Every finding on record at Life Care Center of Carrollton

Based on interview and record review, the facility failed to protect one residents right to be free from abuse when Resident #2 hit Resident #1 in the face with an open hand. This affected one of four sampled residents. The facility census was 58.Review of the facility abuse policies updated 04/01/2026 include: - It is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation; -The resident has a right to be free from abuse - Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse; - Physical abuse includes, but is not limited to, hitting, slapping, punching, biting, and kicking. Review of Resident #1's care plan dated 12/28/25, showed: -The resident had the potential to be physically aggressive and had a history of hitting staff, related to a diagnosis of vascular dementia;-The resident was at risk of being unable to make his/her needs be known due to diagnosis of dementia.Review of Resident #2's care plan, dated 01/09/26, showed: -The resident used a walker to walk and a wheelchair for long distance walking;-The resident had impaired communication due to dementia;-The resident was at risk of changes in mood due to dementia;-The resident's care plan addressed that the resident displays inappropriate behavior towards staff members but not towards other residents. Review of the Resident#1s progress note, dated 03/25/25, showed Licensed Practical Nurse (LPN) A documented Resident #1 and Resident #2 were yelling at each other and by the time he/she got to the residents, Resident #2 hit Resident #1 on the left side of his/her face with his/her open hand. He/she was able to separate the residents and Resident #2 was placed on one-on-one observation to monitor his/her behavior and ensure no other residents were hit. Review of the facilities abuse investigation, dated 03/25/26, showed: -Resident #1 refused to give Resident #2 his/her walker, Resident #2 then struck Resident #2;-Both residents were separated immediately;-Resident #2 was placed on one-on-one supervision by staff; -Neither resident had any injuries;-Contributing factors towards the incident: cognitive impairment, similar equipment (walkers not easily distinguishable), possible unmet psychosocial needs (anxiety, territorial behavior). Review of Resident #2's nursing progress note, dated 03/25/26, showed: -LPN A documented that Resident #2 hit a resident on the left side of the face with his/her open hand;-Both residents were separated and Resident #2 was placed on one-on-one monitoring by staff to ensure this did not occur again. During an interview on 04/02/2026 at 12:10 P.M. Licensed Practical Nurse (LPN) A said:- NA A and LPN A were the only staff on the hall at the time of the incident;-He/She was at the other end of the hallway passing medications when the nursing assistant (NA) A yelled for help for assistance with Resident #1 and Resident #2;-When he/she got to the residents NA A was beside the residents and LPN A witnessed Resident #2 hit Resident #1 across the left side of his/her face with an open hand;-LPN A separated the residents and placed Resident #2 on one-on-one observation with certified nursing assistant (CNA) A;-Resident #2 had been verbally agitated with Resident #1 in the past and has said that he/she did not like him/her.-The residents had not had any physical altercations prior to this one;-A resident hitting another resident is considered abuse. During an interview on 04/02/2026 at 12:16 P.M. CNA A said:-He/She provided one-on-one supervision of Resident #2 after Resident #2 hit Resident #1 with his/her open hand;-A resident hitting another resident is abuse. During an interview on 04/02/2026 at 2:30 P.M. the Administrator said:- Nursing staff had been in-serviced on abuse and neglect on 3/16/26, prior to the incident;- After Resident #2 hit Resident #1, staff received de-escalation training;- Since staff had recently been provided with abuse and neglect training, training was not provided again. - Residents have the right to be free from abuse. Intake 2964661

Based on interview and record review, the facility failed to protect two residents (Resident #2 and #3) right to be free from physical abuse when Resident #1 held Resident #2's arm down and squeezed Resident #2's jaw and when Resident #1 pushed Resident #3 against a wall. The facility census was 57.On 11/24/25 the Administrator was notified of the past noncompliance which occurred at the facility on 11/01/25 and 11/18/2025. On 11/1/25, the facility administrator was notified of the incident, an investigation immediately began, and corrective actions were implemented to include:- Resident #1 was initially placed on one on one watch, then sent to the emergency room for evaluation, and on 11/19/25 he/she was sent to the psychiatric hospital for further care;- On 11/18/25 an Ad Hoc Quality Assurance and Performance Improvement (QAPI)(refers to Quality Assurance and Performance Improvement (QAPI) activities that are impromptu, as-needed, and specific to a particular problem or initiative, rather than part of regular, scheduled meetings or programs) meeting was held reviewing the past non-compliance regarding the resident-to-resident altercation;- The Director of Nursing (DON) provided staff education for abuse, abuse prevention, resident to resident altercation, and the Elder Justice Act; - The actions to address the non-compliance were completed on 11/19/25.Review of the facility's Abuse Prevention Policy dated 6/17/24, showed:- It is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation;- The facility will identify, assess, and care plan for appropriate interventions, as well as monitor residents with needs and behaviors which might lead to conflict or neglect, including verbally aggressive behavior and physically aggressive behavior.Review of the facility Abuse Identification Policy dated 6/17/24, showed:- Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain, or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, causes physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse; - Willful is defined as the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm;- Physical abuse includes, but is not limited to, hitting, slapping, punching, biting, and kicking.Review of the facility Abuse Protection of Residents Policy, dated 6/17/24, showed:- The facility will ensure that all residents are protected from physical and psychosocial harm during and after the investigation;- Removal of access by the alleged perpetrator to the alleged victim and assurance that ongoing safety and protection is provided for the alleged victim and, as appropriate, other residents.1. Review of Resident #1's admission MDS (Minimum Data Set), a federally mandated assessment tool completed by facility staff, dated 10/9/25., showed:- Moderate cognitive impairment;- Diagnoses included: Alzheimer's disease (a brain condition that slowly damages memory, thinking, learning and organizing skills), anxiety, and insomnia (disorder that can make it hard to fall asleep or stay asleep);- Required supervision from staff for activities of daily living (ADL's) to include showering, toileting, and transfers.Review of the resident's care plan, dated 11/19/25, showed:- The resident had the potential to be both verbally and physically aggressive and has been observed becoming agitated by residents who are non-verbal and yell at times;- The resident would remain one on one until cleared by psychology;- The resident when noted to be agitated would be removed from areas of other residents;- The staff would monitor the resident frequently and observe for any verbal aggression or threat of physical harm and intervene immediately.Review of the resident's nursing progress notes for the month of October 2025, documentation showed:- On 10/11/25 at 7:34 P.M., Resident #1 was seen in the hallway yelling at another resident and threatening to hit him/her with a rag if the other resident didn't stop yelling then knocked the hat off of the other resident's head;- On 10/16/25 at 7:30 P.M., Resident #1 kept trying to get out of the doors and was instructed a number of times not to. The last time Resident #1 attempted to, he/she got close to the nurse's face and said he/she was going to burn the place down with the nurse inside and started laughing as he/she walked away;- On 10/31/25 at 10:08 P.M., Resident #1 was tired and not acting like him/herself and hadn't slept well in a while.Review of the resident's nursing progress notes for the month of November 2025., showed:- On 11/1/25 at 4:13 P.M., Resident #1 was witnessed by staff leaning over Resident #2 holding their hands down on their abdomen while squeezing Resident #2's jaw with his/her other hand. The residents were separated with no injuries noted and frequent monitoring of Resident #1 had been initiated; - On 11/1/25 at 7:46 P.M., Received orders from the provider to send Resident #1 to a local hospital emergency room for evaluation and treatment.