Every finding on record at Life Care Center of Burlington

The facility had a census of 74 residents. Based on observation, interview, and record review the facility failed to provide the services of a full-time certified dietary manager for 73 residents who resided in the facility and received their meals from the kitchen. This placed the residents at risk for inadequate nutrition. Findings included: - On 12/09/24 at 08:25 AM, observation in the facility's kitchen revealed staff preparing and serving breakfast. Dietary Staff (DS) BB assisted with serving the meals. On 12/09/24 at 08:30 AM, DS BB verified she was the Dietary Manager and stated she had not completed a state-approved dietary manager certification course or test. Upon request, the facility did not provide a policy regarding the Certified Dietary Manager. The facility failed to employ a full-time certified dietary manager to evaluate residents' nutritional concerns and oversee the ordering, preparing, and storage of food for 73 residents in the facility. This placed the residents at risk for inadequate nutrition.

The facility had a census of 74 residents. The sample included 18 residents. Based on observation, record review, and interviews the facility failed to ensure a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when staff failed to provide sanitary catheter (a tube inserted into the bladder to drain urine) care and failed to implement Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) for Resident (R)40. The facility failed to implement an adequate water management program to prevent and /or mitigate risks from waterborne pathogens. This placed the residents at risk of contracting an infection or communicable diseases. Findings included: - A review of the facility's TELS system (a web-based platform that helps with building operations, including maintenance, service requests, and asset management) dated 03/08/24 revealed staff were instructed to conduct required monthly Legionella (a serious type of lung infection caused by inhaling water droplets or mist contaminated with Legionella bacteria) meetings and upload documentation. The sheet lacked documentation of the test for Legionella or that water was flushed throughout the facility. The second sheet had a picture of an unlabeled device. A review of the hot water temperature checks logbook sheets on 11/07/24, 12/22/24 12/29/24, and 12/05/24 revealed documentation regarding hot water temperatures in random rooms but lacked documentation regarding whether a flush was conducted. On 12/10/24 at 09:45 AM, observation revealed Certified Nurse Aide (CNA) N and Licensed Nurse (LN) G placed gloves on but not gowns. CNA N unfastened R40's incontinence brief from the sides pulled it down in between the resident's legs, and provided perineal (private area) care to R40's front perineal area. Further observation revealed LN G assisted R40 to turn on his left side. CNA N tucked the incontinence brief underneath R40's buttocks, then removed and discarded her gloves, used hand sanitizer, applied new gloves, applied barrier cream to the resident's back perineal area, removed and discarded her gloves, and applied new gloves. Further observation revealed CNA N assisted the resident in turning on his right side. LN G removed the incontinence brief and discarded it in the trash, then LN G removed and discarded her gloves and applied new gloves while CNA N fastened the resident's brief. Both staff placed the uncovered catheter bag into the resident's left leg of his gray jogging pants and then placed the right leg into the gray pants. Both staff assisted the resident in turning from side to side to pull up his gray pants. Continued observation revealed LN G placed the uncovered catheter bag on the left side of the bed with the bag touching the floor. CNA N raised the bed which brought the uncovered catheter bag off the floor. Both staff removed and discarded their gloves. CNA N washed her hands, while LN G tied up the trash bag and took it to the dirty utility room where she washed her hands. On 12/10/24 at 09:55 AM, CNA N, and LN G both stated that staff were supposed to use EBP and verified they should have donned a gown before providing catheter care for R40. On 12/10/24 at 01:30 PM, Maintenance Staff (MS) V and Administrative Staff A stated the TELS system in the computer popped up monthly when the maintenance needed to conduct a Legionella test. MS V stated he checked the hot water temperature weekly in 15-20 rooms and conducted a water flush in the toilet of each room. MS V verified he had not documented the flushes. Administrative Staff A stated the facility had no designated Water Management Plan. Administrative Staff A stated if the community would have an outbreak of Legionella in their water system, they would test the facility water or whenever it indicated for maintenance check on the facility TELS system in the computer. On 12/11/24 at 11:19 AM, Administrative Nurse E stated he expected staff to follow the EBP precautions for R40. Administrative Nurse E stated the door had an EBP sign for staff to follow and supplies were on the back of R40's room door. On 12/12/24 at 12:28 PM, Administrative Nurse D stated he expected staff to have proper personal protective equipment (PPE) on when a resident is on EBP, and staff should not let a resident's uncovered catheter bag touch the floor. The facility's Legionella and Legionnaires' Disease Policy, revised 06/04/24, documented the facility would identify cases of Legionnaires disease promptly to determine if the case may be associated with the facility and would report Legionnaires' disease cases to local public health authorities quickly to investigate and prevent additional infections. The facility's EBP policy, revised 06/03/24, documented EBP as indicated for residents with any of the following: 1) infection or colonization with a Centers for Disease Control (CDC) targeted Multidrug-Resistant Organisms (MDRO-bacteria that resist treatment with more than one antibiotic) when contact precautions do not otherwise apply. 2) Wounds and or indwelling medical devices if the resident is not known to be infected or colonized MDRO. 3) Indwelling medical devices including urinary catheters, feeding tubes, and tracheostomies (opening through the neck into the trachea through which an indwelling tube may be inserted). The facility failed to implement a water management program to prevent and/or mitigate risk from waterborne pathogens. The facility further failed to provide sanitary catheter care and implement EBP. This placed the residents at increased risk of contracting infectious diseases.

The facility had a census of 74 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to ensure all residents remained free from abuse when Resident (R)17 stomped on R8's foot after R8, who was cognitively impaired, went into R17's room. This placed the residents at risk for injury and ongoing abuse. Findings included: - The Electronic Medical Record (EMR) for R17 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), hypertension (high blood pressure), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R17 had intact cognition and was dependent upon staff for toileting, lower body dressing, and transfers. R17 required substantial assistance for bathing, and mobility, and did not ambulate. R17 received antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) and antidepressant (a class of medications used to treat mood disorders) medication. R17's Care Plan, dated 11/21/24 and initiated on 08/11/22, documented R17 had a history of behaviors and directed staff to intervene as necessary to protect the rights and safety of others, approach and speak calmly, divert attention, remove from the situation, and administer medications as needed. The care plan further directed staff to observe for behavior episodes and attempt to determine the underlying causes. The update, dated 04/20/24, documented R17 had the potential to be physically aggressive related to anger, dementia, a history of harm to others, and poor impulse control. The care plan directed staff to de-escalate her behaviors by talking, listening, and directing her to a quieter area. R17's Nurse's Note, dated 08/13/24 at 04:41 AM, documented that R17 went to the nurse's desk and told her that she stomped on another resident's foot several times when they entered her room. The note further documented that staff educated R17 not to do that. A review of R8's EMR revealed a Nurse's Note, dated 08/13/24 at 04:43 AM that documented R8 had her foot stomped on by another resident. Staff assessed R8 who had no complaints of pain or any other discomfort. On 12/10/24 at 08:21 AM, observation revealed R17 sat at the dining table and joked about staff apparel. On 12/10/24 at 03:30 PM, Consultant GG stated she did not have an incident report when R17 stomped on R8's foot, but she would start an investigation and report the incident to the State Agency. On 12/11/24 at 11:06 AM, Certified Nurse Aide (CNA) M stated R17 had behaviors and liked to pick on the other residents to get them upset. CNA M stated she was unaware of any resident-to-resident altercations but said she would notify the nurse if she ever saw any. On 12/11/24 at 11:19 AM, Administrative Nurse E stated that staff were to notify the charge nurse of any resident-to-resident altercations, and an investigation would be started. Administrative Nurse E further stated staff will make sure the two residents are separated and kept safe. On 12/11/24 at 12:30 PM, Administrative Nurse D stated the incident should have been reported so an investigation could be completed, and interventions put into place. The facility's Abuse - Identification of Types policy, dated 06/17/24, documented the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The risk for abuse may increase when a resident exhibits behavior that may provoke a reaction by staff, residents, or others, such as hitting, kicking, shoving, biting, spitting, threatening gestures, throwing objects, touching or grabbing, and wandering into others rooms or spaces. The facility failed to prevent resident-to-resident abuse when R17 stomped on R8's foot several times. This placed the residents at risk for injury and ongoing abuse.

The facility had a census of 74 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to identify a resident-to-resident incident as abuse and report immediately to the administrator when Resident (R)17 stomped on R8's foot after R8, who was cognitively impaired, went into R17's room. This placed the residents at risk for unidentified and ongoing abuse. Findings included: - The Electronic Medical Record (EMR) for R17 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), hypertension (high blood pressure), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R17 had intact cognition and was dependent upon staff for toileting, lower body dressing, and transfers. R17 required substantial assistance for bathing, and mobility, and did not ambulate. R17 received antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) and antidepressant (a class of medications used to treat mood disorders) medication. R17's Care Plan, dated 11/21/24 and initiated on 08/11/22, documented R17 had a history of behaviors and directed staff to intervene as necessary to protect the rights and safety of others, approach and speak calmly, divert attention, remove from the situation, and administer medications as needed. The care plan further directed staff to observe for behavior episodes and attempt to determine the underlying causes. The update, dated 04/20/24, documented R17 had the potential to be physically aggressive related to anger, dementia, a history of harm to others, and poor impulse control. The care plan directed staff to de-escalate her behaviors by talking, listening, and directing her to a quieter area. R17's Nurse's Note, dated 08/13/24 at 04:41 AM, documented that R17 went to the nurse's desk and told her that she stomped on another resident's foot several times when they entered her room. The note further documented that staff educated R17 not to do that. A review of R8's EMR revealed a Nurse's Note, dated 08/13/24 at 04:43 AM that documented R8 had her foot stomped on by another resident. Staff assessed R8 who had no complaints of pain or any other discomfort. On 12/10/24 at 08:21 AM, observation revealed R17 sat at the dining table and joked about staff apparel. On 12/10/24 at 03:30 PM, Consultant GG stated she did not have an incident report when R17 stomped on R8's foot, but she would start an investigation and report the incident to the State Agency. On 12/11/24 at 11:06 AM, Certified Nurse Aide (CNA) M stated R17 had behaviors and liked to pick on the other residents to get them upset. CNA M stated she was unaware of any resident-to-resident altercations but said she would notify the nurse if she ever saw any. On 12/11/24 at 11:19 AM, Administrative Nurse E stated that staff were to notify the charge nurse of any resident-to-resident altercations, and an investigation would be started. Administrative Nurse E further stated staff will make sure the two residents are separated and kept safe. On 12/11/24 at 12:30 PM, Administrative Nurse D stated the incident should have been reported so an investigation could be completed, and interventions put into place. The facility's Abuse - Conducting an Investigation policy, dated 06/17/24, documented when an incident or suspected incident of resident abuse, and/or neglect, injury of unknown source, exploitation, or misappropriation of resident property, staff would respond immediately to protect the alleged victim, and report to administration or designee for an investigation to occur. The facility failed to identify a resident-to-resident incident as abuse and report immediately to the administrator when R17 stomped on R8's foot after R8 went into R17's room. This placed the residents at risk for unidentified and ongoing abuse.

The facility had a census of 74 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to provide protective measures and investigate an incident of resident-to-resident abuse by Resident (R)17, who stomped on R8's foot after R8, who was cognitively impaired, went into R17's room. This placed the residents at risk for unidentified and ongoing abuse. Findings included: - The Electronic Medical Record (EMR) for R17 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), hypertension (high blood pressure), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R17 had intact cognition and was dependent upon staff for toileting, lower body dressing, and transfers. R17 required substantial assistance for bathing, and mobility, and did not ambulate. R17 received antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) and antidepressant (a class of medications used to treat mood disorders) medication. R17's Care Plan, dated 11/21/24 and initiated on 08/11/22, documented R17 had a history of behaviors and directed staff to intervene as necessary to protect the rights and safety of others, approach and speak calmly, divert attention, remove from the situation, and administer medications as needed. The care plan further directed staff to observe for behavior episodes and attempt to determine the underlying causes. The update, dated 04/20/24, documented R17 had the potential to be physically aggressive related to anger, dementia, a history of harm to others, and poor impulse control. The care plan directed staff to de-escalate her behaviors by talking, listening, and directing her to a quieter area. R17's Nurse's Note, dated 08/13/24 at 04:41 AM, documented that R17 went to the nurse's desk and told her that she stomped on another resident's foot several times when they entered her room. The note further documented that staff educated R17 not to do that. A review of R8's EMR revealed a Nurse's Note, dated 08/13/24 at 04:43 AM that documented R8 had her foot stomped on by another resident. Staff assessed R8 who had no complaints of pain or any other discomfort. On 12/10/24 at 08:21 AM, observation revealed R17 sat at the dining table and joked about staff apparel. On 12/10/24 at 03:30 PM, Consultant GG stated she did not have an incident report when R17 stomped on R8's foot, but she would start an investigation and report the incident to the State Agency. On 12/11/24 at 11:06 AM, Certified Nurse Aide (CNA) M stated R17 had behaviors and liked to pick on the other residents to get them upset. CNA M stated she was unaware of any resident-to-resident altercations but said she would notify the nurse if she ever saw any. On 12/11/24 at 11:19 AM, Administrative Nurse E stated that staff were to notify the charge nurse of any resident-to-resident altercations, and an investigation would be started. Administrative Nurse E further stated staff will make sure the two residents are separated and kept safe. On 12/11/24 at 12:30 PM, Administrative Nurse D stated the incident should have been reported so an investigation could be completed, and interventions put into place. The facility's Abuse-Conducting an Investigation policy, dated 06/17/24, documented that any allegation of abuse was promptly and thoroughly investigated. The facility would prevent further abuse, neglect, exploitation, and mistreatment from occurring while the investigation was in progress and take corrective action. Residents have the right to live at ease in a safe environment without the fear of retaliation when allegations are reported. Staff would report and respond immediately to protect the alleged victim and an investigation would be conducted as appropriate. The facility failed to provide protective measures and investigate an incident of resident-to-resident abuse by R17, who stomped on R8's foot after R8 went into R17's room. This placed the residents at risk for injury and ongoing abuse.

The facility had a census of 74 residents. The sample included 18 residents with three reviewed for hospitalization . Based on observation, interview, and record review the facility failed to provide written notification for the facility-initiated transfers and further failed to notify the Office of the Long-Term Care Ombudsman (LTCO-a public official who works to resolve resident issues in nursing facilities) when Residents (R) 42, R32, and R217 discharged to a hospital. This placed the resident at risk for uninformed care decisions and impaired resident rights. Findings included: - R42's Electronic Medical Record (EMR) documented diagnoses of fracture of shaft of right fibula (a break in the middle section of the right lower outer leg bone), displaced fracture of right tibia (a broken bone in the inner part of the ankle that has moved out of place), displaced dome fracture of right talus (the top surface of the talus bone (the dome) has fractured and moved out of its normal position). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 11. The MDS documented R42 was dependent on staff assistance for most activities of daily living, including mobility, and used a wheelchair. The MDS documented R42 had shortness of breath and almost constant severe pain. R42 had a fall with fractures and orthopedic (bone) surgery since the prior MDS assessment. R42's Care Plan dated 11/21/24 documented R42 was at risk for falls and directed staff to anticipate and meet her needs, ensure her call light was within reach, and respond promptly to all requests for assistance, initiated 11/10/24. The plan directed staff to observe for, and report signs and symptoms of hip fracture complications, initiated 11/10/24. The plan documented that Physical Therapy (PT) and Occupational Therapy (OT) were to evaluate and treat per orders, initiated 11/10/24. The Progress Note, dated 10/29/24 at 12:34 AM, documented that staff assisted R42 to the bathroom when her legs gave out and she was lowered to the floor. R42 went to her knees, bent her right leg, and heard a pop. She reported severe pain and requested to go to the emergency room . The Progress Note, dated 10/29/24 at 02:39 AM, documented R42 was sent to the emergency room by ambulance at approximately 12:15 AM. The Progress Note, dated 10/29/24 at 11:54 PM, documented R42 was pale, sweaty, had a bounding pulse, and was in and out of consciousness. Staff called 911 and transferred R42 to the emergency room . R42 was admitted to a hospital ICU (Intensive Care Unit). A review of R42's clinical record lacked evidence the resident or representative was provided written notice of transfer/discharge when R42 was transferred to the hospital. The facility was unable to provide evidence of written notification of the transfers or notification to the LTCO. On 12/09/24 at 09:10 AM, observation revealed R42 lay in bed with her call light in reach. She stated she got up to go to the bathroom, fell , and sustained fractures in November. On 12/10/24 at 10:38 AM, Social Services Staff X stated the facility did not notify the LTCO when a resident was not discharged but instead was placed on medical leave with Medicaid payment for the bed hold. She verified the facility had not given the resident written notice of the discharge or transfer to the hospital and had not sent the notice to the LTCO. The facility's Notice of Transfers and Discharges policy, dated 10/29/24, stated the facility would provide written notification including the following: The reason for the transfer or discharge and the location to which the resident is transferred or discharged . A copy of the notice of transfer or discharge will be sent to a representative of the Office of the State Long-Term Care Ombudsman for all facility-initiated transfers or discharges. The facility failed to provide written notification for R42's facility-initiated transfer and further failed to notify the LTCO of the transfer, placing R42 at risk for uninformed care decisions and impaired resident rights. 32358 - R32's Electronic Medical Record (EMR) documented R32 had a diagnosis of emphysema (long-term, progressive disease of the lungs characterized by shortness of breath), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), acute (a condition characterized by a relatively sudden onset of symptoms that are usually severe) respiratory failure (a serious condition that occurs when the lungs can't get enough oxygen into the blood or remove enough carbon dioxide from the body), and bradycardia (low heart rate, less than 60 beats per minute). R32's Modified Quarterly Minimum Data Set (MDS), dated [DATE], documented R32 had a Brief Interview of Mental Status (BIMS) score of 13, which indicated intact cognition. The MDS documented the resident had COPD, respiratory failure, and heart failure. R32's Care Plan, revised 10/02/24, documented that R32 had heart failure, bradycardia, and COPD and instructed staff to encourage R32 to call for assistance if chest pain started. Staff were directed to observe R32 and report as needed (PRN) any changes in lung sounds, edema (swelling), shortness of breath, and weight change to the physician. The Progress Notes, dated 08/03/24 at 11:40 AM documented the nurse went in to assess R32's oxygen levels and R32's oxygen saturation was 69% (normal oxygen level is between 95% and 100%). The nurse changed R32's nasal cannula (a medical device that provides supplemental oxygen to a patient through two prongs that fit into the nostrils) to a face mask (a device worn over the nose and mouth to supply oxygen to a patient). R32 was sent to the hospital and admitted . The Progress Notes, dated 09/13/2024 at 04:14 PM documented R32 was very short of breath. R32 received an as-needed (PRN) Lasix (diuretic medication) at 11:30 AM and a breathing treatment at noon though neither intervention had any effect on R32's ease of breathing. The note documented R32 was sent to the hospital and admitted . A review of R32's clinical record lacked evidence the resident or representative was provided written notice of transfer/discharge when she was transferred to the hospital. The facility was unable to provide evidence of written notification of the transfers or notification to the LTCO. On 12/09/24 at 03:44 PM, observation revealed R32 sat in a wheelchair at a dining room table and participated in a bingo activity. On 12/11/24 at 09:18 AM, Social Service X verified the facility had not provided written notification of transfer to R32 or her representative or the LTCO when R32 was transferred to the hospital on the above dates. Social Services X stated she was unaware she was supposed to. On 12/12/24 at 12:28 PM, Administrative Nurse D stated he was unsure who was responsible for providing written notice to the resident or her representative about the reason for her transfer to the hospital or for notifying the ombudsman. Administrative Nurse D said he thought it was Social Service X's duty. The facility's Ombudsman Program Policy, revised 09/26/24, documented that before a facility transfers or discharges a resident the facility must notify the resident and representative of the transfer or discharge and the reason for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the LTCO office. The facility failed to provide written notice to R32 or her representative and failed to notify the LTCO regarding R32's facility-initiated transfers to the hospital. This placed the resident at risk of uninformed care choices and impaired resident rights. 32360 - The Electronic Medical Record (EMR) for R217 documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), psychosis (any major mental disorder characterized by a gross impairment in reality perception), impulse disorder (sudden, forceful, irresistible urges to do something anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). The Admission Minimum Data Set (MDS), dated [DATE], documented R217 had severely impaired cognition and required set-up assistance for eating, toileting, bathing, dressing, and personal hygiene. R217 was independent with mobility, transfers, and ambulation. R217 had inattention, disorganized thinking, delusions, and verbal behaviors one to three days of the observation period, and significantly disrupted his care and the environment. R217's Care Plan, dated 10/24/24, documented R217 was at risk for elopement, and directed staff to encourage R217 to participate in activities to divert the resident from exit-seeking behavior. Staff were directed to provide frequent monitoring and provide for safe wandering. The update, dated 11/06/24, directed staff to give the resident choices about care and activities. When the resident became agitated, staff were to intervene before the agitation escalated, guide away from the source of distress, and engage calmly in conversation. If R217's response was aggressive, staff were to calmly walk away and approach later. The plan directed to obtain a psychiatric/psychogeriatric consult as indicated, and administer medications as ordered. The Nurse's Note, dated 11/15/24 at 02:13 PM, documented R217 was admitted to an acute behavioral unit. R217's EMR lacked documentation staff notified the LTCO of the resident's discharge from the facility. On 12/11/24 at 09:17 AM, Social Service X stated she had not notified the LTCO about the hospitalization and did not know she was supposed to do so for hospitalization transfers. On 12/11/24 at 12:30 PM, Administrative Staff A stated Social Service X did send a notification to the LTCO regarding discharged residents but was fairly new and didn't know that all discharged residents were to be sent. The facility's Notice of Transfers and Discharges policy, dated 10/29/24, documented the facility would send a copy of the transfer/discharge to a representative of the LTCO for all facility-initiated transfers or discharges. The facility failed to notify the LTCO of R217's facility-initiated discharge to an acute behavioral unit. This placed the resident at risk for impaired rights.

