of aspiration but failed to identify for how long of a period and nurses notes of 10/15/10 at 8:00 P.M. noted the tube feeding was being held "until medication takes effect" but did not state how long the feeding was held. All entries lacked documented evidence of any notification of the physician regarding the decision to hold the feedings. Surveyor observation of Resident #27 on 10/19/10 at 1:30 P.M. noted the resident to be laying in bed with [MEDICATION NAME] 1.2 running via pump at 55 ml per hour. Observations at 2:40 P.M., 4:15 P.M., 5:30 P.M. and 6:30 P.M. revealed the tube feeding to be/remain off. This finding was verified with another surveyor. Review of the nurses notes and behavior grids lacked documentation of any reason for the tube feeding being held or of notification to the physician. During an interview with Licensed Practical Nurse (LPN) #13 at 10:30 A.M. on 10/21/10, she stated that if nothing works to calm her (Resident #27) "then we disconnect it - usually no more than an hour or two. There for a while it was daily, now not so much." She verified she had at times disconnected the feeding and was unaware of any significant weight loss. Interview with Registered Nurse (RN) #23 revealed she too had disconnected the tube feeding "for a short time" due to the resident's behaviors. Interview with LPN #17 at 11:00 A.M. on 10/21/10 revealed she did not work that hall but had heard the nurses on that hall discuss the tube feeding being held due to the resident's behaviors. Review of the facility weight records for Resident #27 revealed a recorded initial admission weight of 141.8 pounds. Her June 2010 weight was recorded as 140 pounds, July 2010 as 137 pounds, August as 136 pounds, September as 130 pounds and the most recent weekly weights documented for 10/14/10 and 10/19/10 as 127 pounds and 122 pounds respectively. Interview with the daughter of Resident #27 at 2:30 P.M. on 10/21/10 revealed that prior to her mother's change in condition which occurred approximately one year ago, her usual body weight was around 150 pounds. She stated since the onset of her illness, her weight had averaged between 140 and 142 pounds. The admission nutritional assessment completed by the DTR on 04/06/10 noted Resident #27's current weight measured 142 pounds. There was no documentation of the Resident's usual body weight (UBW) or a calculation of her ideal body weight (IBW) range or current body mass index (BMI) on the assessment form. When assessed by the DTR, the recommendation was made to discontinue the [MEDICATION NAME] feeding at lunch due to her determination that the nocturnal feeding would meet her nutritional requirements. She also recommended the supplemental protein powder additive be discontinued, although her note stated her review of the record indicated the resident had a past history of skin issues and documented the resident currently had a reddened area on her bottom. Available laboratory testing results did not include an assessment of [MEDICATION NAME] or total protein stores for her to review prior to her discontinuing the protein supplement. Review of the laboratory values of 09/03/10, however, noted Resident #27's total protein to be low at 6.1 g/dL (normal 6.4 g/dL to 8.3 g/dL). An interview was conducted with the registered and licensed dietitian (RD/LD) and the registered dietetic technician (DTR) on 10/21/10 between 9:20 A.M. and 10:20 A.M. The RD/LD and DTR stated all residents on tube feedings are considered at risk and are reviewed monthly. Both agreed when reasonable the goal is to try to keep the resident at their usual body weight, describing any extra weight as "insurance" in case of illness. During the interview the DTR calculated that Resident #27 remained on a regimen that supplied 1800 calories until her return from the hospital in June 2010. At that time her intake was reduced to 1728 calories. Upon Resident #27's return from the hospital on [DATE], her change in feeding orders resulted in a decrease in caloric intake to 1440 calories/24 hours. After dietary review on 08/26/10, it was determined that at a rate of 50 ml/hr, Resident #27 was experiencing a caloric deficit. The increase in the rate resulted in a daily intake of 1584 calories which the DTR determined was in an acceptable range. Documentation in the dietary progress note of 08/26/10 revealed, "although weight (currently) greater than her ideal body weight range, concern that slight kilocalorie deficit may result in slow weight loss." According to review of the dietary progress notes of 07/22/10, Resident #27 had already experienced a slight weight loss of 6.8 pounds since admission "now stabilized at 135 pounds, below her goal, but as feeding is providing greater than 100% of her needs with weight stabilized, current weight is acceptable." An "Update" nutritional note of 10/14/10 noted Resident #27 remains dependent upon tube feeding to meet her needs. It was also documented in this note the resident now triggers for significant weight loss for 3 and 6 months, and determined that since her weight had stabilized at 127 pounds (the next weekly weight on 10/19/10, however, noting an additional 5 pound loss to 122), that "weight in the 120's will be acceptable." When specifically questioned, they verified the entries on the nutritional assessments and dietary progress notes, but could not explain why a weight in the 120's was acceptable when the previously stated goal was to maintain Resident #27 at her usual body weight. The RD/LD and DTR stated they look at skin records, weights, intake records, feeding abilities, medications, laboratory values and medications, and they talk with staff regarding any other issues such as depression or pain when gathering information to complete the nutritional assessments. When specifically asked if they review the nurses notes, the dietitian replied, "Oh yes, usually that's the first thing I look at before taking the chart." When nurses notes entries regarding the holding of the tube feedings were brought to their attention, both admitted they were unaware of the entries. Review of the facility policy entitled, "Tube Feeding", dated as revised 01/08 revealed at bullet four: "Problems with the administration of the tube feeding are monitored and corrected by nursing:" and at bullet five: "...The dietitian's responsibilities include evaluation of ....and other problems to ensure adequate nutrition."