- On 11/1/25 at 11:29 P.M., Resident #1 returned from the hospital. Restless and walking up and down the hallways;- On 11/7/25 at 11:54 A.M., Received new orders from psychiatry to start Trazodone (medication used to treat depression) 50 milligrams (mg) twice daily, at noon and at night, changed Seroquel (anti-psychotic medication) from 150mg at night to 50mg twice daily and to discontinue the Thorazine (anti-psychotic medication). - On 11/14/25 at 1:22 P.M., Resident #1 had been up wandering the halls and staff had been continuously redirecting the resident out of other resident's rooms;- On 11/16/25 at 7:47 P.M., Resident #1 was upset that another resident was hollering, had his/her belt in hand and said he/she was going to hit the resident that was hollering. The belt was removed and the resident was redirected;- On 11/18/25 at 12:55 P.M., Nurse was attempting to give the resident medication, and the resident grabbed the medication cup and smashed it in his/her hand; - On 11/18/25 at 7:41 P.M., Resident #1 pushed Resident #3 up against the wall and was in his/her face talking. The two residents were separated and it was explained to Resident #1 that he/she couldn't do that. Resident #1 said he/she did that because all that resident does is complain. Resident #1 was given as needed Ativan 0.5mg, and placed on one on one watch, the Director of Nursing was notified who then notified the resident's family, provider, and the state agency. Orders received to send resident to a local emergency room (ER) to evaluate and treat the resident;- On 11/18/25 at 10:00 P.M., Resident #1 returned from the ER via ambulance with no new orders, all lab work normal, and resident is one on one with staff at this time;- On 11/19/25 at 11:42 A.M., Referral sent to psychiatric hospital was approved for a psychiatric evaluation and stay. Both family and provider made aware;- On 11/19/25 at 11:53 A.M., Resident #1 left with facility for psych evaluation.2. Review of Resident #2's Quarterly MDS, dated [DATE], showed;- Moderate cognitive impairment;- Diagnoses: stroke, dementia, and hemiplegia (severe or complete loss of strength leading to paralysis on one side of the body);- Required substantial assistance from staff for activities of daily living (ADL's) to include showering, toileting, and transfers.Review of the resident's care plan, dated 11/11/25, showed:- The resident was often observed talking to him/herself which can be upsetting to some residents;- Staff were to allow Resident #2 to wander as safely as able, monitor frequently, and promptly remove Resident #2 from areas of agitated residents;- The resident was at risk for falls related to confusion and balance problems and staff were to check on the resident frequently.Review of the resident's nursing progress notes for the month of November 2025, showed:- On 11/1/25 at 4:43 P.M., Resident #1 was leaning over Resident #2 holding Resident #2's hands down on his/her abdomen and squeezing Resident #2's jaw. The residents were separated, no injuries identified and the family, hospice and the provider were notified;- On 11/2/25 at 1:20 A.M., Resident #2 did not remember the incident yesterday and was not able to communicate needs.3. Review of Resident #3's Significant Change in Status MDS, dated [DATE], showed:- Severe cognitive impairment;- Diagnoses: traumatic brain injury, dementia, and arthritis;- Required substantial assistance from staff for activities of daily living (ADL's) to include showering, toileting, and transfers.Review of the resident's care plan, dated 11/11/25, showed:- The resident had potential to be physically aggressive, and staff would need intervene before agitation escalates;- Staff would guide the resident away from the source of distress and engage in calming conversation;- Staff would attempt to redirect the resident back to his/her room and if unable to do so, attempt to remove other residents away from him/her.Review of the resident's nursing progress notes for the month of November 2025, showed:- On 11/18/25 at 7:27 P.M., The facility notified the resident's spouse of the resident-to-resident altercation that occurred at 7:00 P.M. - On 11/18/25 at 11:11 P.M., Resident #3 seemed confused about the altercation with Resident #1 earlier in the day.- On 11/19/25 at 12:24 P.M., Resident #3 had been asked if he/she remembered the altercation with Resident #1 and he/she did not remember.During an interview on 11/24/25 at 10:04 A.M., Licensed Practical Nurse (LPN) A said:- He/she hadn't seen Resident #1 hurt anyone before and no one involved had prior issues with one another, but if loud noises happen, Resident #1 can get upset and staff will try to de-escalate and move Resident #1 to another area and remain one on one until Resident #1 calms down;- A resident-to-resident altercation could be abuse and residents had the right to be free from assault.During an interview on 11/24/25 at 10:20 A.M., Certified Medication Technician (CMT) A said:- Resident #1 had pushed Resident #2 back and held Resident #2's throat then both residents had been separated; - Resident #1 had been sent to the ER, but the ER sent Resident #1 right back and the facility continued to perform one on one watch until Resident #1 was sent out to the psychiatric hospital;- He/She had received training on abuse and neglect, de-escalation and redirecting of residents since the incidents.During an interview on 11/24/25 at 10:25 A.M., Certified Nursing Assistant (CNA) A said:- Resident #1 had pushed and grabbed Resident #2;- Resident #2 had one good arm and held Resident #1 back;- Both of the residents had been separated and had one on one watches until Resident #1 was sent out to the ER;- Staff had received training on abuse and neglect, de-escalating and redirecting residents after the incident.During an interview on 11/24/25 at 10:30 A.M., the Director of Nursing (DON) said:- Neither Resident #2 nor Resident #3 had been struck by Resident #1;- Resident #2 had his/her hands held down by Resident #1 and Resident #1 said he/she was going to hit Resident #2 then staff intervened;- Resident #3 had been pushed against a wall by Resident #1 and Resident #1 was being threatening to Resident #3. No marks had been left on the residents and staff had intervened immediately;- Resident #1 had been sent to the ER initially, and after testing and evaluation, Resident #1 was returned to the facility and placed on one-on-one watch;- The facility had sent a referral to the psychiatric hospital and Resident #1 remained one on one until transferred;- Training had been held with all staff on abuse and neglect policies, policy for prevention and for reporting after the incidents.During an interview on 11/24/25 at 10:40 A.M., the Social Services Director said:- Resident to resident incidents could be abuse and the residents definitely had the right to not be assaulted;- Resident #1 was normally sweet but could get overstimulated at times;- He/She believed the facility was looking for placement for Resident #1 after he/she returned from the psychiatric hospital.During an interview on 11/24/25 at 1:25 P.M., the Senior Executive Director and acting Administrator said:- Resident to resident incidents could be considered abuse and residents had the right to not be assaulted or touched by another resident;- Resident #1 was at the psychiatric hospital and the facility was looking for another facility for Resident #1;- If the facility was unable to find placement for Resident #1 and he/she had improved then Resident #1 would be readmitted to this facility. Intakes 2672548, 2658037

Based on interviews and record review the facility failed to protect a resident's right to be free from misappropriation of resident property when a staff member, CNA B requested and accepted money from Resident #1. The facility census was 57. Review of the facility's Abuse Prevention Policy, updated on 06/17/24, showed:- It is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, as well as exploitation;- Identify, correct and intervene in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur to include trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms, if any. Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's property or money without the resident's consent;- Residents' property includes all residents' possessions, regardless of their apparent value to others since they may hold intrinsic value to the resident;- Examples of resident property include jewelry, clothing, furniture, money, and electronic devices;- Examples of misappropriation of resident property include but are not limited to: * Unauthorized or coerced use by staff of resident's personal property; * Unauthorized or coerced purchases on a resident's credit card; * Unauthorized or coerced purchases from resident's funds; * a resident who provides a gift to staff in order to receive ongoing care, based on staff's persuasion and; * staff who accept money from a resident for any reason including when staff have made the resident believe that staff was in a financial crisis or the resident believes that he/she is in a relationship with the staff person., and through intimidation, threats, or coercion; - Exploitation is defined as taking advantage of a resident for personal gain, through the use of manipulation, intimidation, threats or coercion. 1.Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 7/21/25, showed:- The resident was cognitively intact; - The resident was independent with all activities of daily living (ADL's);- Diagnoses included: right leg above the knee amputation, end stage renal disease (a permanent loss of kidney function where kidneys no longer work well enough to sustain life, requiring dialysis or a kidney transplant for survival), depression, schizophrenia, and anxiety.Review of the resident's nursing progress notes for the month of August 2025., showed:- On 8/20/25 at 6:15 P.M., the Administrator documented she had spoken with the resident's representative to alert and update them of an incident concerning the resident being financially exploited by an employed certified nursing assistant (CNA).