The facility had a census of 74 residents. The sample included 18 residents, with two reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to ensure Resident (R) 47 received assistance eating her breakfast meal. This placed the resident at risk for choking, impaired nutrition, and further decline in ADL ability. Findings included: - The Electronic Medical Record (EMR) for R47 had diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), dysphagia (swallowing difficulty), and cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R47 had severely impaired cognition, and required substantial assistance with all ADLs except for eating, for which she required supervision. R47 had no weight loss or gain and received a mechanically altered diet. R47's Care Plan, dated 11/26/24, initiated on 08/01/23, directed staff to provide supervision and touching assistance at meals. The update, dated 05/31/24, directed staff to encourage the resident's socialization and interaction with tablemates during meals, observe and report any dysphagia, and provide and serve diet as ordered. The update, dated 11/26/24, directed staff to provide appropriate finger foods when available to encourage intake. On 12/10/24 at 09:05 AM, observation in the memory care unit revealed two certified nurse aides (CNAs) getting residents to the dining tables for breakfast. Administrative Nurse E talked to Licensed Nurse (LN) H while a dietary staff member and Administrative Staff A passed meal trays. Further observation revealed at 09:10 AM, R47 and R9 sat at a dining room table waiting for breakfast. At 09:14 AM, R47 was provided biscuits and gravy, eggs, and oatmeal. Further observation revealed R9, a cognitively impaired resident, began to feed R47 small bites of her meal. R9 also held up R47's cup to provide her with a drink. Continued observation revealed R9 continued to assist R47 until 09:30 AM when Administrative Staff E, who was assisting another resident at a table across the room, saw R9 assisting R47 and told LN H to tell R9 not to assist R47 with breakfast. LN H went to the table and told R9 that R47 was able to feed herself and told R9 not to assist R47. LN H did not offer assistance to R47. On 12/10/24 at 09:58 AM, observation revealed R47 had her bowl of oatmeal in her left hand and used her right hand to scoop out a handful of oatmeal and proceeded to eat it. R47 continued to do this until she had eaten the whole bowl. R47's hands were dirty with oatmeal, and she reached for her baby doll and got oatmeal all over the doll. Continued observation revealed R47 had pieces of egg and oatmeal on her lap which she picked up and ate. R47 attempted to clean the food particles on her lap but appeared unsure what to do with them so she ate them or wiped them off her pants. R47 was not wearing a clothing protector. Observation revealed at 10:07 AM, Aadministrative Nurse E walked over to R47 and wiped her hands off with her napkin. On 12/10/24 at 10:15 AM, LN H stated R47 was able to feed herself and should not receive assistance from other residents. LN H further stated if R47 was tired, staff would cue and encourage her as needed. On 12/11/24 at 11:15 AM, CNA M stated R47 was independent with meals unless she had a bad day and was over-tired, then staff would cue her. CNA M further stated that R9 was not supposed to assist another resident and that staff should have assisted R47. On 12/11/24 at 12:30 PM, Administrative Nurse D stated that residents were not to assist other residents with meals due to choking hazards. Administrative Nurse D said he had already provided education to the memory care staff on making sure staff assisted the residents as needed. The facility's Activities of Daily Living (ADLs) policy, documented that residents would receive assistance needed to complete ADLs, and any changes would be reported to the nurse. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Any resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The facility failed to ensure staff provided R47 with the necessary ADL assistance with her breakfast meal. This placed the resident at risk for choking, impaired nutrition, and further decline in ADL ability.

The facility had a census of 74 residents. The sample included 18 residents with one reviewed for hospice services. Based on observation, record review, and interview the facility failed to ensure collaboration between the hospice provider and the facility for Resident (R)45, regarding the plan of care and the services provided including visit frequency, medications, and medical equipment. This placed the resident at risk of impaired end-of-life care. Findings included: - R45's Electronic Medical Record (EMR) documented the resident had diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), and (encephalopathy (a broad term for any brain disease that alters brain function or structure). R45's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) score of 11 which indicated moderately impaired cognition. The MDS documented R45 was independent with eating, oral hygiene, toileting hygiene, and personal hygiene. R45 required The MDS documented R45 received hospice services. R45's Care Plan, revised 10/15/24, documented the resident required extensive staff assistance with toileting use and transfers and limited staff assistance with personal hygiene. The care plan documented R45 received hospice services and instructed staff to expect weight loss, adjust the provision of activities of daily living (ADLs) to compensate for the resident's changing in abilities, encourage participation to the extent the resident wishes to participate, and assess residents coping strategies and respect the resident's wishes. The care plan instructed staff to administer medications as the physician ordered and notify the physician immediately if there was breakthrough pain. The care plan instructed staff to reposition R45 for comfort as needed (PRN), work cooperatively with the hospice team to provide the resident's spiritual emotional, intellectual, physical, and social needs, and work with nursing staff to provide maximum comfort for the resident. The care plan lacked a contact number for hospice; what supplies, equipment, and medications hospice would provide; when hospice staff would be in the building, and what care they would provide. The Physician Order, dated 07/17/24 at 12:10 PM, instructed staff to admit R45 to hospice service. On 12/11/24 at 12:28 PM, Administrative Nurse D verified that R45's Care Plan lacked information regarding the phone number when hospice staff would visit the facility, and what medications and supplies they would provide. The Hospice Service Agreement, signed by the hospice on 11/19/24 and the facility executive director on 12/05/24, documented the facility shall designate a member of an interdisciplinary group who is responsible for working with hospice to coordinate care provided by the facility staff and hospice staff to any hospice patient. The facility failed to ensure collaboration between the hospice provider and the facility for R45. This placed the resident at risk of impaired end-of-life care.

The facility reported a census of 64 residents with 11 selected for review including two residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to ensure the staff transferred the two residents reviewed, Resident (R)1 and R2 in a safe manner. Both residents required a full body mechanical (Hoyer) lift for transfers, and both had a fall when the staff transferred them with assistance of one staff member when the resident's required assistance of two staff. Findings included: - The Medical Diagnosis tab in the Electronic Medical Record (EMR) for R1 included diagnoses of muscle weakness, need for assistance with personal care, morbid obesity, impulse disorder, anxiety disorder (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), and schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought). The Annual Minimum Data Set (MDS) dated [DATE] assessed R1 with a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. She required extensive assistance of two or more staff for transfers and had impairment to both sides of her lower extremities range of motion. The Falls Care Area assessment dated [DATE], revealed R1 as a risk for falls related to needing assistance with activities of daily living (ADL's) and she required two staff members and use of the Hoyer lift (total body mechanical lift used to transfer residents) for transfers. The Quarterly MDS dated [DATE] revealed R1 continued to have a BIMS score of 15, was totally dependent on two or more staff for transfers, and had no lower extremity range of motion impairment. The Care Plan dated 12/07/22 revealed R1 required extensive assistance of two staff for transfers with a Hoyer lift and using a blue sling. The staff were to remind the resident not to hold on to the Hoyer lift bars during the transfer. The Progress Notes located in the EMR dated 02/17/23 at 05:20 PM revealed an unidentified Certified Nurse's Aide (CNA) called Licensed Nurse (LN) G to R1's room. R1 was laying on her right side, on the floor. LN G did not find any injuries. During transfer with the Hoyer lift to the commode, part of the sling came off the hook causing R1 to fall to the floor. The note lacked identification of additional staff present to assist with the transfer. The Witness Statement undated by CNA M for an incident dated 02/17/23, revealed while she assisted R1 from the wheelchair to the toilet/commode using the Hoyer lift, the strap slipped off the front hook and R1 fell to the floor. CNA M then immediately notified the nurse. The statement lacked an identification of an additional staff present to assist with the transfer. The Progress Note located in the EMR dated 02/19/23 by Administrative Nurse D, revealed the interdisciplinary team met to discuss R1's incident. While in the Hoyer lift being transferred to the commode, an unidentified CNA moved the wheelchair back to place the commode under R1 and when the strap from the right side of the lift slipped off the lift hook, R1 fell to the ground. The facility educated staff to use the other bariatric lift from now on with R1. The note lacked identification of additional staff present during the transfer of R 1 with the Hoyer lift. On 09/20/23 at 01:37 PM, observed R1 in her bed with a sign above the bed on the wall identifying the color of lift sling required for the resident. Further observation of the room revealed a lift sling in the resident's recliner and a bariatric commode in place in her room. On 09/20/23 at 01:42 PM, R1 stated she required the use of a lift for transfers and had for years. R1 stated two staff members assisted her with transfers, occasionally one staff who was more experienced and in a hurry, would transfer her, however that did not happen very often. R1 stated she fell from the lift one time when being transferred to the commode after she shifted her weight, she fell to the floor. R1 stated one of the straps slipped and when she shifted her weight the strap popped off on one side, which threw her body and weight and the person involved did not have enough weight to support her. R1 stated she could not recall who the staff member was, but she knew she should not have been transferring me by herself. R1 stated the CNA fetched someone to help me off the floor. On 09/21/23 at 09:45 AM, LN G stated she was on duty when R1 fell from the lift on 02/17/23, she could not recall who the staff member was, however the staff transferred R1 by herself with the lift, and they were to have two staff members present for transfers. LN G stated the correct lift was used and thought the loop came off of one of the hooks during the process of transferring R1 to the commode and stated she had let the administrative staff know the staff member transferred R1 by herself. On 09/21/23 at 10:03 AM, Administrative Staff A stated CNA M transferred R1 with the Hoyer lift when she fell , and she expected two staff members to assist when using the Hoyer lift. The facility policy Mechanical Lift Use revised 07/22/21, revealed the facility will ensure that two associates should be present during the transfer of residents who require a mechanical lift, and at least one of the two associates must be over the age of 18. The facility failed to ensure assistance of two staff provided to R1 during transfers. This deficient practice resulted in a fall, placing R1 at risk for injury. - The Medical Diagnosis tab located in the Electronic Medical Record (EMR) for R2 included diagnoses of Parkinson's Disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), dementia (progressive mental disorder characterized by failing memory, confusion), muscle weakness, lack of coordination, and bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods). The Admission Minimum Data Set (MDS) dated [DATE] assessed R2 with a Brief Interview of Mental Status score of 10, indicating moderate cognitive impairment. R2 was totally dependent on two or more staff for transfers. The Activities of Daily Living [ADL's] Functional/Rehabilitation Care Area assessment dated [DATE] revealed R2 required extensive assistance to total dependence with transfers. The Quarterly MDS dated [DATE] assessed R2 with a BIMS score of eight indicating moderate cognitive impairment and she required extensive assistance of two or more staff for transfers. The Care Plan dated 07/14/23, revealed R2 required the Hoyer lift (total body mechanical lift used to transfer residents) and two staff assistance with transfers. The Caregiver Education form dated 08/16/23, revealed R2 could not transfer with the sit to stand lift (mechanical lift that assists a resident to move from sitting to standing position) with her feet placed to the back of the foot plate and to encourage her to pull up to stand with the lift. The staff were to contact the Rehabilitation Department with any further questions or concerns. The Progress Notes dated 08/17/23 at 02:55 AM by Licensed Nurse (LN) H revealed the staff used the sit to stand lift this shift to attempt to transfer R2 and she was not able to hold her own weight causing her legs to give out. R2 was hanging on with both hands to the lift, the sling continued to be under her arms, and her feet in front of her on the foot plate of the lift. R2 had to be lowered to the floor by a nurse and a staff. The untitled facility form, that included the nursing staff assignments dated 08/16/23 revealed LN H, CNA N, and CNA O assigned to the hall R2 resided on for the 06:00 PM to 06:00 AM shift. The Witness Statement undated for incident on 08/16/23 by Certified Nurse Aide (CNA) N, revealed a report documented CNA N was told by an unidentified nurse that R2 required a sit to stand lift for transfers. CNA N went to put the resident to bed and as she hooked her up on the lift, her legs gave out, and she started to slide to the floor. CNA N called for an unidentified nurse and they lowered R2 to the floor. Another unidentified CNA and CNA N used the Hoyer lift to lift R2 off of the floor and to the bed. CNA N included in her statement it was not safe to use the sit to stand lift with R2. The statement further lacked indication that additional staff were present when CNA N went to transfer R2. The Witness Statement undated for incident on 08/16/23 by CNA O, revealed she was in another resident room when CNA N came to get her to help her, and LN H get R2 off of the floor due to slipping in the sit to stand lift. On 09/20/23 at 08:49 AM, observed R2 in her room in bed, a sit to stand lift was in the room. On 09/20/23 at 04:09 PM, R2 stated she fell from the lift one time, from the lift that stands you up and one staff was helping me, and I ended up on the floor and she had to go get help from someone else so they could lift me off of the floor. R2 stated she was receiving therapy during that time, and they were working on her standing. On 09/21/23 at 10:03 AM, Administrative Staff A stated she expected two staff to use the Hoyer lift and would need to double check on the sit to stand, however she thought two staff assisting was the expectation. The facility policy Limited Lift Program [Safe Patient Handling] revised 08/09/23 revealed the facility would provide education on hire and annually for the proper use of lifts including the need to have two associates present during the transfer and no associate under the age of 18 should operate a lift. The facility failed to ensure assistance of two staff provided to R2 during transfers. This deficient practice resulted in a fall, placing R2 at risk for injury.