- On 8/20/25 at 6:20 P.M., the Administrator documented she alerted the primary care provider that the facility reported an incident regarding alleged financial abuse of Resident #1 by CNA B to the Department of Health and Senior Services. Review of the facility investigation that included staff interviews and statements, dated 8/17/25, showed the following:- On 8/16/25 CNA C said, Resident #1 came to the desk and said he/she had been giving CNA B money to help out. -On 8/16/25 LPN A documented the resident was at the nurse's station telling the nurse and CNA C that he/she had been financially helping CNA B because CNA B said he/she was going to lose his/her home and was not able to pay the bills. LPN A notified the Administrator of the situation. -On 8/17/25 CNA C reported he/she heard the resident tell the charge nurse he/she gave CNA B $300 this morning to go to Walmart.Review of the police report #2025-002449, dated 8/19/25, showed:- The Officer spoke with the Administrator who stated she had begun investigating CNA B receiving money from Resident #1 on 8/17/25;- The Administrator's investigation showed CNA B had been attempting to coheres the resident into moving in with him/her;- CNA B was advised he/she could not move the Resident out of the building per facility policy;- The Administrator stated CNA B borrowed approximately $220 from Resident #1 and had told her it would be paid back to Resident #1;- The Administrator informed the officer that CNA B was suspended, and Resident #1 was their own person;- The Officer documented he/she reported to the Administrator that the incident was surely a policy violation for an employee to accept money from a resident and the Administrator informed the Officer she was going to hotline the information. Review of the Resident's care plan, updated 8/19/25, showed the resident identified as someone who would offer staff and other residents' money or would buy things for them and was at risk for financial abuse and exploitation due to being so free with his/her money.During an interview on 9/25/25 at 10:04 A.M., the Regional Director of Clinical Services said he was only familiar with what the investigation showed. He was not aware CNA B attempted to move the resident out of the facility. He knew CNA B had been terminated and thought the resident had been giving CNA B money off and on for a while but not sure on the amount. During an interview on 9/25/25 at 10:40 A.M., CNA B said: - He/she knew nothing about Resident #1's missing money;- He/She started to load the resident's property into his/her private vehicle and the Administrator called and told her he/she should resign immediately. - He/She said the financial transaction with Resident #1 had been between CNA B's spouse and the resident and that he/she was going to pay back the money. - He/she used the money from Resident #1 to pay his/her cell phone bill. It was $220.00 that's all it was; During an interview on 9/25/25 at 10:58 A.M., Resident #1 said:- He/She had nothing to hide and didn't remember when he/she gave CNA B money, but CNA B had asked for money a couple of months ago and Resident #1 was not sure how much money he/she had gave to CNA B and mentioned a few different dollar amounts which ranged from $220 to $500; - He/She said the Administrator spoke to him/her about giving CNA B money and he/she believed that since it was a facility employee, the facility should reimburse him/her the money, but the Administrator did not reimburse the resident any money back.- He/She said CNA B was trying to him/her to move in with him/her to pay the bills; - He/She no longer talks to CNA B because he/she is a scam artist; - CNA B never paid back him/her back for the money given to pay the phone bill; - He/She would like to have the money back. During an interview on 9/25/25 at 11:42 A.M., the Administrator said:- Staff called her at 7:08 A.M. on 8/17/25 Sunday morning saying CNA B was at the facility to move the resident out and she informed the staff that CNA B couldn't remove the resident from the building. - The resident is his/her own person and only family can help move a resident out, but not staff. CNA B did not maintain professional boundaries. - She found out about CNA B taking Resident #1s money later during her investigation. The Account Specialist was notified by the resident about the money being taken by CNA B.- On 8/17/25 she spoke with police who took the report and said they would not be pursuing criminal charges but would make report to the state if needed.- The employee is promising to return the money to the resident, but the facility had not refunded any money to the resident at this time.- She gave CNA B a notice of termination on 9/18/25 but he/she had been suspended since 8/17/25, the day of the initial report.- The amount owed to the resident was $220. - During the course of the investigation the facility learned that other employees had given CNA B $217 the previous month for his/her phone bill. During an interview on 9/25/25 at 12:30 P.M., the Director of Nursing (DON) said:- The resident is own person and can make own decisions but, he/she needs oversight to make safe choices and decisions; - This resident is easy to take advantage of because of his/her decision making is impaired the facility should not have to repay the resident since the resident is her own person. During an interview on 9/25/25 at 1:03 P.M., the Account Specialist said:- She found out about the Resident #1 incident the day after it happened, Monday; - She questioned and reassured the resident they weren't in trouble, we were just wanting to help; - The resident then said CNA B had asked him/her for $220;- She immediately informed the Administrator about what she had learned from the resident.On 9/25/25 at 12:50 P.M. the Regional Director of Clinical Services provided a copy of the receipt to show reimbursing in the amount of $220.00. The receipt was and signed by the resident on 9/25/25.Intake 2594404

Based on observation, interview, and record review, the facility failed to provide acceptable a sink accommodation for one resident (Resident #14) to the hot water at his/her sink and failed to provide transfer assistance for one resident so they could eat (Resident #156). This affected two of 15 sampled residents. The facility census was 58. Review of facility policy Activities of Daily Living (ADLs), revised 2/12/24, showed: - The resident will receive assistance as needed to complete ADLs. - Any change in the ability to perform ADLs will be reported to the nurse; - Assist residents with bed repositioning as necessary to promote good body alignment; Review of facility policy Resident Rights, revised 9/10/24, showed: - The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services; - The resident has the right to reside and receive services in the facility with reasonable accommodation of resident and preferences; - The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely; 1. Review of Resident #14's Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 2/18/25, showed: - Resident is cognitively intact; - Resident is dependent on a wheelchair for mobility; - Resident has limited range of motion on both sides of body for the lower and upper extremities; - Resident requires set up assistance for eating and oral hygiene; - Resident is dependent for toileting, showering and dressing; - Resident requires substantial assistance by staff for personal hygiene; -Diagnoses: Cerebral Palsy. Review of Care Plan, revised 1/9/25, showed: - Resident requires up to total assist with ADLs due to Cerebral Palsy; - Resident has his/her own teeth. Place toothpaste on his/her toothbrush and provide basin. Resident is able to brush own teeth; - Staff should encourage resident to perform tasks that he/she is able to do, such as washing own face; - Resident uses an electric wheel chair for mobility and is able to propel self; - Resident is encouraged to make his/her room as home-like as possible; - Resident has Cerebral Palsy and has multiple contractures (rigidity of joints and shortening of tendons leading to deformity);His/her room has been adapted in some way to help resident remain as independent as possible. Staff should encourage resident to engage in activities that will help improve coordination and encourage resident to do as much for self as possible. Observation on 4/22/25 at 2:58 P.M. showed the resident's sink had an accommodation device attached to the cold-water facet of the reisdent's sink so that the resident could turn on the cold water independently. The hot water facet had no accommodation device attached that would allow the reisdent to turn on the hot water independently. During an interview on 4/25/25 at 10:13 A.M., the Resident said he/she would like to be able to use the hot water and have the choice between cold and hot like other residents. He/she is able to independently turn on the cold water because of the assistive device. He/she is unable to turn on the hot water because their is no assistance device. During an interview on 4/25/25 at 10:24 A.M., the Maintenance Supervisor said he was not aware that the resident could not utilize the hot water. Normally physical therapy will notify him if any adjustments or accommodations that need to be made for residents. He was sure he could install a device like the one installed on the cold water facet, that would allow the resident to be able to use the hot water. During an interview on 4/25/25 at 11:48 A.M., COTA (Certified Occupational Therapy Assistant) A said occupational therapy had done an assessment on the resident's room a few years ago and set them up with the accommodation to operate their cold water so the resident could brush own teeth. They never set the resident up with hot water because all they needed was cold water for teeth brushing. It would not be hard to put in another device on the sink so the resident could operate his/her hot water. Currently therapy provides care to help the resident with their arms which have restricted mobility. No assessment had been done to see if the resident can reach farther into the sink, other than to use own toothbrush. During an interview on 4/25/25 at 1:30 P.M., the Administrator and DON said: - Unless there's a safety issue involved all residents should have access to hot and cold water in their room; - Reasonable accommodations should be made so residents can operate the fixtures, drawers, and cabinets in their rooms; - Room assessments for accommodations are done by nursing staff and the therapy department; - There are no safety issues with Resident #14 that would prevent them from having hot water access in their room; 2. Review of Resident #156's Entry MDS, dated [DATE], showed: - No cognitive status assessment completed; - No functional abilities assessment completed; Review of resident admission record, dated 4/24/25, showed a diagnosis of Dementia and osteoarthritis (arthritis causing loss of mobility and stiffness). Review of the resident's Care Plan, dated 4/14/25, showed: - Resident chooses to eat meals in his/her room and eats independently. Staff should offer assistance when serving meal tray; - Resident will remain independent with transfers through next review date; - Resident has moderate cognitive impairment; - Staff should allow adequate time for resident to respond to questions. Do not rush and ask yes/no questions with simple, brief, consistent words; - Observe for physical/non-verbal indicators of discomfort or distress and follow up as needed; - Anticipate and meet resident's needs, assist with ADLs as needed; - Resident has an alteration in musculoskeletal status due to diagnoses of osteoarthritis. Observe and report complications related to arthritis such as stiffness which is usually worse on wakening, decline in mobility, or decline in self-care ability; Observation on 4/23/25 at 8:30 A.M., showed: - Resident lying on his/her back struggling to raise to a sitting position with a grimace of facial pain; - A bedside table with their breakfast tray sitting on it and out of reach for the resident; - Resident's call light is out of reach, underneath the resident's blanket which is turned down; During an interview on 4/23/25 at 8:32 A.M., the resident said: - Breakfast was delivered to his/her room about 15 minutes ago; - He/she was not provided any help getting out of bed and was very stiff and in pain; - The staff member who originally delivered his/her food came into room to check on his/her progress and said they would get help to get the resident out of bed; - The staff member did not push the call light to alert the nursing staff and exited the room; - The resident asked the surveyor for help to get out of bed; During an interview on 4/23/25 at 8:42 A.M., CMT B said he/she would notify the nursing staff to help the resident since he/she was currently engaged in passing medications to residents in the hall. Observation on 4/23/23 at 9:02 A.M., showed CNA F entering resident's room and helping him/her out of bed. During an interview on 4/23/25 at 10:57 A.M, CMT B said within 10 minutes of being notified that the resident needed help he/she told two CNAs and the charge nurse at the nurse's station about the resident's request for help. During an interview on 4/24/25 at 8:34 A.M., the resident said he/she again struggled to get out of bed this morning but he/she was able to do it after a while. Yesterday's breakfast was completely cold by the time they got to it and no one offered to replace his/her breakfast tray or to warm it up. During an interview on 4/25/25 at 1:30 P.M., the Administrator and DON said depending on other tasks and work assignments it normally should not take more than 15 minutes for staff to help transfer a resident from their bed so they can eat breakfast in their room. MO251239

Based on observation, interview, and record review, the facility failed to store, prepare and serve food in accordance with professional standards of food service safety when staff failed to date and label food items, failed to dispose of expired food items, and failed to perform temperature checks on food items after the cooking process was completed. This effected all the residents at the facility. The facility census was 58. Review of facility policy, Food Safety, revised [DATE], showed: - Danger Zone means temperatures above 41F and below 135F, that allow the rapid growth of pathogenic microorganisms that can cause foodborne illness. Bacteria multiply rapidly in a moist environment in the danger zone. Rapid death of most bacteria occurs at 165F or above; - Food is stored a minimum of six inches off the floor; - When an item is transferred to a new container the container will be labeled with the name of the contents and date transferred. A Use by Date is noted on the label; - Food is labeled with the date received if not already indicated on the item; - Leftovers are dated properly and discarded after 72 hours unless otherwise indicated; - Frozen, raw meat that is placed in a cooler, is in a pan and labeled with pulled and use by dates; Dry Storage: - Opened packages of food are resealed tightly to prevent contamination of the food item and use by date will be used when applicable; - Food not safe for consumption or the safety of the food is in question will be removed from storage; Steam Tables: - Must be able to maintain hot foods at temperatures of 135F or above; - Must not be used for cooking or warming foods, only for keeping food hot; Review of facility policy, Food Temperature Control, revised [DATE], showed: - Food temperatures are checked at the completion of the cooking process and before being placed on the serving line; if issues are identified, they are corrected, or the food is discarded; - Hot foods are held at a minimum of 135F or per state requirements; - While foods are on the serving line, the foods will be maintained at a safe temperature; - The steam table is not used to prepare and/or reheat foods; 1. Observation of the kitchen on [DATE] at 8:30 A.M., showed: Freezer: - Package of frozen food opened [DATE] and resealed with no content label; - Package of frozen onion rings opened and resealed with no open or expiration date on package; Refrigerator: - Defrosting frozen chicken not labeled with a use by date; - Lettuce package opened ,d+[DATE], resealed with no expiration date; Dry Storeroom: - Raisin Bran resealed in plastic container with expiration date of [DATE] not discarded; - Fruit Loops resealed in plastic container with expiration date [DATE] not discarded; - Cheerios resealed in plastic container with expiration date [DATE] not discarded; - Left over gravy mix not sealed; Main Kitchen Area: - Tortilla chips with expiration date [DATE] not discarded; Small Refrigerator: - Bag of apples, unlabeled, unsealed, and no expiration date; - Chicken base opened and resealed, expiration date unreadable; 2. During a continuous observation of the kitchen on [DATE], showed: - 10:15 A.M. [NAME] beans placed on steam line without any temperature check taken; - 10:20 A.M. Gravy placed on steam line from microwave without any temperature check taken; - 10:40 A.M. All of the puree and mechanically prepared items completed and placed on the steam line without temperature checks taken; - 11:12 A.M. Temperature checks conducted on all items on the steam line. Gravy has a temperature of 108F which is below the safe holding temperature of 135F required. - 11:16 A.M. The gravy is transferred to the stove for reheating; - 11:24 A.M. The DM (dietary manager) takes a temperature check while the gravy is still on a lit burner. The gravy now temps at 155F; Observation of the kitchen refrigerator on [DATE] at 2:20 P.M., showed leftover cooked sausage patties dated [DATE] with expiration date [DATE] that had not been discarded. During an interview on [DATE] at 11:30 A.M., the DM said: - The gravy was cooked improperly and should have been prepared on the stove instead of heated up in the microwave by one of the dietary staff; - Temperature checks are normally done on the steam line before serving the meal and not on the stove for side dishes. Main course meals like today's chicken should have temperature checks done until they reach the required temperature for cooking; During an interview on [DATE] at 3:28 P.M., the DM and Dietician said: - The danger zone for food bacteria growth are temperatures below 135F, 145F for fish, 155F for ground beef, and 165F for chicken. - Both staff members agreed that taking the temperatures at the steam table prior to serving was sufficient to ensure the safety of the residents and had no issues with not taking temperatures after cooking is completed at the stove; - Food items that are opened should be resealed and dated, items that are expired should be thrown away on the date of expiration; During an interview on [DATE] at 1:30 P.M., the Administrator said: - She would expect food items that have been opened to be resealed, dated with the open date and the new expiration date if being stored for future use; - Items that have been resealed should be clearly labeled as to the contents; - She would expect food temperature checks to be done prior to placing items on the steam table, prior to serving and prior to being served on the hall for residents; - She would not expect expired items in the refrigerator or storeroom; - All containers should be sealed tight when being used for leftovers or future serving.

Based on interview and record review, the facility failed to provide personal funds and a final accounting within thirty days upon discharge for two residents (Resident #157, Resident #53). The facility census was 58. Review of the facility policy, Resident Trust Policy and Procedures, dated [DATE], showed: - Conveyance of Funds after Death of Resident: After fulfilling any other authorized payments, the facility shall provide any remaining resident funds and a final statement of the resident's fund activity to the individual or probate jurisdiction administering the resident's estate. These will be provided within thirty days of the resident's death. 1. Review of the facility's interim aging report, dated [DATE], showed the following residents had money in the facility's operating account: -Resident #157 discharged on [DATE], with a balance of $803.00. -Resident #53 discharged on [DATE], with a balance of $5,618.32. Review of Request for Resident Refund invoices showed: -On [DATE], Business Office Manager (BOM) submitted invoice #,d+[DATE] to corporate office to refund $803.00. -On [DATE], BOM submitted invoice #,d+[DATE] to corporate office to refund $5,618.32. During an interview on [DATE] at 9:30 A.M., the BOM said: - Resident #157's refund has been processed in the system but the check had not been released by corporate and that will occur at the end of the month; - Resident #53's overage was due to family paying rent one month ahead of time and there was a balance at the time of discharge. Corporate should have the check issued by end of month; - She said that refunds should be processed and sent to discharged residents or family members upon resident death within 30 days of discharge; - She has been in contact with the corporate office to get these refunds processed. During an interview on [DATE] at 1:30 P.M., the Administrator said refunds should be provided within 30 days for deceased and discharged residents when required.