The facility identified a census of 65 residents with 20 residents that resided on the memory care unit. The facility reported 27 residents tested positive for COVID-19 (highly contagious respiratory disease spread from person to person through droplets released when an infected person coughs, sneezes, or talks) from 06/13/23 through 07/11/23, with 12 of those residents residing on the memory care unit. Based on observation, record review, and interview, the facility failed to utilize appropriate infection control practices to prevent transmission of COVID-19 throughout the facility and failed to monitor residents who tested positive for COVID-19. Findings included: - On 07/13/23 the facility reported five current residents with active COVID-19 with four of the five residing on the memory care unit. Resident (R)4, R5, R9, and R8 resided on the memory care unit, and R6 resided in another area of the facility. Review of R4's Electronic Medical Record (EMR) revealed he tested positive for COVID-19 on 07/03/23 and was tested due to exhibiting one or more symptoms (lacked what symptoms) of COVID-19. EMR lacked additional documentation of any assessment/symptoms R4 had while he remained positive with COVID-19 through 07/14/23 and lacked documentation when he came out of isolation on 07/14/23. The assessment tab lacked respiratory screenings for the duration of the COVID-19 isolation period. Review of R5's EMR revealed she tested positive for COVID-19 on 07/05/23 and had a temperature of 101.4 degrees Fahrenheit (F) during the night. The EMR lacked additional documentation of any assessment/symptoms R5 had while positive when reviewed through 07/16/23 and lacked documentation when she came out of isolation. The assessment tab lacked respiratory screenings for the duration of the COVID-19 isolation period. Review of R6's EMR revealed she tested positive for COVID-19 on 07/04/23 and was tested due to a positive result of another resident or associate. The nurse's notes from 07/04/23 through 07/15/23 lacked assessment/monitoring of COVID-19 symptoms on 07/06/23, 07/07/23, 07/09/23, and 07/14/23. The last documented symptom on 07/12/23 noted nasal congestion and fatigue. The facility performed a respiratory screen on the day and night shift on 07/08/23, but no other respiratory screens under the assessment tab for the duration of the COVID-19 isolation period were present. On 07/13/23 at 10:40 AM, observation revealed closed doors leading to the memory care unit wing of the facility. Upon entry to the unit, 10 residents sat in the dining room area, and one staff member ambulated with a resident down the hallway. The staff members in the unit had masks in place covering their nose and mouth however, they lacked wearing any eye protection. On 07/13/23 at 12:03 PM, R4's room had receptacles for trash and linen, which lacked a cover even though the resident was on isolation precautions for COVID-19. R4 sat in the dining room area in his wheelchair next to another resident visiting. On 07/13/23 at 12:12 PM COVID positive R5's room lacked signage noting R5 was on droplet precautions. R5 sat in the dining room area during the observation. On 07/13/23 at 12:17 PM, observed Housekeeping Staff U with a wire basket cart with folded towels, uncovered, in the memory care unit. Housekeeping Staff U moved the cart of folded towels from the memory care unit to outside the doors of the unit and into the clean side of the laundry area. On 07/13/23 at 12:18 PM, Housekeeping Staff U stated linens should be covered during transport. On 07/13/23 at 12:19 PM, Housekeeping Staff V stated linens should be covered during transport and the towels would be considered contaminated since they were taken into the Memory Care Unit, since residents with COVID-19 did not stay in their room on that unit. On 07/13/23 at 01:26 PM, observed signage at the second entrance door into the facility. To the right of the door on the window above the doorbell revealed a sign indicating there was a COVID-19 outbreak in the facility. An additional sign, on the left side of the door opposite of the door handle, was a sign which revealed visitors should wear masks regardless of vaccination status. On 07/13/23 at 01:34 PM, observed Unidentified delivery visitor LL who lacked having a mask in place over their mouth and nose, exiting the memory care unit along with Housekeeping Staff V. On 07/13/23 at 01:35 PM, Unidentified delivery visitor LL stated he did not know there was a COVID-19 outbreak in the facility, was in the facility the day before as well, and stated the facility staff did not inform him of the outbreak. On 07/13/23 at 01:36 PM, Housekeeping Staff V stated he did not know visitors should wear a mask when in the facility. On 07/13/23 at 01:40 PM Administrative Nurse F assisted R5, who sat in a positioning style wheelchair at a dining room table, by holding the foam cup with a straw up to her mouth so she could take drink from the straw. Administrative Nurse F wore a mask that covered her nose and mouth, however lacked gloves, face shield, and gown. After taking several sips from the straw, R5 coughed several times and did not cover her mouth. Another resident walked through the dining room area and Administrative Nurse F left R5's side and placed the ambulatory resident's walker in front of her, without performing hand hygiene before touching the walker. Observation on 07/13/23 at 02:14 PM revealed Licensed Nurse (LN) H in the memory care unit with a mask in place to mouth and nose, however lacked eye protection. On 07/17/23 at 10:04 AM, Administrative Nurse E stated when a resident tested positive for COVID-19, the LN was to complete a respiratory symptoms screening, located under the assessment tab in the EMR every shift. On 07/17/23 at 10:18 AM, Administrative Nurse E stated R5 and R4 lacked COVID-19 symptom monitoring in the EMR and R6 had some progress notes regarding her symptoms. Administrative Nurse E stated the respiratory screening under the assessment tab must be scheduled in the system and she lacked access to be able to schedule the assessments. Administrative Nurse E stated the nursing staff should wear gloves when assisting a resident who was positive with COVID-19 to eat/drink, however, was not sure if they should wear a face shield/protective eye wear or a gown. Administrative Nurse E stated if the resident coughed, then staff should wear eye protection and a gown and gloves would help as pretty much everyone in the memory care unit had been exposed to COVID-19. On 07/17/23 at 11:36 AM, LN G, stated she was responsible for the residents on the memory care unit as well as those on the north hall, and the memory care unit had two residents who were still on precautions. LN G stated in general, when going to the memory care unit she did not add additional PPE (personal protective equipment) other than the mask she had on, unless doing personal care with them. LN G stated when assisting a resident to eat who was positive for COVID-19, staff should wear a gown, face mask, face shield, and gloves. LN G stated the facility provided a list of residents who were positive for COVID-19, staff would also get that information in their report and there would be an isolation cart outside of the resident's room. LN G stated when a resident tested positive for COVID-19, then their oxygen level, lung sounds, level of alertness, food and fluid intake should be documented and there was a COVID screening under the assessment tab or a progress note could be made in the EMR. LN G stated the facility provided a list of residents with a date, of when a resident could come out of isolation, and stated residents needed to be on isolation for at least 10 days. If the resident had a fever, then staff should let the doctor know and the doctor would decide when that resident could come out of isolation. On 07/17/23 at 12:01 PM, Administrative Nurse D stated when a resident was positive for COVID-19, the nursing staff were to do a respiratory assessment and document the assessment in the EMR under the assessments tab. Administrative Nurse D stated he thought the respiratory assessment should be done every shift but would have to look. Administrative Nurse D stated a sign was not necessary on the door of a resident to indicate transmission-based precautions as there would be PPE at the doorway, however, if the PPE cart was between two rooms, then there should be signage on the door. Administrative Nurse D stated if the staff were helping a resident with feeding who was positive for COVID-19, then the staff should have on a gown, gloves, mask and protective eyewear regardless of whether the resident was in the room or the dining room. Administrative Nurse D stated he was not aware of how the determination was made on when a resident could come out of isolation, and would need to ask Administrative Nurse E, as she determined and provided the facility with a list. On 07/17/23 at 12:14 PM, Administrative Nurse E stated a resident could come out of their room [ROOM NUMBER] days after a positive test. Administrative Nurse E stated she would make a list of residents who was on isolation and when they could come out, and most of the residents did not have symptoms when it was time to end isolation. Administrative Nurse E stated she did not look to see if a resident was having symptoms before coming out of isolation, the LN did that, and generally they do not test the resident before taking them out of isolation. On 07/17/23 at 01:02 PM Certified Medication Aide (CMA) R and Certified Nurse Aide (CNA) M were in the memory care unit in the dining room area, where two COVID-19 positive residents were located, with a mask in place, but lacked protective eyewear. On 07/17/23 at 01:03 PM, CMA R stated she had not been instructed to wear protective eyewear when in the memory care unit. On 07/17/23 at 01:04 PM CNA M stated that the staff wore eyewear when COVID-19 was really bad but did not think they had to now when in the memory care unit. The facility policy COVID-19 dated 06/27/23 revealed when there are suspected or confirmed COVID-19 cases on the memory care unit, as it may be challenging to restrict residents to their rooms, the facility should implement use of eye protection and N95 or other respirators (or facemasks if respirators were not available) for all associates when on the unit to address potential for encountering a wandering resident who might have COVID-19. When there are newly identified active cases in the facility, health care providers should care for residents using an N95 or higher-level respirator, eye protection (goggles or a face shield that covers the front and sides of the face), gloves, and gown. For discontinuation of isolation precautions for residents who were positive for COVID-19, a symptom-based strategy for discontinuation or a test-based strategy should be used. For the symptom-based strategy, at least 10 days passed since symptoms first appeared and at least 24 hours passed since the last fever without use of fever-reducing medications, and symptoms have improved. If the resident was not moderately to severely immunocompromised (having an impaired immune system) and who were asymptomatic (without symptoms) throughout the infection, may have transmission-based precautions discontinued when at least 10 days passed since the date of the first positive viral diagnostic test. The test-based strategy indicated for asymptomatic residents, when results were negative from at least two consecutive respiratory specimens collected 48 hours apart, for a total of two negative specimens and for symptomatic residents, a resolution of fever without the use of fever-reducing medications and symptoms have improved, and results are negative from at least two consecutive respiratory specimens collected 48 hours apart for a total of two negative specimens. The facility policy Outbreak and/or Pandemic Control and Management dated 05/12/23 revealed the facility should provide training to facility associates on recognizing what constitutes and outbreak and included but was not limited to the following: how to monitor residents for signs and symptoms of respiratory illness and how to keep residents, visitors, and associates safe by using correct infection control practices including proper hand hygiene and selection and use of PPE. The facility policy Laundry Services dated 08/16/22 revealed all clean linens should be stored and transported in covered carts. Upon return to the laundry, the linen cart should be taken into the dirty side of the room and cleaned using a Hospital grade EPA (Environmental Protection Agency) registered disinfectant. The facility failed to ensure visitors were aware of COVID-19 Outbreak status, failed to ensure the staff in the memory care unit had on eye protection when in the unit, failed to ensure staff caring for those who were positive for COVID-19 utilized the appropriate PPE, failed to ensure appropriate signage in place to resident doors to alert those of the implemented transmission based precautions, and failed to ensure staff transported linens appropriately. These practices increased the risk of spreading the COVID-19 infection.

- The Electronic Medical Record (EMR) documented R53 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus type 2 (when the body cannot respond to the insulin), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), chronic diastolic heart failure (a condition in which the hearts main pumping chamber becomes still and unable to fill properly), and pulmonary hypertension (high blood pressure). R53's Medicare 5 Day Minimum Data Set (MDS), dated [DATE], documented R53 had moderately impaired cognition and required extensive assistance of two staff for bed mobility, transfers, dressing, toileting, and limited assistance of one staff for ambulation. The assessment further documented R53 had lower functional impairment on one side, was at risk for skin breakdown, had one stage two (partial thickness pressure injury) pressure ulcer, and had pressure relieving devices for his bed and chair. The Braden Scale Assessment (assessment for predicting pressure ulcer risk), dated 10/07/22, documented a score of 17, indicating a mild risk for pressure ulcer development. The Pressure Ulcer Care Plan, dated 10/08/22, documented R53 was at risk for skin breakdown and directed staff to obtain weekly skin checks. The care plan lacked direction to staff regarding the use of an orthopedic (CAM) walking boot for his right foot and/or R53's risk for skin alterations related to the medical device. The update, dated 11/04/22, documented R53 had a stage two pressure ulcer to his right heel, and directed staff to administer treatments as ordered, assess wound healing and report improvements and declines to the physician; follow facility protocols for the prevention and treatment of skin breakdown, non-weight bearing on his right foot, and see the wound doctor. The Physician's Order, dated 10/08/22, documented a right lower orthopedic (CAM) boot when walking and directed staff to administer a multivitamin daily. R53's clinical record lacked documentation of skin assessment until 10/14/22 (seven days after admission). The Weekly Skin Integrity Data, dated 10/14/22, documented R53's skin was intact. R53's medical record lacked evidence staff assessed skin under the orthopedic boot at least daily to identify signs of pressure or device-related skin alterations. The Physician's Order, dated 10/20/22, documented R53's right heel had fluid filled purple blister and directed staff to obtain a wound care evaluation and heel pads. The Physician's Order, dated 10/21/22, directed staff to cleanse, rinse, and dry the wound to the right heel, cover with duoderm signal (a dressing for the management of lightly to moderately exuding [discharge] wounds), change every 72 hours and as needed until resolved. The Wound Observation Tool, dated 10/26/22, documented R53 had a blister on his right heel, measured 4 centimeters (cm) x 3.5 cm, and was first observed 10/21/22. The Physician's Order, dated 10/27/22 documented non-weight bearing on R53' right lower extremity due to open area on his right heel. The Wound Observation Tool, dated 11/03/22, documented R53's blister had opened during a physician visit on 10/27/22 was now a stage two pressure ulcer and measured 5.9 cm x 3.6 cm x 0.1. The Wound Observation Tool, dated 11/16/22, documented R53's right heel wound measured 2.1 cm x 2.6 cm x 0.2 cm, with 75% epithelial tissue (a thin layer of tissue that covers organs) and 25% gray slough (dead tissue). The tool further documented R53 was seen at the wound clinic and the wound was improving, had good blood flow, and obtained new treatment orders to wash the right heel with soap and water, rinse, pat dry, apply Mupirocin (a topical antibiotic cream) to the right heel, and place gauze, a foam dressing, and wrap with cling, every dayshift. The Physician's Order, dated 01/21/23, directed staff to always float R53's heels. On 01/30/23 at 09:44 AM, observation revealed Licensed Nurse (LN) G donned clean gloves, and cleaned R53's right heel with soap and water, rinsed the wound with normal saline. Further observation revealed LN G applied Mupirocin ointment to the wound, placed a foam dressing on the wound and wrapped it with Kling dressing (absorbent gauze that stretches and conforms to the body shape). On 01/30/23 at 09:44 AM, R53 stated he obtained the wound on his heel from the orthopedic walking boot he wore and stated it would take a few months to heal. On 01/30/23 at 09:55 AM, LN G stated R53 came to the facility with the orthopedic (CAM) walking boot due to an ankle fracture and staff were not supposed to remove the boot until his first follow-up appointment. LN G stated they felt the blister was from the boot rubbing the back of his heel. On 01/31/23 at 10:44 AM, Consultant GG stated there had not been an order for the boot to remain on until the first appointment and stated staff should have done daily skin checks and skin checks on R53's shower days. The facility's Skin Integrity and Pressure Ulcer Injury Prevention and Management policy, dated 08/25/21, documented a skin inspection on admission and re-admission to the facility may identify pre-existing signs of possible deep tissue damage already present. The policy further documented a nurse would complete further inspections and provide treatment if needed as certain risk factors may have been identified that increased a patient's susceptibility to develop or impair healing of pressure ulcer. The facility failed to prevent a facility acquired stage two pressure ulcer for R53, who was admitted with a orthopedic walking boot, when staff failed to routinely monitor the skin under the orthopedic device. This placed the resident at risk for further breakdown and resulted in a stage two pressure injury. 37450 The facility had a census of 60 residents. The sample included 15 residents of which three residents were reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to identify and implement interventions to prevent the development of an avoidable facility acquired pressure ulcer for Resident (R)49. The facility failed to identify and place treatments including monitoring of wound status, failed to involve the physician, and failed to act upon nutritional interventions to support wound healing and prevention of further pressure injuries. R49's pressure injury progressed to a stage three (full thickness pressure injury extending into the tissue beneath the skin) wound. The facility further failed to implement interventions to prevent, treat and promote healing for R53. Findings included: - The Medical Diagnosis section within R49's Electronic Medical Record (EMR) included diagnoses of type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) with other skin ulcer, lymphedema (swelling caused by accumulation of lymph), chronic pain, restless leg syndrome, history of venous thrombosis (clot that developed within a blood vessel), edema, heart failure, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and right below knee amputation. R49's Quarterly Minimum Data Set (MDS), dated [DATE], documented R49 had intact cognition, and required extensive assistance of one to two staff for bed mobility and transfers. The MDS further documented functional range of motion impairment both side of lower extremities. R49 used a wheelchair for mobility and had a limb prosthesis (artificial limb). R49 was at risk for pressure ulcer/injury, had an unhealed stage three pressure ulcer, not present on admission. The MDS further documented R49 had a pressure reducing device for bed and chair, no turning/repositioning program, no nutrition, or hydration interventions to manage skin problems, had application of ointment/medication other than to feet, application of dressings, and pressure ulcer care. The Care Plan, dated 03/02/22, documented R49 had a pressure ulcer development related to diabetes mellitus, and directed staff to serve diet as ordered, and required supplemental protein, amino acids, vitamins with minerals as ordered to promote wound healing. On 06/14/22 the care plan directed staff to serve double portions of protein with all meals. R49's Care Plan, updated 11/17/22, documented R49 was at nutrition risk related to weight loss and had a stage three pressure injury on the left heel. The Dietary Progress Note on 07/24/22 documented the Registered Dietician (RD) recommended a prealbumin (blood test that measure protein nutrients in diet) level to be checked. The Progress Note on 07/29/22 at 03:04 PM documented R49 had soft heel on left foot; the area was dark in color. The heel was wiped with skin protector and off loaded. The resident would wear a boot, elevate lower extremity at rest and would be monitored and treated daily. The note included the resident was going to the wound clinic. The medical record lacked evidence the physician was notified of the wound. The Progress Note on 08/01/22 at 02:28 PM documented the wound to left heel presented with a halo of yellow tinted skin, areas of red and purple tinted tissue beneath covered blister. The area was cleansed, rinsed, dried and skin prep applied. The medical record lacked evidence the physician was notified of the wound. The Progress Note on 08/06/22 at 04:38 PM documented R49 transferred with a full body lift and the wound had thick tissue, was purple in color, and mushy to the touch. The note recorded therapy was doing diathermy (deep heating beneath skin for therapeutic purposes) to the wound. The heel had been off loaded. On 08/07/22 the Weekly Skin Integrity Data Collect Assessment documented R49's skin was intact, he had a blister, and a left heel wound. The medical record lacked the physician was notified/aware of wound. On 08/10/22 the Nutrition Progress Note documented the provider's office was contacted regarding an order for pre-albumin and the provider would get back with facility with response (17 days after the RD recommendation on 07/24/22). On 08/19/22 the Resident at Risk Interdisciplinary Team Note documented R49 had a deep tissue injury and the staff nurse reported to the physician to get orders to follow up with provider. The Progress Note on 08/23/22 at 04:51 PM documented R49 was seen by the provider, who ordered a wound consult and an x-ray to the left heel. The Wound Observation Tool, dated 09/01/22, documented an air mattress and off-loading boot as preventative measures. The tool recorded R49 had an acquired left heel pressure ulcer, identified on 08/29/22, which was a stage three. The note recorded the physician was notified on 07/29/22. The wound had granulation tissue and 15 percent (%) necrotic (pertaining to the death of tissue in response to disease or injury) tissue, measured 4 centimeters (cm) length by 3.5 cm width by 0.2 cm depth. New orders were obtained from the wound care provider. The Dietary Progress Note on 09/12/22 documented a recommendation to change multivitamin to multivitamin with minerals and check pre-albumin. The medical record lacked evidence the wound was assessed from 11/11/22 to 12/01/22 (19 days). The Dietary Progress Note, dated 11/17/22, recommended double protein food items at mealtimes. The Wound Observation Tool, dated 12/01/22, documented the wound was unchanged, had not improved, and measured 2.5 cm in length by 3.2 cm in width by 0.3 cm depth. On 12/09/22 the Resident at Risk Interdisciplinary Team Note documented the heel wound was improving. The resident had a wound care provider and the RD recommended double portions for R49. On 12/26/22 the Dietary Wound Note documented R49 had a stage three pressure ulcer, which was unchanged per nursing report. The note recorded the RD recommended to add double protein on 11/17/22, but it had not been implemented. The RD recommended to add double protein and skim milk three times a day at all meals. The Wound Observation Tool, dated 01/06/23, documented the wound was unchanged, had 20% slough (dead tissue, usually cream or yellow in color) measured 2.1 cm in length by 2.0 cm in width and 0.3 cm in depth, it was followed by a wound care provider and ordered treatment provided. The Progress Note, dated 01/25/23, documented an order was received for double portion protein with meals (following the recommendation of 11/17/22). On 01/30/23 at 08:58 AM, observation revealed R49 ate in the dining room, wearing an offloading boot to his left leg, and a prosthetic leg to the right leg. Observation revealed R49 had a pressure reducing mattress on his bed, but the bed lacked an air mattress. On 01/31/23 at 10:15 AM, observation revealed Licensed Nurse (LN) G changed the dressing to R49's left heel. LN G stated the resident should have an air mattress on his bed, but R49 had switched beds in the room when a roommate was being admitted to the room. The new admission then was transferred to a different room, taking the air mattress. The air mattress removal date was 01/20/23, but LN G said an air mattress would be provided to R49 that day. On 01/31/23 at 07:52 AM, R49 reported he did not feel he was getting double portions but said he got milk with each meal. R49 also reported he had not had an air mattress on his bed since he moved to the hall, he now resided on (he moved on 12/12/22). On 01/31/23 at 11:33 AM, Consultant GG verified the care plan lacked interventions to prevent and treat R49's pressure ulcer, lacked wound assessments between 11/11/22 to 12/01/22 in which the wound had not improved, and stated the staff should have followed up on the Registered Dieticians recommendations in a timely manner. The facility's undated Skin Integrity and Pressure Ulcer/Injury Prevention and Management policy documented based on the comprehensive assessment of a resident, the facility must ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates they we unavoidable, and a resident with pressure ulcer receives necessary treatment and services, consistent with professional standards of practice , to promote healing and prevent infections and prevent new ulcers from developing. The facility failed to prevent the development of an avoidable facility acquired pressure ulcer for R49 who developed a pressure injury. The facility failed to identify and place treatments, failed to involve the physician, and failed to act upon nutritional interventions to support wound healing and prevention of further pressure injuries. R49's pressure injury progressed to a stage three pressure wound.