Based on interview and record review, the facility failed to ensure the Do Not Resuscitate Order's (DNR, medical order that instructs the health care provider not to do resuscitative measures if a person's heart stops) for Resident #2 and Resident #24 were correct when the guardian's name was printed on the DNR instead of the name of the resident. This affected two of 15 sampled residents (Resident #2 and Resident #24). The facility census was 58. Review of the facility's policy titled, Advanced Directives and Advance Care Planning, dated, 09/26/24, showed: -Residents have the right to self-determination regarding their medical care; -This includes the right to direct his/her own medical treatment, including the right to execute or refuse to execute an advanced directive; -The MDS should reflect the appropriate advance directives; -This information is reviewed at least quarterly. 1. Review of the Resident #2's Quarterly Minimum Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 03/04/25, showed: -Moderate cognitive impairment; -Partial assist for Activities of Daily Living (ADLs); -Diagnoses included, dementia, anemia and high blood pressure. Review of care plan dated 01/09/25, showed: -ADL self care deficit related to dementia; -The resident had a DNR in place; -Code status will be reviewed every quarter Review of the resident's medical record showed: - On 1/26/24 a physician's order for Do Not Resuscitate; -DNR showed the name of the resident's guardian printed on the line reserved for the name of the resident; -The DNR form was signed by the resident's guardian on 11/11/22 and by the physician on 11/12/22. During an interview on 04/24/25 at 02:28 P.M., Certified Nurses Aide (CNA) A said: -The nurses or the Social Services Designee (SSD) take care of getting signatures for the DNR's; -The guardian signs the DNR if the resident is incapacitated; -The name of the resident should be printed on the line designated for the resident; -The guardian's name should not be printed on the line reserved for the resident. During an interview on 04/24/25, at 02:42 P.M., Licensed Practical Nurse (LPN) A said: -The resident does not make his/her own decisions; -The resident is a DNR code status; -The name of the resident should be printed on the line designated for the resident; -The guardian's name should not be printed on the line reserved for the resident. 2. Review of Resident #24's Annual MDS, dated [DATE], showed: -Severe cognitive impairment; -Dependent for ADLs and transfers; -Diagnoses included dementia, anxiety and muscle weakness. Review of the resident's care plan dated 04/10/25, showed: -ADL self care deficit related to dementia; -The resident has a DNR; -Code status will be reviewed every quarter. Review of the resident's medical record showed: - On 05/20/20 a physician's order for Do Not Resuscitate; - DNR showed the name of the resident's guardian printed on the line reserved for the name of the resident; -The DNR form was signed by the resident's guardian and physician on 05/20/22. During an interview on 04/24/25 at 03:24 P.M., CNA B said: -The name of the resident should be printed on the line designated for the resident; -The guardian's name should not be printed on the line reserved for the resident; -SSD oversees the DNR forms. During an interview on 04/24/25, at 03:45 P.M., LPN B said: -The resident is a DNR code status; -The name of the resident should be printed on the line designated for the resident; -The guardian's name should not be printed on the line reserved for the resident; -SSD reviews the DNR forms. During an interview on 04/25/25 at 11:18 A.M., the SSD said: -She reviews the resident DNRs every quarter; -Resident #2 and Resident #24 are both DNR code status; -The DNR is not correct if the guardian's name is printed where the resident's name is indicated; -The responsible party signed the DNR's for Resident #2 and Resident #24 because both residents are incapacitated; -The name of the resident should not be printed on the line designated for the resident; -The DNR for Resident #2 and Resident #24 are not correct; -The DNRs for Resident #2 and Resident #24 should be correct. During an interview on 04/25/25 at 01:16 P.M. the Director of Nursing (DON) said: -The resident's name should be printed on their DNR not the name of the responsible party; -She expects the DNRs to be correct; -SSD in charge of making sure the DNRs are correct. During an interview o 04/25/25, at 01:20 P.M., the Administrator said: - She expects the name of the guardian should not be printed on the line designated for the resident; -The DNR for Resident #2 and Resident #24 are not correct; -She expects the DNRs for Resident #2 and Resident #24 should be correct.

Based on observation and interview, the facility failed to maintain a clean and comfortable homelike environment. This had the potential to affect all residents. The facility census was 58. Review of the facility policy, Housekeeping Services, dated 06/04/24 showed: -The facility will provide a safe, clean and homelike environment; -The floors will be cleaned daily. Review of the facility policy, Home Like Environment, dated 06/12/24, showed: -The facility will provide a safe, clean and homelike environment; - It is the responsibility of all staff to create a homelike environment and promptly address any cleaning needs. 50980 1. Observation on 4/23/25 at 9:34 A.M., showed: - Housekeeping completed their morning clean up of the dining room; - Handwashing station and near the standing flag in the dining room has large amounts of dirt and food debris on the floor; - Food debris and crumbs on the floor leading to the kitchen area from the dining room; - Food debris visible on the floor behind chairs lining the wall; During an interview on 4/23/25 at 9:40 A.M., Housekeeper A said: - He/she does the sweeping and moping of the dining room floor and they don't normally sweep in the corners daily, just the main part of the floor; - Monday's are deep cleaning days and that's when they work the sides of the room; 2. Review of Resident 8's Admission MDS, dated [DATE], showed: - Resident is cognitively intact; - Diagnosis: Anemia, renal insufficiency (kidney impairment), diabetes, and schizophrenia; Observation on 4/24/25 at 12:45 P.M., Resident' room showed: - Loose dirt all along the closet and door entrance of resident's room; - Floor extremely worn with dented marks and embedded dirt spots throughout the room; During an interview on 4/24/25 at 12:50 P.M., the Resident said: - I would prefer my room was clean but housekeeping comes in and does the job as fast as they can so they can get the job done and get out without cleaning the floors properly. 3. Review of Resident #38's Quarterly MDS, dated [DATE], showed: - Resident has impaired cognition ; - Diagnosis: Coronary artery disease, anemia, diabetes, and depression; Observation of the Resident's room on 4/23/25 at 7:51 A.M., showed: - Multiple dead bugs on the floor along the baseboards in resident's room; - Bathroom floor had heavy dirt and trash debris; During an observation on 4/24/25 at 1:33 P.M., showed: - Heavy loose dirt and dust build on the floor alongside the walls of the resident's room; - Floors extremely worn with [NAME] marks and embedded dirt spots throughout the room; During an interview on 4/24/25 at 1:36 P.M., the resident said he/she would prefer that the room was clean and dust and dirt be removed on a daily basis due to his/her medical conditions. During an interview on 4/25/25 at 9:00 A.M., Housekeeping Supervisor said: - Housekeeping staff service resident rooms by removing the trash, wiping down all surfaces with disinfectant, spray down the windows, sweep the floors and mop the floors with a wet disposable mop head. They sweep the whole room including corners and bathrooms. Corners can be difficult due to the mop size. During an interview on 4/25/25 at 1:30 P.M., the Administrator said housekeeping staff should sweep along the baseboards and in the corners of the rooms and the facility every time they deep clean or if the area is dirty. MO#251239

Based on observation, interview, and record review, the facility failed to provide trauma informed care for one sampled resident (Resident #37) with a diagnosis of Post-Traumatic Stress Disorder (PTSD, a mental health condition that is triggered by a terrifying event). This affected one of 15 sampled residents. The facility census was 58. Review of the facility policy, Trauma Informed Care, dated 09/06/24 showed: -Based on the comprehensive assessment of a resident, this facility must ensure that residents who are diagnosed with a mental disorder or who have a history of trauma/or PTSD, receive appropriate treatment and services to attain the highest practicable mental and psychosocial wellbeing; -Trauma informed care is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma; -A trauma informed approach to care recognizes the widespread impact and signs and symptoms of trauma in residents and incorporates knowledge about trauma into care plans, and practices to avoid re-traumatization; -The facility should collaborate with the resident's family, friends and any other health care professionals to develop and implement and individualized plan of care with interventions; -In situations where a trauma survivor is reluctant to share his/her history, the facility should still attempt to identify triggers which may re-traumatize the resident and develop interventions which minimize or eliminate the effect of the trigger on the resident. 