The facility had a census of 60 residents. The sample included 15 residents, with five reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide consistent bathing services for four sampled residents, Resident (R) 5, R17, R23, and R54. This placed the residents at risk for complications related to poor hygiene. Findings included: - The Electronic Medical Record (EMR) for R5 documented diagnoses of diabetes mellitus type 2 (when the body cannot respond to the insulin), chronic respiratory failure (when lungs can't get enough oxygen), hypertension (high blood pressure), bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods, personality disorder (a lack of guilt and an inability to form lasting relationships), and neuromuscular dysfunction of the bladder (when there is leak of bladder control due to brain, spinal cord or nerve problems). R5's Quarterly Minimum Data Set (MDS), dated [DATE], documented R5 had moderately impaired cognition and required extensive assistance of two staff with bed mobility, toileting and extensive assistance of one staff for dressing and personal hygiene. The assessment further documented bathing did not occur during the lookback period. The Care Plan dated 10/19/22 directed staff to assist with ADL as needed, to inspect the residents feet daily for open areas, edema or redness, and cut the resident's nails straight across and file the rough edges with a emery board. The December 2022 and January 2023 Bathing Report and Facility Shower Sheets documented R5 requested showers on Wednesday and Sundays and documented R5 had not received a bath or shower during the following days. 12/26/22-01/07/23 (13 days) 01/09/23-01/30/23 (22 days) The EMR documented R5 refused a shower 01/01/23 and 01/04/23. On 01/30/23 at 04:17 PM, observation revealed R5's hair disheveled and she continuously scratched her head. Further observation revealed R5 had numerous hairs approximately one-half inch long on her chin. On 01/30/23 at 04:17 PM, R5 stated her head was itchy. On 01/31/23 at 10:01 AM, Licensed Nurse (LN) G stated the resident often refused her baths and stated she did not push the residents if they refused their bath because it was their right to do so. On 01/31/23 at 10:53 AM, Certified Nurse Aide (CNA) M stated R5 received evening baths and was not certain if she refused or not. CNA M further stated if a resident refused, she would go back at least three times and ask, then fill out the shower sheet, give it to the charge nurse, and document in the computer. On 01/31/23 at 11:55 AM, Consultant GG stated she expected staff to offer the resident showers or baths two to three times per week and fill out the shower sheet. The facility Activities of Daily Living (ADLs) policy, dated 07/1721, documented to ensure the facility identifies and provide care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standard of practice that would meet each resident's physical, mental, and psychosocial needs. The facility must provide care and services for hygiene which include bathing, dressing, grooming, and oral care. The facility failed to provide consistent bathing services for R5. This placed the resident at risk for complications related to poor hygiene. - The Electronic Medical Record (EMR) for R17 documented diagnosis of edema (swelling resulting from an excessive accumulation of fluid in the body's tissues), depression (abnormal emotional state characterized by exaggerated feelings of sadness), and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R17 had intact cognition and was dependent upon two staff for toileting, dependent upon one staff for bathing, required extensive assistance of two staff for dressing, and limited assistance of one staff for personal hygiene. The Care Plan, dated 10/26/22, documented R17 preferred to shower once a week on Monday morning. The care plan further directed staff to keep the resident's skin clean and dry as she continually picked at her skin. The November 2022 Bathing Report and Facility Shower Sheets documented R17 requested a shower on Monday mornings and documented R17 did not receive a bath or shower on the following Monday: 11/07/22 The EMR lacked documentation R17 refused a shower. The December 2022 Bathing Report and Facility Shower Sheets documented R17 requested a shower on Monday mornings and documented R17 did not receive a bath or shower on the following Monday: 12/26/22 The EMR lacked documentation R17 refused a shower. The January 2023 Bathing Report and Facility Shower Sheets documented R17 requested a shower on Monday mornings and documented R17 did not receive a bath or shower on the following Mondays: 01/02/23 01/16/23 01/30/23 The EMR lacked documentation R17 refused a shower. On 01/26/23 at 10:28 AM, observation revealed R17 in bed watching television, Further observation revealed her ws hair uncombed, and her upper denture fell down as she talked. On 01/31/23 at 10:01 AM, Licensed Nurse (LN) G stated the resident often refused her baths and stated she did not push the residents if they refused their bath because it was their right to do so. On 01/31/23 at 10:53 AM, Certified Nurse Aide (CNA) M stated R17 requested a shower on Monday mornings and usually did not refuse one on her shower day. CNA M further stated if a resident refused, she would go back at least threee times and ask, then fill out the shower sheet, give it to the charge nurse, and document in the computer. On 01/31/23 at 11:55 AM, Consultant GG stated she expected staff to offer the resident showers or baths two to three times per week and fill out the shower sheet. The facility Activities of Daily Living (ADLs) policy, dated 07/1721, documented to ensure the facility identifies and provide care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standard of practice that would meet each resident's physical, mental, and psychosocial needs. The facility must provide care and services for hygiene which include bathing, dressing, grooming, and oral care. The facility failed to provide consistent bathing services for R17. This placed the resident at risk for complications related to poor hygiene. - The Electronic Medical Record (EMR) for R23 documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness, and hopelessness, and chronic fatigue (sleep abnormalities, pain, and other symptoms that are made worse by exertion). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R23 had severely impaired cognition and required extensive assistance of two staff for bed mobility, activity occurred once or twice by two staff for transfers, toileting, and dressing. The assessment further documented bathing did not occur during the look back period. The Care Plan, dated 10/19/22, documented R23 was on hospice care and required assistance with ADLs and the hospice aide would come to the facility on e to three times per week and would assist with bed baths or showers, nail and oral care. The December 2022 Bathing Report and Facility Shower Sheets documented R23 requested showers on Sunday and Thursday dayshift and documented R23 had not received a shower or bed bath during the following days: 12/07/22-12/15/22 (9 days) 12/17/22-12/27/22 (11 days) The EMR lacked documentation R23 refused a shower. The January 2023 Bathing Report and Facility Shower Sheets documented R23 requested showers on Sunday and Thursday dayshift and documented R23 had not received a shower or bed bath during the following days: 01/21/23-01/30/23 (10 days) The EMR lacked documentation R23 refused a shower. On 01/26/23 at 09:05 AM, observation revealed R23 had on a green top that had dried stains on it and her hair was disheveled. On 01/31/23 at 10:01 AM, Licensed Nurse (LN) G stated the resident often refused her baths and stated she did not push the residents if they refused their bath because it was their right to do so. On 01/31/23 at 10:53 AM, Certified Nurse Aide (CNA) M stated R23 was on hospice and they would come twice a week to give the resident a bed bath and that the facility would also offer two additional bed baths for the resident, but the resident would often refuse the extra baths. CNA M further stated if a resident refused, she would go back at least threetimes and ask, then fill out the shower sheet, give it to the charge nurse, and document in the computer. On 01/31/23 at 11:55 AM, Consultant GG stated she expect staff to offer the resident showers or baths two to three times per week and fill out the shower sheet. The facility Activities of Daily Living (ADLs) policy, dated 07/1721, documented to ensure the facility identifies and provide care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standard of practice that would meet each resident's physical, mental, and psychosocial needs. The facility must provide care and services for hygiene which include bathing, dressing, grooming, and oral care. The facility failed to provide consistent bathing services for R23, who was on hospice. This placed the resident at risk for complications related to poor hygiene. - The Electronic Medical Record (EMR) for R54 documented diagnoses of protein calorie malnutrition (inadequate intake of food), dyspepsia (recurring upset stomach), and cognitive communication deficit (problems with communication). R54's Quarterly Minimum Data Set (MDS), dated [DATE], documented R54 had moderately impaired cognition and dependent upon two staff for bed mobility, transfers, dressing, toileting, and dependent upon one staff for personal hygiene. The MDS further documented bathing did not occur during the lookback period. The Care Plan, dated 11/04/22, directed staff to check R54's nail length and trim, clean on bath days and a necessary and was totally dependent upon one staff for personal hygiene and oral care. The November and December 2022 and January 2023 Bathing Report and Facility Shower Sheets documented R54 requested a shower on Wednesday and Saturdays and documented R54 did not receive a bath or shower on the following days: 11/01/22-12/17/22 (46 days) 12/19/22-01/04/23 (17 days) 01/05/23-01/30/23 (26 days) The EMR lacked documentation R54 refused a shower. On 01/30/23 at 09:17 AM, observation revealed R54 in her Broda chair (positioning chair) and was observed to have multiple chin hairs approximately one-half inch long. On 01/31/23 at 10:01 AM, Licensed Nurse (LN) G stated the resident often refused her baths and stated she did not push the residents if they refused their bath because it was their right to do so. On 01/31/23 at 10:53 AM, Certified Nurse Aide (CNA) M stated R54 did not normally refuse her showers. CNA M further stated if a resident refused, she would go back at least three times and ask, then fill out the shower sheet, give it to the charge nurse, and document in the computer. On 01/31/23 at 11:55 AM, Consultant GG stated she expect staff to offer the resident showers or baths two to three times per week and fill out the shower sheet. The facility Activities of Daily Living (ADLs) policy, dated 07/1721, documented to ensure the facility identifies and provide care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standard of practice that would meet each resident's physical, mental, and psychosocial needs. The facility must provide care and services for hygiene which include bathing, dressing, grooming, and oral care. The facility failed to provide consistent bathing services for R54. This placed the resident at risk for complications related to poor hygiene.

The facility identified a census of 60 residents. The facility had one main kitchen. Based on observation, record review and interview, the facility failed to ensure the director of food and nutrition services had the required qualifications of a certified dietary manager (CDM). This placed residents at risk for unmet dietary and nutritional needs. Findings included: - On 01/25/23 at 09:07 AM Dietary BB stated she was not certified nor enrolled in a dietary manager course. Dietary BB stated the Registered Dietician reviewed resident's charts at least monthly via video/phone but was not routinely in the facility. On 01/31/23 at 08:39 AM Dietary BB stated she was currently working on the prerequisites for the certification course and hoped to begin the dietary manager courses in the next few months. On 01/31/23 at 03:35 PM Dietary BB stated she had only been working as the dietary manager at the facility since March 2022. The facility policy Departmental Leadership Requirements revised 08/15/22 documented: if a qualified or other clinically qualified nutrition professional was not employed full-time, the facility must designate a person to serve as the director of food and nutrition services who was a certified dietary manager; or a certified food service manager; or has similar national certification for food service management and safety from a national certifying body; or has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; have two or more years of experience in the position of a director of food and nutrition services and have completed a minimum course of study in food safety, by no later than October 1, 2023. The course should include topics integral to managing dietary operations such as, but not limited to, foodborne illness, sanitation procedures, food purchasing/receiving. The facility failed to ensure the director of food and nutrition services was a certified dietary manager. This deficient practice placed all residents at risk for unmet dietary and nutritional needs.

The facility identified a census of 60 residents. The facility had one main kitchen. Based on observation, record review and interview, the facility failed to ensure that food items stored in the refrigerator were properly labeled and dated. This deficient practice had the potential for food borne illnesses for the residents. Findings included: - Upon the initial tour of the facility kitchen on 01/25/23 at 08:35 AM revealed the Traulsen three-door stainless steel refrigerator had a gallon sized plastic bag labelled turkey with a 01/23/23 date on the top shelf left side, two sandwich sized zip-lock plastic bags that contained an onion and one contained a tomato, both were not labeled or dated. There was one open bag of shredded coleslaw mix with no date, three small individual containers of cottage cheese unlabeled and undated, 12 chocolate dessert bowls were unlabeled and undated. There was also a Styrofoam container with brown sliced meat that had no label or date. The bottom of the refrigerator had red dried liquid noted. The Victory brand three-door stainless steel refrigerator revealed in left door top shelf had a five-pound bag of shredded cheese dated 11/07/22, a block of white sandwich sliced cheese with no open date, a white and orange blocks of cheese in plastic bags without dates. The left door bottom shelf grey tub contained a wrapped ham, and two sandwich bags that each contained two slices of bologna dated 01/07/23 and 01/14/23. On 01/31/23 at 11:12 AM Dietary Staff BB stated items placed in the refrigerator or put in ziplock bags for storage should all be labeled and dated. Dietary Staff BB stated the refrigerator and freezer temperatures should be recorded on the daily temperature log twice daily. The facility policy Sanitation and Food Safety revised 09/08/22 documented: food was stored and maintained in a clean, safe and sanitary manner following guidelines to minimize contamination and bacterial growth. Pre-packaged food was to be placed in a leak-proof, pest-proof, non-absorbent, sanitary container with a tight-fitting lid. The container should be labeled with the name of the contents and the date) when the item was transferred to the new container). A Use by Date should be noted on the label or product when applicable. Leftovers were to be dated properly and discarded after 72 hours unless otherwise indicated. The facility failed to ensure dietary staff properly labeled, dated or discarded opened food items stored in zip-lock bags, prepared bowls of pudding, bologna stored in refrigerators. This deficient practice had the potential for food borne illnesses for residents.