1. Review Resident #37's Quarterly Minimum Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 01/14/25, showed: -No cognitive impairment; -Independent for Activities of Daily Living (ADLs); -Takes antipsychotic, (a class of psychiatric drugs prescribed to treat mental health conditions), medication on a routine basis; -Diagnoses included, PTSD, schizophrenia, depression and anxiety. Review of the resident's care plan dated 02/13/25, showed: -Physically aggressive toward staff; -Refuses to take all medications; -At risk of change in mood or behavior. -There was no care plan regarding PTSD or staff interventions. Review of the resident's medical record showed: -Resident admitted on [DATE] with a history of adult physical abuse confirmed during a subsequent encounter; -Behavior note dated 11/11/2024, at 12:36 A.M., the resident yelled out most of the night. Resident observed yelling at the T.V. Staff attempted to talk to the resident. The resident asked staff to leave the room and not return. The staff left the room and the resident could still be heard yelling through the night; -Behavior note dated 4/24/2025 at 03:35 P.M., the resident refused to take medication this morning and refused to eat lunch. Staff went into resident's room to check on him/her. The resident wouldn't talk to the staff; -Event note dated 11/01/2025 at 03:18 P.M., the resident is hollering out. The staff went into the resident's room and the resident was setting on the floor; -Physician's Order Sheet (POS) dated April 2025, showed a diagnosis of PTSD. Observation and interview on 04/23/25 at 08:43 A.M., showed: -The resident's door was closed; -Upon entering the room the resident lay in bed in with his/her eyes open; -The resident said he/she is not from this town and then spoke unintelligible words at a fast rate of speed. Observation and interview on 04/24/25 at 11:18 A.M., showed: -The resident's door was closed; -Upon entering the room the resident lay in bed in with his/her eyes open; -The resident would not speak; -The resident looked at the ceiling and then said leave and shut the door. During an interview on 04/24/25 at 02:28 P.M., Certified Nurse's Aide (CNA) A said: -He/She did not know the resident had a diagnosis of PTSD; -The resident yells out at times and spends a lot of time in his/her room; -The resident can be heard yelling in his/her room and when the staff check on him/her the resident tells them to leave; -Sometimes the resident will refuse lunch; -The resident has attempted to hit another resident before; -The resident's care plan should include a diagnosis of PTSD and what upsets them; -Staff should know what triggers or upsets the resident; -The staff should know how to de-escalate the resident. During an interview on 04/24/25 at 02:42 P.M., CNA B said: -There are no longer any residents at the facility with a diagnosis of PTSD; -He/She was not aware the resident had a diagnosis of PTSD; -The resident's care plan should have the trauma history and what the resident's triggers are; -He/She did not know what the resident's triggers were or how to mitigate them. During an interview on 04/25/25, at 08:56 A.M., LPN A said: -The resident stays in his/ her room most of the time; -The resident has behaviors at times; -He/She was not aware the resident had a diagnosis of PTSD; -He/She did not know what the resident's triggers were; -The resident's diagnosis of PTSD should be care planned; -The resident's triggers and any interventions should be care planned; -The care plan determines how to care for the resident; -Staff could unintentionally trigger the resident if they do not know what his/her triggers are. During an interview on 04/25/25 at 09:23 A.M., the Resident's Guardian said: -The resident had a psychiatric stay on 09/13/23 and his/her assessment identified a history of PTSD; -He/She was notified by the facility on March 2024, that the resident hit another resident; -The facility said the resident was triggered by another resident and that is why he/she lashed out; -He/She expects the resident's diagnosis of PTSD to be on the resident's care plan; -He/She expects the staff to be able to identify the resident's specific triggers; -He/She expects the staff to know what specific interventions are required to mitigate triggers for the resident and de-escalate the resident. During an interview on 04/25/25 at 1:16 P.M. the Director of Nursing (DON) said: -She was not aware of Resident #37's PTSD diagnosis; -She expects the staff to look at the resident's care plan and know what triggers Resident #37; -PTSD should be included in Resident #37's care plan along with specify interventions; -The MDS Coordinator is responsible for updating the care plans; -The nurses add parts to the care plan if needed; -At the end of the day the MDS coordinator is responsible for adding PTSD to the care plan. During an interview on 04/25/25, at 1:20 P.M., the Administrator concurred with the DON.

Based on observations, interviews and record review, the facility failed to ensure staff provided services that met professional standards of quality of care when staff failed to obtain an order to check blood sugars and failed to ensure medications for a new admission were obtained. This affected one of the five sampled residents, (Resident #3). The facility census was 62. Review of the facility's policy for blood glucose monitoring, reviewed 9/15/23 showed, in part: - Associates who obtain capillary blood glucose specimens will do so in accordance with their scope of practice and in accordance with all applicable local, state, and federal guidelines. Review of the facility's policy for administration of medications, reviewed 8/24/23 showed, in part: - The facility will ensure medications are administered safely and appropriately per physician order to address resident's diagnoses and signs and symptoms; - Medication administration is the responsibility of those individuals who through certification and licensure are authorized in their state to administer medications in a skilled nursing facility; - Staff who are responsible for medication administration will adhere to the ten rights of medication administration: right drug, right resident, right dose, right route, right time and frequency, right documentation, right assessment, right to refuse, right evaluation/response, right education and information. 1. Review of Resident #3's Admission Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff showed it had not been completed; - 8/30/24 - the resident was admitted ; - 9/1/24 at 1:45 P.M., the resident was discharged . Review of the resident's physician order sheet (POS), dated August 2024 showed: - Order date: 8/30/24 - Atorvastatin Calcium 80 milligrams (mg.) in the evening for hyperlipidemia (elevated levels of lipids and cholesterol); - Order date: 8/30/24: Lantus (long acting) insulin, inject 20 units at bedtime for diabetes mellitus; - Did not have a physician's order to obtain blood sugars. Review of the resident's medication administration record (MAR), dated August 2024 showed: - Atorvastatin Calcium 80 mg. in the evening for hyperlipidemia; - Lantus insulin, inject 20 units at bedtime for diabetes mellitus; - Staff did not document they administered the Atorvastatin on 8/30/24 or on 8/31/24; - Staff documented the resident refused the Lantus insulin on 8/30/24 and it was administered on 8/31/24; - Staff did not document any blood sugars. Review of the resident's baseline care plan, dated 8/30/24 showed it was not completed. Review of the resident's POS, dated September 2024 showed: - Order date: 8/30/24 - Atorvastatin Calcium 80 mg. in the evening for hyperlipidemia; - Order date: 8/30/24 - Lantus insulin, inject 20 units at bedtime for diabetes mellitus; - Did not have a physician's order to obtain blood sugars. Review of the resident's MAR, dated September 2024 showed: - Atorvastatin Calcium 80 mg. in the evening for hyperlipidemia; - Lantus insulin, inject 20 units at bedtime for diabetes mellitus; - Staff did not document any blood sugars on 9/1/24; - The resident was discharged to home on 9/1/24 at 1:45 P.M. During an interview on 9/24/24 at 3:09 P.M., the Infection Preventionist (IP) said: - There should not be a delay in getting the resident's medications if they were a new admit; - Should have a physician's order to obtain blood sugars. During an interview on 9/24/24 at 5:15 P.M., Licensed Practical Nurse (LPN) A said: - He/she admitted the resident to the facility on [DATE]; - The family brought in some medications but he/she could not remember what they were; - The family brought in the resident's Novolog (fast acting) insulin and Lantus insulin; - He/she should have contacted the physician and obtained an order for blood sugars; - He/she could not remember if he/she ordered the Atorvastatin from the pharmacy. During an interview on 9/24/24 at 4:44 P.M., the Director of Nursing (DON) said:- There should have been an order for blood sugars to be obtained if the resident was taking insulin; - She was unsure why the resident did not get the Atorvastatin, but he/she should have. MO241451

Refer to Event ID 1PK412. This deficiency is uncorrected. For previous examples, please refer to Statement of Deficiencies dated 1/5/24. Based on observation, interview and record review, the facility failed to ensure facility staff provided three of 15 sampled residents (Resident #2, #43, and #46), that were unable to complete his/her own activities of daily living, the necessary care and services to maintain good personal hygiene, when staff failed to reposition or provide incontinent care within a timely manner. The facility census was 59.