The facility had a census of 60 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to review and revise Resident (R) 49's plan of care with resident centered interventions to prevent and/or promote healing for a facility acquired pressure injury, which placed the resident at risk for continued unhealed wound. Findings included: - The Medical Diagnosis section within R49's Electronic Medical Record (EMR) included diagnoses of type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) with other skin ulcer, lymphedema (swelling caused by accumulation of lymph), chronic pain, restless leg syndrome, history of venous thrombosis (clot that developed within a blood vessel), edema, acquired after care following surgical amputation, heart failure, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and need for assistant with care. R49's Quarterly Minimum Data Set (MDS), dated [DATE], documented R49 had intact cognition, required extensive assistance of one to two staff for bed mobility and transfers. The MDS further documented functional range of motion impairment both side of lower extremities, used a wheelchair for mobility and had a limb prosthesis. R49 was at risk for pressure ulcer/injury, had an unhealed stage three (full thickness tissue loss) pressure ulcer, not present on admission. The MDS further documented R49 had a pressure reducing device for bed and chair, no turning/repositioning program, no nutrition or hydration interventions to manage skin problems, had application of ointment/medication other than to feet, application of dressings, and pressure ulcer care. The Care Plan, dated 03/02/22, documented R49 had a pressure ulcer development related to diabetes mellitus, to serve diet as ordered, and required supplemental protein, amino acids, vitamins with minerals as ordered to promote wound healing. On 06/14/22 care plan directed staff to serve double portions of protein with all meals. The Care Plan, dated 11/17/22, documented R49 was at nutrition risk related to weight loss and [NAME] a stage three pressure of left heel. The Progress Note on 07/29/22 at 03:04 PM documented R49 had a soft heel on left foot, area was dark in color. Heel wiped with skin protector and off loaded. The resident would wear a boot, elevate lower extremity at rest and monitored and treat daily. The note included the resident going to wound clinic. The Wound Observation Tool, dated 09/01/22, documented an air mattress and off- loading boot as preventative measures, R49 had an acquired left heel pressure ulcer, identified on 08/29/22, which was a stage three (full thickness wound). The Progress Note, dated 01/25/23, documented an order was received for double portion protein with meals. (recommendation of 11/17/22) On 01/33/23 at 07:52 AM, R49 reported he did not feel he was getting double portions but said he got milk with each meal. R49 also reported he had not had an air mattress on his bed since he moved to the hall he now resided on (he moved on 12/12/22). On 01/31/23at 11:33 AM, Consultant GG verified the care plan lacked interventions to prevent and treat R49's pressure ulcer. The facility's Comprehensive Care Plan and Revisions policy, dated 03/02/22, documented the facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident's representative, if applicable, is involved in developing the care plan and making decisions about his or her care. When these changes occur, the facility should review and update the plan of care to reflect the changes to care delivery. The facility failed to review and revise R49's plan of care with resident centered interventions to prevent a facility acquired stage three pressure ulcer or promote healing of the wound, which placed the resident at risk for continued unhealed wound.

The facility had a census of 60 residents. The sample included 15 residents, with one reviewed for indwelling (tube placed in the bladder to drain urine into a collection bag) urinary catheterand urinary tract infection. The facility failed to provide Resident (R) 35 with appropriate catheter care which placed R35 for risk of infection. Finding included: -The Medical Diagnosis section within R35's Electronic Medical Record (EMR) included diagnoses of multiple sclerosis (progressive disease of the nerve fibers of the brain and spinal cord), neuromuscular dysfunction of bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system), malignant (cancer) neoplasm (tumor) of left and right breast, secondary malignant neoplasm of bone and chronic pain. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R35 had intact cognition, required extensive assistance of one person for activities of daily living, had an indwelling urinary catheter and was always continent of bowel. The Urinary Incontinence/Indwelling Care Area Assessment (CAA), dated 08/24/22, documented R35 was at risk for urinary complications related to catheter. The Care Plan, initiated on 05/24/21 documented R35 of urinary tract infection due to catheter. The care plan directed staff to encourage adequate fluid intake, provide treatments as ordered. The Physician Order dated 12/29/21 directed indwelling catheter to straight drainage, change for infection, obstruction or when closed system is compromised, and to change each month. The Progress Note, dated 12/19/22 at 08:58 PM, documented R35 returned to the facility post hospitalization . R35 was on contact precautions due to bacteria in urine and the catheter had been changed on 12/16/22. The note further documented R35 was not currently on antibiotics and the culture and sensitivity was abnormal. On 01/31/23 at 08:29 AM, observation revealed Certified Nurse Aide (CNA) N assisting R35 with morning cares. CNA N wore gloves and provided catheter care. During the care, CNA N, with the same gloved hands, adjusted her face mask and pushed up her glasses twice without removing or changing gloves. CNA N then continued to dress R35 ( wearing the same soiled gloves) with clean brief and adjust clothing. On 01/31/23 at 03:08 PM, Consultant Staff GG verified staff should remove gloves after cleansing the catheter area and should not touch mask or glasses, contaminating masks, glasses, and gloves, during the procedure. Consultant Staff GG stated the soiled gloves should have been removed before providing a clean brief to the resident. The facility's Indwelling Urinary Catheter Management policy, dated 04/01/22, documented based on comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choice. Use Standard Precautions, including the use of gloves and gown as appropriate, during any manipulation of the catheter or collecting system. The facility failed provide appropriate catheter care, by not changing gloves during care after contamination, which placed R35 at risk for urinary tract infections.

The facility had a census of 60 residents. The sample included 15 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to report blood sugars (the concentration of glucose [sugar] in the blood) outside of physician ordered parameters for two sampled residents, Resident (R) 5, and R9. This placed the residents at risk for physical decline and complications related to hyperglycemia (high blood sugar). Findings included: - The Electronic Medical Record (EMR) for R5 documented diagnoses of diabetes mellitus type 2 (when the body cannot respond to the insulin), chronic respiratory failure (when lungs can't get enough oxygen), and hypertension (high blood pressure). R5's Quarterly Minimum Data Set (MDS), dated [DATE], documented R5 had moderately impaired cognition and required extensive assistance of two staff with bed mobility, toileting and extensive assistance of one staff for dressing and personal hygiene. The MDS further documented R5 received insulin (a hormone produced in the pancreas by the cells in the pancreas) daily during the look back period. The Diabetes Mellitus Care Plan, dated 10/19/22, directed staff to obtain blood sugar checks as ordered, review complications with the resident/family/caregiver, administer medication as ordered, and inspect feet daily for open areas, and staff to watch for and notice any significant changes. The Physician's Order, dated 01/03/22, directed to check R5's blood sugar before breakfast, and two hours after meals for the diagnosis of diabetes mellitus type 2, and notify the physician if blood sugar was above 400 or below 60. The Medication Administration Record, dated 11/28/22 at 08:07 PM, recorded R5's blood sugar was 419. The medical record lacked documentation the physician was notified. The Medication Administration Record, dated 12/08/22 at 08:27 PM, recorded R5's blood sugar was 440. The medical record lacked documentation the physician was notified. On 01/26/23 at 07:45 AM, observation revealed R5 in bed with her eyes closed. On 01/31/23 at 11:55 AM, Consultant GG stated staff should follow the physician orders and to notify if the blood sugars are out of parameters. The facility Changes in Resident's Condition or Status policy, dated 04/02/21, documented the facility would notify the provider of changes in the resident's condition or status, The policy further documented, the facility must immediately consult the physician when there is a need to alter treatment significantly. The facility failed to report blood sugars out of physician ordered parameter for R5, placing her at risk for physical decline and complications related to hyperglycemia. - The Electronic Medical Record (EMR) for R9 documented diagnoses of diabetes mellitus type 2 (when the body cannot respond to the insulin), traumatic brain injury (an injury that affects how the brain works), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). R9's Quarterly Minimum Data Set (MDS), dated [DATE], documented R9 had intact cognition and was independent with bed mobility, transfers, dressing, toileting, and personal hygiene. The MDS further documented R9 received insulin (a hormone produced in the pancreas by the cells in the pancreas) daily during the look back period. The Diabetes Mellitus Care Plan, dated 12/14/22, directed staff to observe and report as needed compliance with diet and document any problems, avoid exposure to extreme heat or cold, medication as ordered. The Physician's Order, dated 12/10/20, directed staff to notify physician as needed for blood sugars less than 60 or greater than 400. The Physician's Order, dated 11/01/22, directed staff to obtain blood sugar checks after meals. The Medication Administration Record, dated 11/10/22 at 08:28 AM, documented R9's blood sugar was 409. The medical record lacked documentation the physician was notified. The Medication Administration Record, dated 12/03/22 at 12:52 PM, documented R9's blood sugar was 419. The medical record lacked documentation the physician was notified. On 01/31/23 at 1:00 PM, observation revealed R9 in bed with the covers pulled up over her head. On 01/31/23 at 11:55 AM, Consultant GG stated staff should follow the physician orders and to notify if the blood sugars are out of parameters. The facility Changes in Resident's Condition or Status policy, dated 04/02/21, documented the facility would notify the provider of changes in the resident's condition or status, The policy further documented, the facility must immediately consult the physician when there is a need to alter treatment significantly. The facility failed to report blood sugars out of physician ordered parameter for R9, placing her at risk for physical decline and complications related to hyperglycemia

The facility had a census of 60 residents. The sample included 15 residents, of which five were reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to obtain a stop date for Resident (R) 48's as needed (PRN) antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension) medication and failed to ensure an appropriate diagnosis for use of an antipsychotic (class of medications that treat psychosis (any major mental disorder characterized by a gross impairment in reality testing)) medication, which placed R48 at risk of receiving unnecessary psychotropic (medication that affects a person's mental status) medication. Findings included: -The Medical Diagnosis section within R48's Electronic Medical Record (EMR) included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion ) with anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) and mood disturbance, major depressive (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness) disorder , generalized anxiety disorder. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R48 had severely impaired cognition, had delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue) and rejected evaluation or care behaviors which occurred one to three days during the look back period. The MDS further documented R48 received antipsychotic on a routine basis, had not attempted a gradual dose reduction or had physician documented a gradual dose reduction as clinically contraindicated. R48 also received daily antianxiety and antidepressant. The Psychotropic Drug Use Care Area Assessment (CAA), dated 11/10/22, documented R48 was at risk for potential complications related to the use of psychotropic medications and would be monitored for side effects related to the use of these medications. The Care Plan, dated 10/23/22, documented R48 had impaired cognitive ability and thought process related to diagnosis of dementia. The care plan included at risk for change in moods or behavior due to medical condition and to give medications as ordered. The Physician Order, dated 10/22/22, directed staff to administer the following psychotropic medications: Lorazepam (antianxiety medication) 1 milligram (mg) every eight hours as needed for anxiety/restlessness. (the order lacked a 14 day stop date) Citalopram (antidepressant medication) 20 mg one time a day for major depressive disorder. Hydroxyzine (medication used to treat anxiety) 25 mg three times a day for generalized anxiety disorder. Mirtazapine ( antidepressant) 15 mg at bedtime for major depressive disorder. Risperidone (antipsychotic) 0.5 mg give two tablets at bedtime for dementia with mood disturbance and anxiety. The Pharmacy Review, dated 10/27/22, documented for the physician to consider discontinuing PRN lorazepam, discontinuing hydroxyzine and consider initiating use of buspirone 5 mg twice a day increasing as tolerated 5 mg/day every three days in divided doses until desired maintenance is achieved. The physician's response on 11/06/22 accepted recommendation. The order was not initiated. The Pharmacy Review, dated 11/28/22, documented the recommendations from 10/27/22 had not been acted upon by the intended recipient of the recommendation in accordance with regulation or facility policy. The Pharmacy Review, dated 12/27/22, documented R48's medical record listed potentially inappropriate supporting diagnoses or indications for the risperidone, currently for dementia, and should it be major depressive disorder (MMD)? The Nursing Progress Note, dated 01/25/23, documented R48 had not utilized her PRN lorazepam in almost three months, the provider notified and requested to discontinue order and the physician agreed, medication had been removed from medication cart per facility protocol. On 01/28/23 the Physician Order directed staff to discontinue use of hydroxyzine and initiate buspirone five mg twice a day. On 01/26/23 at 11:47 AM, observation revealed R48 entered the dining room in a wheelchair, dressed and groomed appropriately. The facility's Medication Regimen Review (MMR) policy dated 11/28/16, documented the consultant pharmacist will conduct MMR's under a pharmacy consultation agreement and will make recommendations based on the information available in the resident's health record. The pharmacist will address copies of the resident's MRR to the Director of Nursing and/or the attending physician and to the Medical Director. The facility should encourage the physician/provider receiving the MRR and the Director of Nursing to act upon the recommendations contained in the MRR and provide an explanation as to why the recommendation is rejected. The attending physician should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident, either 30 or 60 days per applicable regulation. The facility failed to obtain a stop date for R48's use of PRN antianxiety (medication and an appropriate diagnosis for use of an antipsychotic medication, which placed R48 at risk of receiving unnecessary psychotropic medication.

The facility reported a census of 59 residents. Based on observations, record review, and interviews, the facility failed to ensure meals served within the facility's scheduled meal service times to the residents in the facility. Findings included: - On 10/10/22 at 08:00 AM, numerous residents were in the dining room waiting for breakfast to be served. At 09:06 AM, staff served breakfast to the residents in the dining room. At 10:00 AM, (two hours after the scheduled mealtime) observation revealed nursing staff delivered several resident hall trays to the south hall. The mealtimes documented on the bulletin upon entering the dining room was 08:00 AM, 12:00 PM and 05:00 PM On 10/10/22 at 09:43 AM, Resident (R1) reported that she consumed most of her meals in the dining room. She reported the meals were served up to one and one-half hour after the scheduled mealtimes for breakfast and lunch, and meals were not always on time. R1 reported the expectation was for meals to be delivered in a timely manner. Observation, on 10/10/22 at 10:03 AM, staff served R1 breakfast hall tray. On 10/10/22 at 10:24 AM, Dietary Staff BB reported that mealtimes were to be served at scheduled times of 08:00 AM, 12:00 PM and 05:00 PM daily. However, when questioned why the meals were served one and one-half hours later than the scheduled mealtime, Dietary Staff BB would not reply. On 10/10/22 at 10:35 AM, Dietary Staff CC reported that scheduled mealtimes were at 08:00 AM, 12:00 PM and 05:00 PM. She reported meals were late at times due to certified Nurse aide's not available in the dining room. She reported was unable to find a solution for the meals to be served at the scheduled mealtimes, as well as staff not able to deliver the hall trays in a timely manner. On 10/10/22 at 12:02 PM, the residents were in the dining room for lunch. At 12:33 PM, staff served lunch to the residents in the dining room. At 01:38 PM, ( one and 1/2 hours after the scheduled mealtime) staff delivered the hall trays to the resident that resided on the south hall. On 10/10/22 at 12:22 PM, R 4 reported that she usually ate breakfast and lunch in the dining room. The resident reported that meals have been later than the scheduled mealtimes, and on several occasions, breakfast and lunch have been served at least one hour or more after the scheduled mealtime. On 10/10/22 at 12:40 PM, R 5 reported on several occasions, staff failed to pass out meals in the dining room up to an hour later than the scheduled mealtimes. On 10/10/22 at 01:08 PM, R 3 reported that she ate her meals in her room daily. She reported that staff served her meals up to an hour late on occasions. On 10/10/22 at 02:13 PM, R 2 reported staff would serve meals up to an hour later than the scheduled mealtimes. On 10/10/22 at 03:11 PM, Administrative Staff A, verified she was aware that breakfast and lunch were not always served as the facility's scheduled mealtimes of 08:00 AM, 12:00 PM and 05:00 PM. The meals should not be one hour later than the scheduled mealtimes. The Facility Frequency of Meals and Snacks Policy, reviewed 04/27/22, documented the Director of Food and Nutrition Services ensures that each meal is served at the designated time unless there is an emergency or resident request. The facility failed to ensure meals served to the residents in the facility in a timely manner, according to the facility's scheduled mealtimes, to ensure no more than 14 hours between a substantial evening meal and breakfast the following day.

The facility reported a census of 55 residents, which included three residents reviewed for accidents. Based on record review and interview, the facility failed to ensure Resident (R) 2, who staff assessed as a fall risk, remained free from accident hazards when staff failed to properly provide ambulatory assistance during toileting in the resident's room. On 05/21/22, at approximately 01:30 AM, Certified Nurse Aide (CNA) M assisted R2 with toileting needs and helped R2 ambulate, without the use of a gait belt (a device used to help prevent falls), out of the bathroom to go to bed. R2 pulled away from CNA M while she was holding onto her left arm with both hands, batted at the aide with her hand, then stumbled and fell into the wall causing a right shoulder fracture which required a trip to the emergency room . Findings included: - The Physician Order Sheet (POS), dated 06/01/22, documented R2 with a diagnosis of dementia with behavioral disturbance (chronic disorder of the mental processes caused by brain disease or injury marked by memory disorders, personality changes and impaired reasoning). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident with short-term and long-term memory problems and severely impaired cognitive skills for daily decision making. The resident required limited assistance of two staff members for transfers and extensive assistance of two staff members with ambulation. The resident used a walker and wheelchair for mobility. The Falls Care Area Assessment (CAA), dated 10/04/21, instructed the staff that R2 was at risk for falls related to a history of falls while at the facility. The resident required assistance from staff to stabilize while standing. The Quarterly MDS, dated [DATE], documented the resident with short-term and long-term memory problems. She required extensive assistance from two staff members for transfers and ambulation. The resident used a wheelchair for ambulation. The Care Plan, revised on 06/07/22, instructed the staff that R2 required some assistance with Activities of Daily Living (ADLs). On 06/16/21, documentation revealed R2 no longer walked by herself, and one to two staff members were to provide assistance with all transfers depending on her behaviors. On 06/19/21, the care plan documented R2 was at risk for falls. On 05/21/22, staff were to give direction to the resident during the overnight hours when exiting the restroom to promote safety so she did not have to pivot, which could cause unintentional loss of balance. The care plan did not address the use of a gait belt during transfers and ambulation. Review of a Fall Risk Assessment, dated 04/19/22 revealed a score of 22, which revealed the resident was at high risk for falls. A Health Status Note, dated 05/21/22 at 03:29 AM, documented by Licensed Nurse (LN) I, revealed staff called her to the resident's room to assess R2's upper arm. Staff reported they were assisting the resident to the bathroom from the bed area. The resident lost her balance and hit her arm into the wall and had been voicing pain since the incident happened. R2 did not fall to the floor. The resident's shoulder area was moderately swollen with discolored skin. Review of the hospital emergency room (ER) records, dated 05/21/22, revealed a radiology report documenting R2 had a humeral neck fracture (broken bone in the upper arm) with moderate displacement. The facility investigation, dated 05/21/22, documented by Administrative Staff A, revealed at approximately 01:30 AM, staff assisted R2 with her toileting and personal hygiene needs. On the way out of the bathroom, R2 attempted to go outside of the room and was guided back into the room by facility staff. On the way to the bed with CNA M, R2 stumbled over her feet and tripped, landing against the wall. R2 did not fall to the floor, but did lose her balance and her right arm landed against the wall. Certified Medication Aide (CMA) S was in the room changing the linens on R2's bed and assisted CNA M to walk R2 back to the bed. At approximately 03:00 AM, staff entered the room during scheduled rounds and R2 reported pain. The staff notified the nurse of the resident's complaint and reported she stumbled into the wall at approximately 01:30 AM. After assessment, the nurse called emergency medical services (EMS) and R2 was sent to the ER for evaluation. The hospital called at approximately 05:40 AM to report R2 experienced a fracture to her right shoulder. Interview, on 07/13/22 at 06:11 AM, CNA M stated the resident had poor safety awareness, was ambulatory, and not steady on her feet. The resident required extensive assist of one to two staff members with ADLs. She helped the resident ambulate to and from the toilet the night she broke her shoulder, but without use of a gait belt. She walked R2 back from the bathroom and held onto her left arm with both hands due to R2 being unsteady on her feet. CNA M further revealed R2 pulled away from her when exiting the bathroom, swatted at her with her hand, and then lost her balance and fell into the wall, hitting her right shoulder and arm. R2 did not fall to the floor. CMA S was in the room when it happened and assisted CNA M to help the resident back to her bed. R2 was angry and complained of pain in her arm. They settled R2 into her bed and she went right to sleep. At 03:00 AM during rounds, the resident complained of pain in her right arm, so she went and reported the incident to LN I. She stated she should have used a gait belt during ambulation and transfer. Interview, on 07/13/22 at 11:09 AM, LN H revealed R2's care plan documented the staff were to provide assistance to the bathroom. When residents required any assistance from staff with transfers, ambulation, and toileting, they should be using a gait belt. If a resident refused use of the gait belt and was cognitively impaired, the staff should alert the nurse so other interventions could be attempted for safe ambulation. Interview, on 07/13/22 at 12:22 PM, Administrative Nurse E revealed she expected the staff to use gait belts with all residents requiring assistance with ambulation and transfers. The CNAs should have the gait belts to use for the residents at all times. CNA M should have used a gait belt while assisting R2 to ambulate back to the bed. The facility policy Fall Management, revised 04/07/22, documented .Avoidable accident means that an accident occurred because the facility failed to . Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and, if not, reduce the risk of an accident . The facility failed to ensure Resident (R) 2, who staff assessed as a fall risk, remained free from accident hazards when staff failed to properly provide ambulatory assistance during toileting in the resident's room. On 05/21/22, at approximately 01:30 AM, Certified Nurse Aide (CNA) M assisted R2 with toileting needs and helped R2 ambulate, without use of a gait belt (a device used to help prevent falls), out of the bathroom to go to bed. R2 pulled away from CNA M while she was holding onto her left arm with both hands, batted at the aide with her hand, then stumbled and fell into the wall causing a right shoulder fracture which required a trip to the emergency room .

The facility reported a census of 51 residents with eight selected for review, including six residents reviewed for quality of care. Based on interview and record review, the facility failed to identify lack of urinary output for Resident (R)1, failed to notify the physician in a timely manner regarding abnormal urine output, failed to collect a urine sample for analysis as ordered by the physician, placing the resident at risk for urosepsis (systemic infection as a result of a serious urinary tract infection), and failed to administer an antibiotic ordered for a urinary tract infection for three days following the order. This deficient practice placed the resident in immediate jeopardy. Additionally, based on observation, record review, and interview, the facility failed to measure and monitor progression of healing for R1 and R3's injuries following falls, and failed to perform neurochecks following a fall for R1. Findings included: - The Order Summary Report, dated 02/04/21, for Resident (R)1 included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS), dated [DATE], indicated R1 had a Brief Interview of Mental Status (BIMS) score of 99, indicating she was unable to complete the assessment. The staff assessment of her cognitive function indicated she had short term and long term memory problems, severely impaired decision making skills, and inattention that was continuously present and did not fluctuate. She did not have any behaviors or reject care. She required extensive assistance of one staff for toilet use and had an indwelling catheter present. R1 was always incontinent of bowel and had an unstageable pressure ulcer present. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 12/01/20, indicated R1 was at risk for urinary complications related to her having a catheter in place to promote healing and prevent further complications to her unstageable pressure wound. She required extensive assistance with incontinence of bowel and catheter care. Catheter care should be completed per policy and procedure and labs monitored per orders as well as color, amount, and if odor is present to urine. The staff provide frequent checks to ensure residents remained clean after incontinence episodes. The Care Plan, dated 12/22/20 included a problem that R1 had a catheter related to a pressure ulcer to her coccyx (sacrum). The staff were to provide catheter care per doctor orders, change the catheter per doctor's orders, provide catheter care every shift, position the catheter bag and tubing below the level of the bladder, and observe for and document for pain/discomfort due to the catheter. Additionally, the staff were to observe for and report to the doctor signs and symptoms of a urinary tract infection such as pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, and urine that was foul smelling. On 02/25/21, (the day the resident returned from the emergency department), the staff added new interventions that included intake and output per facility policy, monitor for infection related to the catheter, monitor for signs and symptoms of dehydration, and make sure the catheter remained secure in place. The Order Summary Report, dated 02/04/21, included an order dated 01/04/21, for indwelling catheter to straight drainage. Use a silicone catheter, as R1 had a latex allergy. The size of the catheter should be an 18 French with a 30cc bulb. The staff should change the catheter monthly on the evening shift and change every 24 hours as needed for blockage or obstruction. Review of the Treatment Administration Record (TAR), dated 02/2021, indicated the staff changed R1's catheter on 02/15/21 as ordered to be done monthly, and again on 02/20/21 at 05:26 PM as ordered to be done as needed. Review of R1's output, located in the electronic medical record (EMR) under the Task tab, revealed that on 02/17/21 at 11:37 AM, R1 had 100 milliliters (mL) of output, and lacked further output until 02/19/21 at 01:45 PM which indicated she had 300 mL of output, which was greater than 48 hours later. R1 did not have any further output again until 02/20/21 at 05:02 AM, which was greater than 15 hours later. The Progress Note, located in the EMR, dated 02/19/21 at 05:59 AM, indicated R1 had no urine output this shift, the drops of urine in the drainage bag at the beginning of the shift was a light clear yellow. Staff flushed the catheter now and only the normal saline returned with a little cloudiness, but no yellow color. The noted lacked indication if the staff notified the physician of lack of output, no urine return when flushed, and cloudiness to the return, but no yellow color. The Progress Note, located in the EMR, dated 02/20/21 at 05:28 PM, indicated R1 was without urine output during the shift, the staff attempted to flush the catheter and was ineffective, and the nurse inserted a new catheter. The nurse observed cloudy, dark, odorous output and she notified the primary care physician. The Physician Order, dated 02/22/21, instructed the staff to obtain a UA (urinalysis) one time only due to the urine being dark, cloudy, odorous, and with sediment. The Progress Note, located in the EMR, dated 02/26/21 at 06:40 AM, late entry for 02/23/21 at 11:35 PM, indicated R1's urine output was pink tinged in the catheter. The Progress Note, located in the EMR, dated 02/24/21 at 03:02 PM, indicated R1 had a catheter in place, the catheter was patent at this time with thick, dark urine observed. Review of the Medical Record lacked a report that the facility obtained a urine sample per the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] The Progress Note, located in the EMR, dated 02/25/21 at 05:00 AM, indicated R1 was sent to the emergency room (ER) via emergency medical service (EMS) for evaluation and treatment due to a change in her status. R1's catheter had dark colored urine return noted with a greenish-yellow discharge, her temperature was 99.3 degrees Fahrenheit, her respirations were between 22-26 breaths per minute, she was clammy and diaphoretic (excessive abnormal sweating in relation to environment and activity that tends to affect the entire body rather than a part of the body). The ER nurse reported to the facility that R1 would return on an antibiotic and that the staff changed the catheter while she was there. The hospital emergency department Disposition Summary, dated 02/25/21, revealed R1 had a catheter complication, the catheter had sediment in the tubing with dark black urine. The staff at the emergency room replaced the catheter and the urine return was pink tinged with a large amount of sediment, and a urine specimen was sent to the lab. The balloon tip of the catheter was degraded, and the catheter tubing, bag, and tip was black in color. R1 received intravenous (IV) fluids and [MEDICATION(S)] (medication used to treat bacterial infections). The hospital Physician Clinical Report, dated 02/25/20, included the clinical impression of a UTI, [MEDICATION(S)] ([MEDICATION(S)]) given and started [MEDICATION(S)] (medication used to treat urinary tract infections), 100 milligrams (mg) twice a day, for five days. Review of the Prescription Drug Script from the hospital, under the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It had a faxed stamp on it with a date handwritten of 02/28/21. The Progress Note, dated 02/25/21 at 03:57 PM, indicated R1 returned to the facility via ambulance around 09:20 AM with no new orders. The note failed to indicate if the staff clarified the orders as it was previously documented she would return on an antibiotic. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The first dose of the medication administered was on 02/28/21 at 08:00 AM. She also received the medication at 08:00 PM. This was three days after R1 returned to the facility from the emergency room with the new order. On 03/02/21 at 03:21 PM, Administrative Staff B, confirmed she was not able to locate any lab reports from the resident's urinalysis ordered on 02/22/21 and would call the lab. On 03/02/21 at 03:51 PM, Administrative Nurse D revealed the staff did not collect the UA ordered by the physician on 02/22/21 and she would expect the staff to collect the UA as ordered. On 03/03/21 at 11:47 AM, Licensed Nurse (LN) J revealed she worked on 02/15/21 but did not change R1's catheter on that date as indicated by the TAR. On 03/03/21 at 12:02 PM, LN K revealed she worked the 06:00 AM to 06:00 PM shift on 02/20/21 and changed R1's catheter that day. She received in report that R1 had no output during the previous shift. LN K revealed she checked on R1 and noted some urine her catheter drainage bag, and when she went to check on her later and she had no further output, so she tried to flush the catheter without success. Then, she changed the catheter and dark, thick, odorous urine returned, and the tubing that she removed had a white coating as well as the bag, and the tip of the catheter was intact and contained some sediment. There was some sediment in the tubing, but it was not completely clogged. LN K faxed the physician but did not receive a response as it was Saturday. She revealed that was the procedure that she was aware of and R1 did not have a fever or complain of pain. On 03/03/21 at 01:11 PM, Administrative Nurse E, responsible for infection control, stated she was not aware that R1 had an antibiotic order when she returned from the emergency roiagnom on [DATE], she tries to look over the emergency room orders when residents return and did not know why the staff did not administer the antibiotic until 02/28/21. 03/03/21 at 01:41 PM, Administrative Nurse D revealed the staff should have notified the physician on 02/20/21 by phone rather than fax. The staff should have called for clarification regarding the antibiotic [MEDICATION(S)] on the Physician Clinical Report, and the antibiotic should have been started sooner than 02/28/21. On 03/03/21 at 03:58 PM, Consulting Physician GG revealed that he received report from the ER that R1's catheter was falling apart and looked old. The facility had a standing order to change it every month. The nurse that worked on 02/20/21 should have called the ER with her concerns since it was a Saturday and the physician clinic was not open. The ER nurse can assist to provide information to a physician, physician assistant, or a nurse practitioner for further direction. R1 could have received treatment sooner and she definitely needed a UA done. He expected the facility should have started the [MEDICATION(S)] the evening she returned from the ER, as she returned back to the facility in the morning, which gave the facility plenty of time to send the script to the pharmacy. It is his understanding that the pharmacy made night deliveries. The facility policy, Changes in Resident's Condition or Status, dated 05/05/20, indicated it was the policy of the facility to notify the primary care provider of changes in the resident's status. The policy included that the facility must immediately consult with the resident's physician for a need to alter treatment significantly. The facility policy, Physician Orders, dated 07/27/20, indicated signed orders including new pre-written medication orders become active upon the release of he orders on a specific date and time. The facility failed to identify lack of urinary output for R1 from 02/17/21 at 11:37 AM, until 02/19/21 at 01:45 PM, which was greater than 48 hours later and did not have any further output again until 02/20/21 at 05:02 AM, which was greater than 15 hours later. The facility failed to notify the physician in a timely manner regarding abnormal urine output, failed to collect a urine sample for analysis as ordered by the physician, placing the resident at risk for urosepsis, and failed to administer an antibiotic ordered for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice placed the resident in immediate jeopardy. On 03/04/21 at 10:15 AM, Administrative Staff A was informed the residents were in immediate jeopardy and was provided the Immediate Jeopardy Template for failure to identify the lack of urinary output, failure to notify the physician in a timely manner regarding dark, thick, odorous urine when the staff changed the catheter due to inability to flush the catheter and lack of output, failed to collect a urine sample as ordered, and failed to administer and antibiotic as ordered. The facility abated the immediate jeopardy on 03/04/21 at 04:45 PM when they completed the following: 1. Provided education to Licensed and certified nursing staff regarding Indwelling Foley Catheter Management Policy including urinary output, administration of antibiotics, and obtaining urine specimens. Educaton on Resident's Condition or Status Policy regarding physician notification of change in resident's condition related to signs and symptoms of urinary tract infection. Education on physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Completed on 03/04/21 at 3:00 PM with plans for absent staff to receive education prior to working their next shift. 2. Director of Nursing and designee audited current in house residents with an indwelling catheter to verify recording of intake and output recordings processing of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Completed 03/4/21 at 4:45 PM. 3. Held a Quality Assurance and Performance Improvement meeting with committee members and the medical director to address the alleged deficient practice. Completed 03/04/21 at 4:45 PM. Following validation of the removal of the immediate jeopardy, on 03/04/21 at 04:45 PM, the deficient practice remained at a scope and severity of a G. Furthermore, The Order Summary Report, dated 02/04/21, for Resident (R)1 included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, the Admission Minimum Data Set (MDS), dated [DATE], indicated R1 She required extensive assistance of two or more staff for transfers, her movement from sitting to standing position was not steady and required staff assistance, as well as transferring surface to surface such as between bed and chair or wheelchair. R1 had a fall in the past month and past two to six months prior to admission/entry or reentry and had not had any falls since admission/entry or reentry. The Falls Care Area Assessment, (CAA), dated 12/01/20, revealed that R1 was at risk for falls due to her history of falls and balance issues and has had fall in facility prior to this admission. Her BIMS score was 99, she had poor safety awareness, and she is not steady without staff assistance. The Care Plan, dated 09/25/20, included that R1 was at risk for falls. The staff were to perform frequent checks and encourage her to lay down and rest, check room every shift to remove any clutter, assist with activities of daily living (ADL's) as needed, and keep her call light in reach. An intervention, dated 03/01/21 for 02/05/21, included that R1 fell from her wheelchair and she is not to be left in her wheelchair unattended and that she has a low bed and fall mat in place to prevent injury. The progress note, located in the electronic medical record (EMR), dated 02/05/21 at 04:08 PM, revealed R1 was found by the staff laying on the floor. She denied striking her head (BIMS 99), there was no apparent injuries noted, no red marks on her head or other parts of her body. R1 stated she went to stand up to go to bed and fell right down. The progress note, located in the EMR, dated 02/05/21 at 07:28 PM, revealed that R1 developed a raised area with red and blue discoloration on the left side of her forehead, which may be related to her recent fall. Resident was alert, vitals assessed, neurochecks were within normal limits, and the staff notified the oncoming nurse of new findings. The note lacked measurements of the area. The Weekly Skin Integrity Data Collection, located in the EMR under the assessment tab, dated 02/05/21 lacked the presence of the raised, red and blue discolored area to the left side of R1's forehead. The event note, located in the EMR under the progress note tab, dated 02/09/21, revealed that review shows that the staff found R1 laying on the floor on her back after she tried to transfer herself from the wheelchair to the bed and at that time she did not show that she had any injuries. The intervention was for the staff to not put her in her room in her wheelchair as she will attempt to transfer herself. Review of the EMR and the hard chart lacked neurochecks for R1 following the fall when the staff determined that she hit her head and a raised area with red blue discoloration was present to the left side of the forehead. Review of the Weekly Skin Integrity Data Collection, located in the EMR under the assessment tab, dated for 02/12/21, 02/19/21, and 02/26/21, lacked any discoloration or raised area present to R1's left side of her forehead. The progress note, located in the EMR, dated 02/26/21 at 06:40 AM, late entry for 02/23/21 at 11:35 PM, indicated that on a head to toe assessment, R1 had a large area of bruising to the left side of her face in the temple region and the resident was unable to verbalize or recall how long the bruising had been there. The note lacked measurements or description of color of the area. On 03/01/21 at 10:39 AM, R1 was resting in bed awake, an area of faded green bruising with light purple in the center was present to the left side of her forehead and temple area. On 03/02/21 at 01:38 PM, Certified Nurse Aide (CNA) N revealed that she was on duty when R1 fell on [DATE], and right after the fall she had a goose egg and a bruise to her head, and that the nurse was aware of the area after returning from break. On 03/02/21 at 02:29 PM, Licensed Nurse (LN) H revealed that when a resident falls neurochecks are started and done for 72 hours if the fall was not witnessed and are completed in the computer under the assessment tab and done on paper. If a resident has injuries from a fall it would be documented in the risk assessment and will transfer to the progress notes, the assessment includes a skin assessment. The weekly skin assessment asks if the skin is intact and if there are new findings, and if so, then we would document what the new finding was and the treatment progress. A hematoma or bruising would be monitored and measured weekly. LN H reported that he was on duty when R1 fell , she did not have any issues, but later he noticed a bump come up on her head and he added that to his report. The neurochecks were done at that time and he reported to the nurse on duty as he was past the end of his shift when the area was noted, and he was on break when the fall occurred and another nurse responded to the fall. 03/02/21 at 04:47 PM, Administrative Nurse D revealed that she performed the initial assessment after R1's fall on 02/05/21 as the charge nurse was on break. She did not perform neurochecks at that time because R1 said she did not hit her head. Furthermore, she revealed that the staff are to do neurochecks on unwitnessed falls or anyone with obvious injuries. R1 has good and bad moments, her most recent BIMS score was 99, and she went by her assessment at the time of the fall to determine if neurochecks needed to be done. She was found laying flat on her back, had no complaints of pain, and no bumps or bruises were present at the time. At the point when the staff noticed the bruising/hematoma neurochecks should have been continued and it should have been documented on the skin assessment and confirmed the area was not on the weekly skin notes. The facility policy Skin Integrity and Pressure Ulcer/Injury Prevention and Management, dated 10/14/20, indicated that a skin assessment should be performed weekly by a nurse and lacked description of what needed to be included in the assessment. The facility policy, Event Management System Policy, dated 05/15/20, lacked instruction for neurochecks following an unwitnessed fall. The facility failed to perform neurochecks continuously following R1's fall on 02/05/21 to ensure she was not having changings in her neurological status indicative of an internal head injury and failed to measure the bruising/hematoma at the time noted on 02/05/21and then weekly following the fall. - Resident (R)3's signed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The significant change Minimum Data Set (MDS), dated [DATE], assessed R3 with a Brief Interview of Mental Status (BIMS) score of 00, indicating severely impaired cognition. The resident required extensive assistance and two-person physical assist for toileting use, dressing, and transfers. The care plan, revised on 12/25/20, documented the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The Electronic Medical Record (EMR) under the progress note tab, dated 12/25/20 at 12:07 PM, evidenced this nurse was getting coffee in the kitchen for another resident. As this nurse walked out of kitchen the resident was falling out of her chair due to falling asleep. She hit her knees then hit the floor with the right side of her head before this nurse could get to her. She had small skin tear around a small gash that was bleeding. No measurements documented. Small bruising to her knees were noted as well. She complained of head and knee pain. Vitals were blood pressure 153/64; pulse 65; respirations 20 with a normal pattern; temperature 98.3, and oxygen level was 94%. Staff assisted the resident to her chair after vitals and physical assessment were complete. She had full range of motion per her normal. Once in chair, a cold damp cloth was applied to area until the bleeding stopped. The 12/26/20 Weekly Skin Integrity Data Collection Tool lacked any documentation of the head wound and evidenced skin intact. The EMR lacked measurements and progression of healing of the scalp laceration. Per observation, on 03/01/21 at 10:55 AM, R3 sat positioned in her wheelchair at the nurses' station, the scalp laceration appeared healed. On 03/03/21 at 12:19 PM, Licensed Nurse (LN) I stated R3 fell and received an injury to the right side of her head, just above her ear. R3's hair required washing to remove the blood. Interview on 03/03/21 at 1:15 PM, with Administrative Nurse D, confirmed the electronic medical record and the hard chart lacked measurements of the scalp laceration and lacked monitoring of the wound for healing. The facility policy, Skin integrity and Pressure Ulcer/Injury Prevention and Management, dated 10/14/2020 documented, when skin breakdown occurs, it requires attention and a change in the care plan to appropriately treat the patient. The facility failed to complete wound measurements and monitor the progression of wound healing to a scalp laceration following a fall.