Based on observations, interviews, and record review, the facility failed to ensure staff discarded an a expired open bottle of Lorazepam for Resident #46, failed to discard an expired open vial of house stock Lorazaepam, and failed to discard two bottles of expired house stock Fish Oil. The staff also failed to date and put the resident's name on an insulin pen after opening and failed to keep the medication cart free of loose pills. Additionally the staff failed to ensure resident's with medications at bedside (Resident #58 and Resident #29) had a physician's order to keep the medications at the bedside. The facility census was 59. Review of the facility's Storage and Expiration Dating of Medications and Biologicals, revised 8/7/23, showed: -The facility should ensure that medications and biologicals are stored in an orderly manner in cabinets, drawers, carts and refrigerators and freezers; -Once any medication or biological is opened the facility should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened; -If a multi dose vial of an injectable medication has been opened or accessed, the vial should be dated and discarded within 28 days; -The facility will not administer or provide bedside medications or biological's without a physician's order; -The facility should destroy or return all discontinued and expired medications or biologicals according to federal regulations. Review of the facility's Guidance for Using Insulin Products, dated 2021, showed: -Upon opening, all insulin vials and pens should be dated and stored away form heat and light. 1. Review of Resident #58's admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 12/8/23, showed: -The resident has moderate cognitive impairment; -The resident is independent with Activies of Daily Living (ADLs); -The resident requires partial assistance with bathing; -Diagnoses included, Dementia, high blood pressure and Asthma. Review of the resident's care plan, dated 12/21/23, showed: -Independent with most ADLs; -Supervision with bathing; -The resident will be administered medications as prescribed by his/her physician. Observation on 1/3/24 at 11:26 A.M. showed: -The resident in his/her room setting in a recliner; -A bottle of Systane Eye drops (used to treat dry eye) with an expiration date of 2/3/22, setting on the sink in his/her room. Observation on 1/4/24 at 2:17 P.M. showed: -The resident in his/her room at the sink washing his/her hands; -A bottle of Systane Eye drops still setting on the sink in his/her room. Review of the resident's Physician's Order Sheet (POS) dated January 2024, showed: -No order for Systane Eye drops; -No order for medication to be kept in the resident's room. During an interview on 1/4/24 at 2:32 P.M., Licensed Practical Nurse (LPN) A said: -He/she did not know the resident had the Systane eye drops in his/her room; -The resident should have physician's order for any medications in the resident's room. 31102 Observation on 1/5/24 at 12:01 P.M., of the [NAME] Medication Nurse's Room showed: - Resident #46 had an opened bottle of Lorazepam (used to treat anxiety) oral intensol, 2 milligrams (mg.)/milliliters (ml.), opened 8/29/23. The label on the box said to discard open bottle after 90 days; - An opened vial of house stock Lorazepam injection, 2 mg./ml., no date on the vial when it was opened. Observation on 1/5/24 at 12:24 P.M., of the East Hall Medication Room showed: - An unopened bottle of house stock Fish Oil 500 mg., expired 10/23; - An opened bottle of house stock Fish Oil 500 mg,. opened 8/1/22, expired 10/23. Observation on 1/5/24 at 12:37 P.M., of the medication cart on the Memory Care Unit showed: - An insulin Aspart (Novolog, fast acting insulin) flexpen, did not have a date when it was opened and did not have a label to indicate which resident it belonged to; - Found two round white pills, one round pink pill, one gray round pill and one oblong pill loose in the drawer of the medication cart. 2. Review of Resident #29's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/23/23, showed: - Cognitive skills intact; - Diagnoses included seizure disorder, anxiety and depression. Observation and interview on 1/2/24 at 10:50 A.M., showed: - The resident had Flonase 50 mcg., Combivent Inhaler 20 mcg./100 mcg. per activation and Advair Diskus, 250 mcg/50 mcg. on his/her bedside table; - The resident said the staff always leave those medications in his/her room. Review of the resident's physician order sheet (POS), dated January, 2024, showed: - Order date: 8/16/23 - Advair Diskus Aerosol Powder Breath Activated 250/50 mcg./dose, one inhalation orally every 12 hours for shortness of breath; Rinse mouth after use, do not swallow; - Order date: 6/16/23 - Combivent Respimat Aerosol Solution 20-100 mcg., inhale two puffs orally four times a day for shortness of breath; - Order date: 6/16/23 - Flonase Allergy Relief Suspension 50 mcg. one spray in each nostril two times a day related to allergies. During a telephone interview on 1/5/24 at 11:42 A.M., Licensed Practical Nurse (LPN) A said: - Medications should not be left at the resident's bedside unless there was a physician's order for them to be left at bedside. During an interview on 1/5/24 at 12:37 P.M., the Director of Nursing (DON) said the nurses and herself check the medication rooms for expired medications. The staff should not use medications that are expired. The medications should be dated when opened. There should not be any loose pills in the medication carts. During an interview on 1/5/24 at 2:56 P.M., the DON said, medications cannot be left at bedside unless there's a physician's order.

Based on observations, record review and interviews, the facility failed to promote the residents right to make choices regarding foods served for Residents #10, #35, #53 and #58 out of 15 sampled residents. The facility census was 59. Review of the facility's Resident Rights policy, with a review date of 9/25/23, showed: -The resident has a right to a dignified existence and self-determination; -The resident has the right to make choices about aspects of his/her life in the facility that are significant to the resident; -The resident has a right to a safe, clean, comfortable and homelike environment including but hot limited to receiving treatment and supports for daily living. Review of the facility's Menus, Substitutions and Alternatives, revised 4/14/23 showed: -Residents with known dislikes of food and beverage items, are offered a substitute of similar nutritive value; -The facility menu has a planned alternate that is nutritionally equivalent; -Residents' preferences are followed to the extent possible; -The facility will provide as available, food that accommodates resident preferences; -The facility will provide alternates to residents who request a different meal choice; -The residents are informed of the alternates at each meal; 1. Review of Resident #10's quarterly Minimum Data Set (MDS) a federally mandated assessment completed by facility staff, dated 10/10/23 showed: -The resident has no cognitive impairment; -The resident is occasionally incontinent of bladder; -The resident has upper extremity impairment on both sides; -The resident is independent with Activities of Daily Living (ADLs); -The resident's daily preferences are very important to the resident; -Diagnoses included, high blood pressure, anxiety and Bipolar Disorder (a mental illness that causes unusual shifts in a person's mood or behavior). Review of the resident's care plan, dated 8/3/23, showed: -The resident has an ADL self-care deficit related to impaired balance; -The resident prefers to eat meals in his/her room; -The resident desires to participate in his/her care; -The staff offer substitutes for uneaten foods. Review of the daily breakfast menu dated, 1/4/24, showed: -Breakfast, juice of choice, cereal of choice, egg cheese bake, sliced bacon, toast beverage of choice and milk. Review of the resident's breakfast meal ticket, dated 1/4/24, showed: -Preferences: Cheerios, Raisin Bran, crispy bacon, fried eggs, and oatmeal; -Beverages: Coffee and water. Observation and interview on 1/4/24 at 9:02 A.M., showed: -The resident was setting in his/her room with a tray of food on the bedside table in front of him/her; -The resident's plate contained egg bake, toast, and no cereal; -A cup of coffee sat on the table; -The resident said he/she tells the staff if he/she is going to eat breakfast; -The resident said the staff do not ask him/her what he/she would like for breakfast; -The resident said he/she liked fried eggs but he/she gets scrambled or some other type of food; -The resident said he/she only likes fried eggs; -The resident said staff do not ask him/her what kind of cereal he/she wants for breakfast; -The resident said he/she expects the staff to ask her what his/her preference for breakfast is. 2. Review of Resident #35's admission MDS dated [DATE], showed: -The resident has no cognitive impairment; -The resident has a urinary catheter; -The resident is occasionally incontinent of bowel; -The resident requires partial assistance with transfers; -The resident is dependent on staff for toileting; -The resident requires substantial assistance with bathing; -The resident's daily preferences are very important; -Diagnoses included, heart failure, anemia (a condition that develops when the body produces a lower than normal amount of healthy red blood cells) and high blood pressure. Review of the resident's care plan dated, 11/3/23, showed: -The resident requires extensive assistance with ADLs due to weakness; -The resident requires set-up assistance with meals. Review of the daily lunch menu dated, 1/2/24, showed: -Tuna noodle casserole, Italian vegetables, garlic bread, banana pudding, beverage of choice; -Alternate lunch choices - Salisbury steak, rice pilaf and buttered spinach. Review of the resident's lunch meal ticket, dated 1/2/24, was blank. Observation and interview on 1/2/24 at 12:31 P.M., showed: -Certified Nurses Aid (CNA) C and CNA D passing trays to the resident's in the dining room; -CNA C and CNA D did not look at the meal tickets before they placed the food on the table in front of the resident's in the dining room; -The resident was setting in the dining room with a plate of food on the table in front of him/her; -The resident's plate contained Salisbury steak, rice pilaf and buttered spinach; -A glass of water sat on the table in front of the resident; -The resident told CNA C he/she does not like rice; -CNA C told the resident he/she did not have to eat the rice but did not offer an alternative food to the resident; -The resident again told CNA C he/she does not like rice; -The resident said he/she would like to have a choice in the food