Based on interview and record review, the facility failed to develop and implement individualized care plan interventions to prevent accidents from occurring for one of one cognitively impaired resident (R3), who had a history of [REDACTED]. R3 then experienced a fall with major injury on [DATE] (12 days after admission), and sustained a [MEDICAL CONDITION] cervical vertebrae. R3 required emergency transportation to a hospital, then to an intensive care unit at a different hospital. R3 discharged from the hospital on [DATE], and then passed away on [DATE], five days after the fall, and 17 days after his admission to the facility. The census included 52 residents. Findings include: R3's admission nursing assessment, dated [DATE], documented that the reason for his admission was increased weakness, requiring more assisted care. R3 required extensive assistance with locomotion, toileting, personal hygiene, transfers, and bed mobility. R3 experienced unsteady gait and balance issues and had poor trunk control. R3 was at risk for falls. R3's Fall Risk Evaluation assessment, dated [DATE], documented that he experienced one or two falls prior to admission. R3 experienced a change in his cognition over the last 90 days, and experienced behaviors such as distraction, wandering, altered perception, restlessness, lethargy (sleepiness), and/or a change in mental function throughout the day. The assessment documented that R3 walked with problems, and required the use of an assistive device. R3 required physical support during a balance test. R3 required at least three high-risk medications, and had three or more [DIAGNOSES REDACTED]. Review of R3's Elopement Risk Evaluation, dated [DATE], documented that he was cognitively impaired with poor decision making skills. Review of R3's baseline care plan, dated [DATE], documented that he was cognitively impaired, or experienced an impaired thought process. Staff must provide simple one to two step instructions and allow extra time to answer questions. The care plan further documented that R3 was at risk for falls. Facility staff must assist with activities of daily living (ADLs) as needed, keep his call light within reach, complete a fall risk assessment, and orient him to his room. There were no further individualized interventions to keep the cognitively impaired resident free of falls. No documentation could be reviewed that addressed how the cognitively-impaired resident would be able to remember to use his call light, or remember orientation to his room. Review of R3's [DATE] Minimum Data Set (MDS) assessment (a federally mandated assessment tool required to be completed) recorded under Section GG (Functional Status) that he required substantial to maximal assistance from caregivers to complete his ADLs, including but not limited to transfers and walking. Review of a nursing note, dated [DATE] at 6:56am, authored by Registered Nurse (RN1) recorded that RN1 heard R3 yelling help me. R3 was found lying on his back on the floor, with his walker at his side. He wore shoes and socks, and his call light was on his bed. R3 repeated oh my, and attempted to sit up. R3 complained of head pain, and was assisted to a sitting position before being moved to his bed. Facility staff notified R3's physician via fax, called R3's family, and notified emergency medical services (EMS). EMS arrived at 4:01am, and transferred R3 to the hospital. The facility's investigation summary documented the fall occurred at approximately 3:30am. Review of a witness statement, dated [DATE], written by Medication Aide (MA1) documented that MA1 assisted R3 with toileting 45 minutes prior to the fall. MA1 documented that R3 was weak and shaky. No documentation could be located that indicated if MA1 notified the charge nurse on duty that R3 was weak and shaky prior to the fall occurring, or if facility staff increased supervision in response to R3's weak and shaky presentation. Review of R3's emergency room Note-Final, dated [DATE] at 4:25am, documented that R3 sustained a C2 (second cervical vertebrae) traumatic spondylolisthesis fracture (hangman's fracture) as a result of the fall. The hospital transferred R3 to the intensive care unit (ICU) of another hospital. Review of R3's Case Management Progress Note, dated [DATE], recorded that the hospital social worker (SW) met with R3's family to discuss discharge. R3's family stated that they were concerned the facility would not be able to manage the pt's (patient's) care needs. The family was hesitant for pt to dc (discharge) back to this location (the facility) d/t (due to) his fall he had there. Review of R3's Case Management Progress Note, dated [DATE] documented that R3 would discharge to a different facility at 2:30pm on [DATE]. On [DATE] at 1:40pm, R3's family member stated that R3 moved to the facility because he required more care, and experienced a fall at his prior facility. The family member stated that R3 was at risk for falling, and that the facility failed to watch him as closely as he needed. Following the fall, R3 discharged to a different nursing facility, and died shortly after admission. The family member stated that R3 died as a result of the fall. On [DATE] at 12:00pm, the MDS coordinator indicated that baseline care plans were developed by the nurse on duty at the time of an admission. After this, the MDS coordinator would go in and finish up the care plan, based on physician's orders and what is going on with the resident. The MDS coordinator indicated that the baseline care plan intervention for R3's falls were universal interventions put into place for all residents. The MDS coordinator indicated that R3 was at high risk for falls. On [DATE] at 12:50pm, the Director of Nursing (DON) indicated that R3's fall care plan was not appropriate for him. The DON indicated that due to R3's impaired cognition, he would not have remembered to use his call light, or remember the layout of his room. The DON indicated that R3 discharged from the hospital to a different nursing facility because his family was concerned that the facility would not be able to meet his needs. As of [DATE] at 3:00pm, RN1 and MA1 failed to return calls. On [DATE] at 9:10am, the Administrator indicated that R3's investigation lacked information regarding his stay at the hospital he was transferred following his emergency room visit, and indicated that the facility failed to notify the State Agency that R3 expired after his fall occurred. The Administrator indicated that the investigation was not complete without the information. Review of the facility policy, dated [DATE], titled Event Management System Policy, documented that the facility would provide an environment that is free from accident hazards, over which the facility has control, and provides supervision and assistive devices to each resident to prevent avoidable accidents. The policy further documented that an avoidable accident was when an accident occurred because of the facility failed to . Implement interventions, including supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice .

The facility reported a census of 60 residents. The sample included 18 residents with 2 residents reviewed for pain. Based on observation, interview, and record review, the facility failed to ensure 1 (#167) resident received adequate pain management, at the time of admission, to alleviate his/her pain. The resident was in severe pain in the facility for 8 hours before receiving his/her needed pain medication. Findings included: - The signed physician's orders [REDACTED].#167, documented the resident admitted on [DATE], with [DIAGNOSES REDACTED]. The admission MDS (minimum data set), dated 10/27/18, revealed the resident had a BIMS (brief interview for mental status) score of 15, which indicated the resident had intact cognition. He/she required extensive assistance of 2 staff for bed mobility, transfer, toileting, and dressing. He/she had impairment in ROM (range of motion) on one side of his/her lower extremity. The resident rated his/her pain as severe, almost constant, and limited his/her day to day activities because of the pain. He/she received an opioid (a narcotic for pain relief). The CAA (care area assessment) for pain, dated 11/2/18, documented the resident had a fracture of his/her ankle before admission to the facility, and required medication to manage his/her pain. The pain care plan, dated 10/20/18, documented to administer pain medication and monitor for possible side effects from the pain medication, educate the family and the resident about pain management, and the resident should request pain medication early, before the pain was out of control. Report changes in the resident's pain location/ type/frequency and intensity, to the physician. Review of the physician's orders [REDACTED].>1.) Admit the resident to the facility, 10/20/18 at 12:15 pm. 2.) [MEDICATION NAME] (pain medication) 10-325 mg (milligram), one every 4 hours PRN (as needed), for pain, 10/20/18. Review of the MAR (medication administration record), evidenced staff administered [MEDICATION NAME] on 10/20/18, however, staff failed to document the time or follow-up for effectiveness. Review of the narcotic controlled substance administration record, dated 10/20/18, documented staff administered [MEDICATION NAME] on 10/20/18 at 8:00 pm (7 hours and 45 minutes after admission). In addition, review of the MAR, from 10/20/18 to 10/31/18, evidenced the resident received [MEDICATION NAME] on 20 occasions. Staff failed to follow-up for effectiveness of the pain medication, and staff documented on 7 occasions, scores of 7-8 out of 10 on a pain scale. Review of the nurse's notes included: On 10/20/18, the entry documentation of 2:35 pm, the resident admitted from an out of town hospital (45.3 mile/44 minute drive), to the facility. He/she had a left lower extremity splint. On 10/21/18, the resident reported pain to his/her left ankle, and staff applied cold packs as well as medicated the resident. Review of the controlled substances list on the narcotic emergency kit, [MEDICATION NAME] was available in the facility. On 11/14/18 at 11:00 am, the resident had a cast on his/her left lower extremity, with his/her foot elevated on the wheelchair foot rest. On 11/15/18 at 5:15 pm, the resident in his/her wheelchair, with his/her left foot elevated on the wheelchair foot rest. On 11/13/18 at 11:44 am, the resident reported he/she was in pain when he/she admitted to the facility, because of the recent surgical incisions and surgical screws in his/her left ankle. He/she arrived to the facility around 11:00 am, and the long ride increased his/her pain, and the pain was so severe, that the pain shot up his/her thigh and made him/her unable to move his/her left leg. He/she explained the pharmacy delivered medications in the evenings, and if the medications were not delivered that night, it may take 24 hours for the medications to be delivered. He/she reported staff said well, it happens, and stated the facility had a lock box for medications, but he/she wasn't going to go thru the process of getting out the pain medication. The resident stated she would be willing to go to the hospital emergency room for pain medication, due to the severe pain. Sometimes when he/she requested pain medication, the response time was more than I was able to wait. It was hard. On one occasion, he/she reported response time of 1 hour and 45 minutes, and that's a long time when my pain level is up there. On another occasion, he/she waited over 1 hour. He/she reported since it happened to him/her, it surely happened to other people. On 11/13/18 at 2:35 pm, direct care staff E reported the resident admitted to the facility in a lot of pain, but in order for staff to get pain medication from the emergency narcotic kit, staff needed to get the physician's orders [REDACTED]. Upon request, staff called the pharmacy, and direct care staff E reported staff had not used the narcotic emergency kit since (MONTH) (YEAR). On 11/15/18 at 4:09 pm, licensed nursing staff F reported the resident did have pain in his/her lower extremity due to a recent surgical procedure. When the resident admitted , he/she was in severe pain, but he/she received a report from the hospital, and the resident had the pain medication around 10:00 am, before dismissal from the hospital. The resident came in under Medicare A, so the medications came from another town (approximately 2 hours travel distance), and the delivery was in the evenings. If staff needed to obtain medication from the emergency narcotic kit, staff must contact the physician for a written prescription, then staff must contact the pharmacy for permission to get a code, and get into the locked box. Licensed nursing staff F reported he/she did not remember getting any pain medication out of the emergency narcotic kit for the resident. The evening charge nurse responsibility was to also pass medications to all the residents, and he/she stated staff did have issues getting residents their medications, and that staff addressed the issue with the pharmacy. On 11/19/18 at 10:54 am, administrative staff H, verified the resident received his/her first [MEDICATION NAME] on 10/20/18 at 8:00 pm, 8 hours after the resident admitted to the facility. On 11/19/18 at 11:41 am, administrative staff A, verified the resident admitted on [DATE] at 12:15 pm. On 11/19/18 at 10:50 am, administrative nursing staff B, reported when a physician ordered a resident's medication, the facility had 24 hours to get the medication into the building, because the pharmacy delivered every evening. If the physician ordered a narcotic, and the medication was not delivered, staff should notify the director of nursing. He/she reported, on occasions, staff struggle with the pharmacy to obtain pain medications to the facility. If the medication was available in the emergency narcotic kit, then staff should obtain the medication from the emergency kit. The resident had a surgical repair, and staff should obtain and administer the pain medication, from the emergency kit, as no one should be in pain. The facility's pain management policy, dated 11/2016, documented in order to help a patient attain or maintain his/her highest practicable level of well-being, and to prevent or manage pain. The facility failed to ensure this resident, who admitted to the facility with severe pain, had his/her pain managed, in a timely manner. The resident was in severe pan in the facility for 8 hours before receiving his/her needed pain medication.

The facility reported a census of 65 residents (with 43 residents in the north and south units), and 3 selected for sample review of elopement, all 3 identified as elopement risk and living outside of the special care unit. Based on observation, interview and record review the facility failed to ensure 1 (#1) of the 3 residents, received adequate supervision and/or assistive devices to prevent elopement from the facility without staff knowledge. The resident exited the facility without staff knowledge, when a staff member turned off the alarm without looking for the resident. The resident was found 30 to 45 minutes later by a bystander, standing in a parking lot, near a busy street. This deficient practice placed the resident in immediate jeopardy. Findings included: - Resident #1's diagnoses, from the physician's orders [REDACTED]. The annual MDS (minimum data set), dated 1/5/18, included a BIMS (brief interview of mental status) score of 12/15, indicating moderately impaired cognition. The resident expressed feeling tired, trouble with sleep, and required supervision for most ADLs (activities of daily living), including locomotion with wheelchair use. The quarterly MDS, dated [DATE], included a BIMS of 13/15, indicating intact cognition. The assessment identified the resident expressed having little interest in doing things, felt down/ depressed/hopeless, trouble with sleep, felt tired, appetite concerns, and felt bad about self. The assessment lacked identification of other mood/behavioral concerns. The assessment identified the resident continued to require supervision for ADL of locomotion, and the resident used a walker and wheelchair for mobility. The 3/15/18 CAA (care area assessment) for cognition, included the resident remained at risk for a decline in cognition due to dementia. Elopement assessments, dated 7/17/17 and 10/24/17, lacked identification of elopement potential. A 1/5/18 assessment identified the resident with impaired cognition, poor decision-making skills (such as intermittent confusion, cognitive deficits or disorientation), was independently ambulatory and with pertinent diagnosis, however, the assessment did not identify the resident at risk for elopement. The subsequent assessments, dated 4/4/18 and 6/3/18, also lacked identification of the resident being an elopement risk. A care plan, dated 3/15/18 instructed staff the resident was an elopement risk per an assessment completed in (MONTH) (YEAR). Staff interventions included adding the resident's information and picture to the elopement notebook. Additionally, an intervention instructed staff to redirect the resident when displaying exit seeking behaviors and complete frequent checks keeping the resident in sight, when possible. The plan of care lacked updated interventions when the resident attempted to leave the facility unattended on 4/12/18 and 4/18/18. On 3/8/18 the staff notified the physician of the resident throwing a plate at a staff member who passed trays in the dining room. The resident stated he/she believed the staff member was going to kill him/her. The physician ordered [MEDICATION NAME] 0.5 milligrams every 8-hour PRN (as needed) for anxiety. On 3/27/18 at 4:00 PM, the staff notified the physician of the resident with increased depressive behaviors. The physician ordered a Geriatric psychiatric evaluation. Nursing notes documented, on 4/12/17 at 2:45 PM, revealed the nurse received a call from the physician office who indicated the resident called the office requesting something stronger for depression. The nurse observed the resident enter and then exit the parlor where he/she made the phone call, and then observed the resident walk towards the therapy outside doors. The resident attempted to exit the building, with this nurse arriving at the door to stop the resident from exiting. Nursing notes documented, on 4/18/18 at 3:02 PM, the resident went to the north hall nursing desk and threw a soiled brief at the CMA (certified medication aide) at the desk. Staff assisted the resident back to the south hall for assistance. The staff notified the nurse the resident being found with his/her feet out of the window, at the end of the South hall. The staff found the resident in the hallway, with a jacket on in his/her wheelchair, and the resident stated his/her the plan was to leave. Staff found the resident opened the window, kicked out the screen and had his/her legs out of the window up to his/her knees and held onto the window frame. Staff assisted the resident back into the facility, into the wheelchair, and placed the resident on every 15-minute visual checks. Nursing notes on 6/3/18 at 12:21 AM, identified the staff notified this nurse, around 6:15 PM, that the resident had managed to make it out of a set of doors in the facility and was found by a prior employee in a parking lot of the Recreation Center, across the street (approximately stepped off at a minimum of 320 feet). The prior employee brought the resident back into the facility. The resident asked the staff, at that time if he/she was just supposed to stay here for good? Staff documented the resident was normally alert with periods of confusion as to why he/she was at the facility and why he/she could not go home. The aides stated, after the fact (elopement), that the resident made comments throughout the day, about leaving and attempting to learn the code to the doors. Upon return into the facility, the staff placed the resident on 15-minute visual checks. The staff documented the resident lacked any injuries from the incident. Staff noted the resident remained alert with some confusion. Review of the resident's behavior monitoring, for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR), lacked evidence of any of the behaviors/incidents documented in the nursing notes. Review of the facility's 2 Elopement books, revealed the south hall notebook contained a picture of the 2 residents identified as elopement risks for the south hall as well as 2 halls/units of the facility. The north hall Elopement book contained a picture of the resident on the north hall, identified as an elopement risk, and contained a picture of 1 resident from south hall identified as an elopement risk, however, lacked a photo and information of resident #1. The facility failed to maintain all elopement books in the facility with the same updated information. The facility investigation, dated 6/4/18, consisted of several non-notarized witness statements, an incident/ accident data entry questionnaire and an incident follow-up and recommendation form. The investigation lacked evidence of a causal factor for the elopement occurring. Observation on 6/6/18 at 3:15 PM revealed the area from where the resident exited the building had a sidewalk leading the visitor parking area of the facility. This lead to a busy street area, approximately 360 steps from the side door to the beginning of the parking lot next door. The parking lots each evidenced curbing around the parking lots. On 6/6/18 at 3:15 PM, observation identified the resident sat in an easy chair in his/her room, with the wheelchair in front of him/her. The resident appeared to watch television. When questioned about going outside alone, the resident indicated he/she didn't know/understand or know what to say. The resident wrinkled his/her face and frowned, seeming to become agitated, wringing his/her hands. On 6/7/18 11:30 AM, observation identified the resident feeding and watering the birds in the lobby area, on the south end of the facility. After completing these tasks, the resident self-propelled the wheelchair to the dining room for lunch. On 6/6/18 at 1:00 PM, administrative staff A and administrative nursing staff B, revealed that licensed nursing staff C, notified staff B on 6/2/18 around 7:00 PM, of the elopement. After reviewing the information provided to staff B on the telephone and the conversation with staff C, then staff A and B determined no elopement occurred, and therefore the staff did not report this incident to the state agency. On 6/6/18 at 1:20 PM, direct care staff D, reported the resident became easily agitated and told staff often and clearly that he/she did not want to be at the facility. The staff reported if he/she heard the door alarm in the special care locked unit, he/she would respond promptly, however, indicated the staff from the unit were not to leave the unit unattended to go and respond to other door alarms. On 6/6/18 at 1:30 PM, direct care staff E reported he/she worked on 6/2/18, when the resident eloped. The staff reported that several agency CNAs (certified nurse aides) were on duty that evening. Staff E reported he/she worked on both north and south halls helping as needed. Earlier in the shift that day, the resident was asking staff and other residents about the code to get out the door. The staff reported that all the agency staff needed to be told about the different alarms, where to find what door was alarming etc., because when he/she talked to them, they were not aware of elopement procedures and who to watch for. The facility staff were trained to go after a resident when seeing them get out the door and to alert the charge nurse. That evening staff E went to supper either right before or during the time the resident went out. The alarm was not sounding when staff E went out to supper, nor was it sounding when staff E got back. The staff further noted he/she did not see the resident out in the parking lot. On 6/6/18 at 3:45 PM, administrative nursing staff F reported the resident should be considered an elopement risk because the resident does go back and forth with his/her [MEDICAL CONDITION] depression. When the resident experienced depression, he/she sometimes sought exits, but not when in the manic phase. On 6/6/18 at 4:11 PM, agency direct care staff G was not aware of any residents on the south and north halls, being at risk for elopement, until after the incident occurred. The staff indicated that during his/her training in the facility, the facility failed to instruct him/her of the elopement books on each hall, however, he/she did know about the elopement book on the west hall (a locked unit). On 6/6/18 at 4:50 PM, dietary staff H reported he/she saw the resident that afternoon, around 6:00 PM when going to the west unit to assist with supper. On 6/6/18 at 4:50 PM, direct care staff I, reported the resident came to the dining room around 5:30PM. Staff I asked the resident if he/she was hungry and the resident replied No. The staff moved on with his/her work. Staff thought the resident left the dining room around 5:50 to 6:00 PM. Also, that evening staff I went to the south hall and upon return, an agency staff was heading toward the doors, and asked staff I for the code to turn off the door alarm. Staff I informed the agency staff of the code and then returned to the kitchen. On 6/6/18 at 4:55 PM, direct care staff J reported upon arriving to work on 6/2/18, he/she immediately noted that most of the staff were Agency staff. Staff J reported first seeing this resident around 2:30 PM, while passing ice water. The resident indicated, at that time, he/she was going home. Staff J teased with him/her a bit about all the stuff and was successful in re-directing the resident. Staff J left the resident in his/her room, watching TV and smiling. Staff J reported the next time he/she saw the resident he/she was self-propelling towards the dining room, approximately 5:45 PM. Staff J responded to a call light for another resident and assisted that resident with cares and to bed. While the staff assisted that resident who takes a long time with cares, staff J heard the alarm sound, however, was unable to leave the resident he/she was assisting. Staff J reported about 6:00 PM, he/she left to respond to the call light, but it stopped alarming about that time. Staff J explained, I know the alarm sounded at least 15 minutes and maybe more. Staff J stayed on the south hall, responding to residents' needs, and later heard the resident was found outside in the recreation centers parking lot. On 6/6/18 at 5:35 PM, direct care staff K, reported he/she worked on 6/2/18, during the evening, and noted a former employee approached him/her in the hallway. That employee told staff K that he/she had been passing by and noted the resident in the parking lot of the recreation center and was bringing him/her back to the facility at approximately 6:15 PM. Staff K immediately went to bring the resident from the lobby area to the south side. The resident appeared in a good mood, without distress or concern. Staff K gave the resident a drink of water and then went and notified the charge nurse. On 6/6/18 at 5:50 PM, direct care staff L reported hearing the alarm sounding, however was unable to respond due to providing other patient care. On 6/6/18 at 6:05 PM, direct staff care M reported working on 6/2/18, in the evening, when the resident eloped from the building. Staff M reported that at approximately 6:30 PM, staff M was assisting another resident with a shower. The water was running, the fan was on, and the door closed and he/she did not hear anything in the room. During the shower, another aide stuck their head through the door and told staff M to listen for the alarm, as a resident had gone outside alone. On 6/6/18 at 6:15 PM, agency direct care staff N reported he/she lacked any first-hand knowledge of the elopement. The staff reported they received instruction to use the care guide directives in the computer for identification of residents at risk for elopement and the residents' pictures were in the care guide. On 6/6/18 at 6:20 PM, licensed nursing staff C reported that evening was a confused mess. As he/she was the only nurse on duty from 6P to 6A, the staff member, got report from 3 different nurses. While receiving report, an aide came and indicated a resident was experiencing chest pain. The nurse immediately left to attend to that resident and had to administer 3 [MEDICATION NAME] tablets along with every 5- minute blood pressure checks for an elevated blood pressure. The staff reported while attending to this resident an aide came in and reported the resident eloped and a former employee returned the resident to the building. The staff reported the resident seemed fine and therefore the staff remained with what appeared to be the more critical patient. After speaking with the ER (emergency room ) and stabilizing the chest pain/blood pressure, staff C did check on resident #1, around 7PM. The resident had no complaint about anything, a skin check did not identify any new skin issues, he/she seemed happy and content. Later that evening the resident went to bed and slept well. The staff reported, that due to the number of agency staff and lack of any injury, the staff requested the aides to complete statements and he/she did not really talk with them about their statements. Staff C notified the DON (director of nursing) and placed the resident on every 15-minute visual checks. On 6/6/18 at 6:45 PM, agency direct care staff P reported, he/she worked the north hall, on 6/2/18 2-10PM. The staff reported he/she did not see the resident leave, being in another resident's room. The staff heard the door alarm begin sounding, but was not sure where or what it was. The staff attempted to completed cares with the resident and then left to respond to the alarm, however, when getting to the door he/she did not know the code to disarm the alarm and the resident turned their call light back on, so he/she returned to that resident's room to see what else was needed. The staff believed the alarm sounded for approximately 20 to 25 minutes time. The staff reported this was his/her first time to work at the facility and did not receive education about the alarms, who was at risk or anything about the elopement risk notebook. Staff reported being able to turn off the alarm the next time, because a dietary staff member was in the hall and gave staff P the code. The staff noted a visitor in the hallway and thought the visitor in the hall set off the alarm when he/she did not know the code either. Approximately 20 minutes after that, a lady who worked at the facility previously, brought the resident back into the building saying the resident was found in the recreation center parking lot, across the street and on the other side of the building from the facility. On 6/7/18 at 11:05 PM, interview with administrative nursing staff B and administrative staff A, identified that with the information they received from the charge nurse, the staff utilized the decision making tree for elopement to determine the resident did not elope. Staff B reported after the state started the investigation on 6/6/18, several other issues came to light which changed the facility's decision. The staff reported he/she was not told how long the alarm rang or that the staff member did not check outside for a resident leaving the building, nor was a resident headcount completed. Furthermore, the initial determination that the resident was not an elopement risk, found to be inaccurate, all contributed to the elopement, as well as inexperienced/untrained staff affecting the outcome. The staff reported being unaware of the resident's elopement attempts in (MONTH) (YEAR). On 6/7/18 at 11:30 AM, ancillary staff R, reported he/she was responsible to provide orientation to new hires, indicated he/she does not provide any education instructions to the agency staff. The facility policy, undated, identified the resident's rights included to live at ease in a safe and secure environment. The residents are assessed at the time of admission for the potential of elopement, then a specific plan and interventions are developed and implemented for those at risk for wandering or elopement. A specific system is developed to notify staff that exit doors have been opened in areas accessible to residents. Elopement policies and practices are communicated to staff in orientation, in-services, care planning, and staff meetings. The facility failed to ensure this confused resident did not leave the facility without staff knowledge, when the staff turned off the alarm without looking for the resident who went outside for approximately 30 to 45 minutes, and was returned to the facility by a bystander. The facility abated the immediate jeopardy on 6/7/18 at 9:30 PM after completing training of all staff on elopement procedures. The training included education on the elopement policy, missing resident checklist, alarm response procedures, including how to determine which door alarm sounded, the expectation regarding immediate response to the sounding door alarm, completion of an outside sweep by the alarming door to ensure that no resident exited unknowingly, and accounting for all residents to ensure that no resident is unaccounted for in the community. Plans were implemented on handling of training for agency staff as well. The deficient practice remained at the scope and severity of a D.

The facility reported a census of 51 residents, with 1 resident identified with a pressure ulcer. Based on observation, interviews and record review, the facility failed to provide treatment and service to promote healing and prevent infection for this 1 (#62) sampled resident with pressure ulcers who developed an avoidable stage 3 pressure ulcer. Findings included: - The facility medical record face sheet evidenced the facility admitted resident # 62 on 2/18/13. The admission assessment identified a purple soft left heel. The initial plan of care, dated 02/18/13 related to risk for skin breakdown documented interventions including, elevate heels off bed surface and float heels - no pressure on heels, reposition every 2 hours in bed and chair, schedule time out of bed, as tolerated, and weekly skin checks. The 2/25/13 MDS (minimum data set) assessment identified the resident admitted with a stage I pressure ulcer. The facility also assessed the resident with impaired cognition, in need of extensive assistance with bed mobility, transfers, toileting and personal hygiene. The 2/25/13 CAA (care area assessment) included, "He/she was admitted with intact blister to left heel. 8 x 4 cm Skin around it blanches well...He/she has cushion in w/c and pressure reducing mattress on bed...His/her heel had mepliex border applied on admission but has since changed to barrier cream and Prevalon boots applied when in bed but he/she often takes them off and staff places feet on pillow to float heel which he/she usually leaves alone..." The 3/2/13 care plan included Podus boots to both feet while up in W/C at all times as well as Prevalon pressure relieving heel protector boots to both feet while in bed at all times. The 03/14/13 MDS and 04/15/13 MDS identified the resident with 1 unstageable pressure ulcer and the 5/22/13 MDS assessment identified the resident with 1 stage 3 pressure ulcer. The 5/27/13 care plan included, wear Podus boot, encourage to change position frequently and pain medication if needed, tubigribs bilaterally to lower extremities, pressure reduction mattress and cushion in wheelchair. " I have Podus boots on during the day and Prevalon boots at night so need to be watched for poor balance and be sure I do not try to get up with the Prevalon boots. A Registered Dietitian note, dated 05/24/13, documented, "...Add Prostat (a protein supplement)." A 06/16/13 physician communication form documented, "Resident refusing to take Prostat. Can we discontinue Prostat...and start multivitamin...for 2 weeks to boost wound healing?" The physician responded to discontinue the Prostat. The clinical record failed to evidence facility staff offered any other type of protein supplement (food high in protein) to the resident. On 5/29/13, physician's orders [REDACTED]. The 6/12/13 wound care clinic process note included, "Left heel is an open wound 2.9 cm (centimeters) x 3.3 cm in width with a depth of 0.6 cm. There is a little bit of eschar as well as some nonviable tissue present. I did perform sharp debridement of the wound and post debridement the wound was 2.9 cm x 3.3 cm with depth of 1.1 cm. There is some undermining at the 5 o'clock position of 1.2 cm. Impression Stage III decubitus ulcer, left heel. The facility pressure ulcer status record for the left heel wound, documented by licensed nurse A, included: 2/18/13 left heel admit with stage 1, 1.8 cm (centimeter) x 3.4 cm x 0 cm 03/01/13 - The left heel remained closed with a white circular callous appearing area. 04/17/13 - The left heel area started opening and skin prep ordered by physician. 04/24/13 - The left heel opened and measured 2.6 cm x 3.8 cm. A & D ointment ordered for treatment of [REDACTED]. 5/8/13 Stage II (2) - 1.3 cm x 0.9 cm x 0.1 cm, area red and open, ordered to continue A & D treatment. 5/15/13 - Stage III (3) - 4.8 cm x 2.8 cm, deteriorated. No pain. The physician evaluated the area and ordered the resident to be seen at the wound care clinic. 5/22/13 - Stage III - 1.4 cm x 1.2 cm x 0.125 cm. 5/29/13 - Stage III - 1.9 cm x 3.1 cm x 0.3 cm. Wound care clinic debrided the wound on 05/23/13. 6/13/13 - Stage III - 3.8 cm x 3.5 cm x 1.2 cm. Slight pain in heel. 6/19/13 - Stage III - 3.4 cm x 2 cm x 0.9 cm. Improved, 80% slough and 10 % eschar beefy red. Observation, on 6/17/13 at 1:40 P.M., licensed nursing staff B and C provided a dressing change on the left heel. Licensed nurse C placed 2 boxes with tubes of ointments directly onto the bed along with the tape. When finished licensed nurse C picked up the tubes of ointment and placed them into his/her scrub pocket. Nurse C proceeded to the treatment cart and took the ointments out of the pocket and placed them into the treatment cart without any type of cleansing. At this time nurse C acknowledged the wound assessed and measured every Wednesday in the facility as well as when the resident attended the wound clinic once a week and further stated the resident had received Prostat , however, the resident had refused it, and the physician discontinued it. Observation, on 6/18/13 at 7:30 AM., revealed the resident asleep in bed, without the ordered Prevalon boots on his/her feet. The heels rested directly on the bed. The Prevalon pressure relieving boots sat on the foot of the bed. On 6/18/13 at 9:20 A.M., certified nursing staff D acknowledged the resident, "Doesn't always have the (Prevalon) boots on when we come in of a morning." Observation, on 6/18/13 throughout the day revealed the resident remained in the wheelchair with feet down. At 8:25 A.M., in the dining room, fed self with left hand, 10:00 A.M., played bingo, 12:00 P.M., stayed in the dining room for lunch, legs still down. At 1:20 P.M., staff pushed the resident to the south TV area. At 1:47 P.M., therapy staff E toileted the resident then placed him/her back into the wheelchair with feet down. The resident remained up in the wheelchair with feet down until 4:45 P.M., when certified staff F toileted the resident. The resident then returned to the wheelchair and to the dining room. At 5:30 P.M., the resident remained in the dining room. The resident remained up in the wheelchair with his/her legs down from at least 8:25 A.M. until 5:30 P.M. (9 hours). On 6/18/13 at 2:15 P.M., certified nursing staff G acknowledged, "I didn't take him/her back to bed." At 4:45 P.M., certified nursing staff F reported the resident, "Not back to bed since shift change." On 6/19/13 at 9:20 A.M., licensed wound nurse A, stated, "The first time I saw it, (the left heel) when (he/she) came in, it was purple and soft. You knew something was there but you could not see it. It was not open at that time. Then it opened. I measure it every week and it is better. Sometimes (he/she) doesn't want to lay down. At times (he/she) will set in his/her recliner." The facility policy, dated 10/7/10, for repositioning included, "Repositioning should be part of the resident's care plan and regular routine to reduce the duration and magnitude of pressure over vulnerable areas of the body. A written repositioning schedule is used and should be specify the intervention (e.g., reposition on side, pillows between knees) and frequency (e.g., every 2 hours)." The facility staff failed to ensure aseptic conditions when providing treatment to prevent infections, failed to follow the plan of care to utilize the pressure relieving boots in bed as ordered, and failed to elevate the resident's lower extremities to reduce [MEDICAL CONDITION] and promote healing. The resident developed an avoidable stage 3 pressure ulcer of the left heel.