he/she eats; -The resident ate the Salisbury steak but did not eat the rice pilaf. Review of the daily breakfast menu dated, 1/4/24, showed: -Breakfast juice of choice, cereal of choice, egg cheese bake, sliced bacon, toast, beverage of choice and milk. Review of the resident's breakfast meal ticket, dated 1/4/24, was blank. Observation and interview on 1/4/24 at 9:06 A.M., showed: -The resident was setting in the dining room with a plate of food on the table in front of him/her; -The resident's plate contained egg bake, toast, bacon and cold cereal; -A glass of water and a glass of juice set on the table in front of the resident; -The resident did not eat the cold cereal; -The resident said the staff has never asked him/her what he/she wants for breakfast; -The staff do not ask him/her what kind of cereal he/she wants for breakfast; -The resident said he/she expects the staff to ask her what his/her preference is for breakfast. During an interview on 1/4/23 at 9:17 A.M.,CNA C said: -He/she should bring the resident something else to eat if they do not like what they are serving; -He/she was not aware the resident did not like rice. 3. Review of Resident #53's quarterly MDS dated [DATE], showed: -The resident has no cognitive impairment; -The resident is independent with ADLs -The resident requires partial assistance with bathing; -Daily preferences are very important to the resident; -Diagnoses included, diabetes mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels), heart failure and high blood pressure. Review of the resident's care plan, dated 11/3/23, showed: -The resident requires minimal assistance with ADLs; -The resident requires et up assistance with showers. A review of the daily breakfast menu dated, 1/4/24, showed: -Breakfast juice of choice, cereal of choice, egg cheese bake, sliced bacon, toast, beverage of choice and milk. Review of the resident's breakfast meal ticket, dated 1/4/24, showed: -Preferences: Cheerios, Raisin Bran, crispy bacon, fried eggs, oatmeal; -Beverages: Coffee and water. Observation and interview on 1/4/24 at 9:46 A.M., showed: -The resident was setting in his/her room with a tray of food on the bedside table in front of him/her; -The resident's plate contained egg bake, toast, and bacon; -A cup of water set on the table next to the residents food; -The resident said staff do not ask him/her what he/she would like for breakfast; -The resident said he/she liked fried eggs he/she gets scrambled or some other type of food sometimes; -The resident said he/she preferred fried eggs; -The resident said he/she expects the staff to ask her what his/her preference for breakfast is. 4. Review of Resident #58's admission MDS dated [DATE], showed: -The resident has moderate cognitive impairment; -The resident is independent with ADLs -The resident requires partial assistance with bathing; -Daily preferences are very important to the resident; -Diagnoses included, Dementia, high blood pressure and Asthma. Review of the resident's care plan, dated 12/21/23, showed: -Independent with most ADLs; -Supervision with bathing; -The resident eats meals in the dining room. Review of the daily breakfast menu dated, 1/3/24, showed: -Juice of choice, cereal of choice, scrambled eggs, bacon, toast, beverage of choice and milk. Review of the resident's breakfast meal ticket, dated 1/3/24, was blank. Observation and interview on 1/3/24 at 9:02 A.M., showed: -CNA C and CNA D passing trays to the resident's in the dining room; -CNA C and CNA D did not look at the meal tickets before they placed the food on the table in front of the resident's in the dining room; -The resident was setting in the dining room with a plate of food on the table in front of him/her; -The resident's plate contained two fried eggs, toast and hot cereal; -A glass of water and a glass of juice set on the table in front of the resident; -The resident ate a piece of toast and did not eat the eggs; -The resident said he/she hates eggs and he/she gets them every morning; -The resident said that staff do not ask her what he/she would like for breakfast; -The resident said he/she expects the staff to ask her what his/her preference is for breakfast. Review of the daily breakfast menu dated, 1/4/24, showed: -Breakfast, juice of choice, cereal of choice, egg cheese bake, sliced bacon, toast beverage of choice and milk. Review of the resident's breakfast meal ticket, dated 1/4/24, was blank. Observation and interview on 1/4/24 at 9: 14 A.M., showed: -CNA C and CNA D passing trays to the resident's in the dining room; -The resident was setting in the dining room with a plate of food on the table in front of him/her; -The resident's plate contained egg bake, toast, bacon and cold cereal; -A cup of coffee and a glass of juice set on the table in front of the resident; -The resident ate a piece of toast and did not eat the egg bake; -The resident said the staff has never asked him/her what he/she wants for breakfast; -The staff do not ask him/her what he/she wants for breakfast; -The resident said he/she does not like eggs; -The resident said he/she expects the staff to ask her what his/her preference is for breakfast. During an interview on 1/4/24 at 10:18 A.M., CNA C said: -The meal tickets are for the kitchen to use identify what the resident wants to eat; -He/she does not look at the meal tickets; -The nursing staff ask each resident what choice they would like for lunch and supper but not for breakfast; -The residents should get to choose different options for breakfast. During an interview on 1/4/24 at 10:20 A.M., CNA D said: -He/she does not look at the meal tickets before the tray is given to the resident; -The CNA's ask the residents what they would like for lunch and supper; -He/she has never asked the residents what they want for breakfast; -He/she did not know how the kitchen knew what choice the residents wanted for breakfast; -The residents should get to choose different options for breakfast. During an interview on 1/4/24 at 10:20 A.M., Dietary Aide A said: -The kitchen uses the meal tickets to know what likes and dislikes the resident has; -He/she did not know why Resident #10's, #35's and #58's meal tickets were blank; -Resident #53 prefers fried eggs for breakfast and he/she did not know why he/she received the egg bake; -Resident's should have a choice of different options for breakfast; -Resident meal tickets should not be blank. During an interview on 1/4/24 at 10:41 A.M., The Dietary Manager said: -The kitchen uses the meal tickets to know what likes and dislikes the resident has; -He/she did not know why Resident #10's, #35's and #58's meal tickets were blank; -Resident #53 prefers fried eggs for breakfast and he/she did not know why he/she received the egg bake; -Resident's should have a choice of different options for breakfast; -Resident meal tickets should not be blank; -He/she is responsible for ensuring all meal tickets have the correct information; -He/she has not had time to update the all the meal tickets. During an interview on 1/5/24 at 10:05 A.M., The Registered Dietitian (RD) said: -He/she expects the residents to have an alternate choice at meals and expects the dietary staff to be responsible for this; -Resident meal tickets should be current and accurate and reflect their food preferences; -Staff that are delivering the food to the residents should have a way to confirm the correct diet, the correct consistency and any allergies before the food is served to the resident; -He/she expects the DM to be responsible for ensuring resident meal tickets are current, accurate and reflect the resident's food preferences. During an interview on 1/5/24 3:10 P.M., the administrator said: -He/she expects the residents to have a choice at all meals; -An alternative choice should be offered at all meal times; -He/expects the staff delivery the food to the residents to check the meal tickets to ensure they are getting the correct food to the correct resident; -The meal tickets should include the resident's name, the type of diet, consistency and any allergies; -The meal tickets should not be blank; -He/she expects the DM to be responsible for the meal tickets being completed.

Based on observation, and interview , the facility failed to keep the floors, doors and handrails in good repair. The facility census was 59. Review of the facility provided Daily Cleaning policy reviewed 7/19/23 showed: -The resident has the right to a safe, clean, comfortable, and homelike environment. -The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior. The facility did not provide a policy on maintenance of floors, handrails and doors. Observations beginning on 1/3/24 at 2:26 P.M. showed areas of missing floor tile strips in multiple hallways that caused rough surfaces with crusted red and black debris and uneven flooring. These areas included: -five foot (ft) by 1 inch (in) strip outside of room [ROOM NUMBER]; -five ft by 1 in strip outside room [ROOM NUMBER]; -four ft by 1 in strip outside room [ROOM NUMBER]; -five ft by 1 in strip outside room [ROOM NUMBER]; -five ft by 1 in strip outside the staff break room; -ten ft by 1 in strip outside the laundry room door; -four ft by 1 in strip outside the dining room entrance; Observations on 1/3/24 beginning at 2:26 P.M. and continued throughout the survey showed: -Wooden handrails in the 100, 200 and 400 hallways had multiple areas of chipped brown paint, exposing the woodgrain underneath, multiple scratches, exposing the woodgrain and multiple gouges into the wood causing rough, unsafe surfaces. -The wooden hallway handrail between rooms [ROOM NUMBERS] was not fastened securely to the wall. Observations on 1/4/23 at 2:42 P.M. showed: -room [ROOM NUMBER] had a large chipped area in the laminate covering, causing a rough, unsafe area. -room [ROOM NUMBER] kick guard (a laminate covering used to protect the lower half of the door from wheelchair scratches and damage) was lose on one side and protruding away from the door frame. -room [ROOM NUMBER] had multiple chips in the laminate of the room door and exposed the wood underneath . -Dining room fire doors had chipped laminate and exposed the wood underneath. -room [ROOM NUMBER] had multiple chips in the laminate and exposed the wood underneath. Observation on 1/4/24 10:30 A.M., showed the baseboard trim separated from the wall three inches next to the packaged terminal air conditioner (PTAC) unit in room [ROOM NUMBER]. During an interview on 01/05/24 at 2:56 P.M the Administrator said handrails were the Maintenance Director's responsibility. During an interview on 01/05/24 at 2:56 P.M the Regional Clinical Operations Director said there was a plan to do a remodel of the facility and repair of the concerned areas.

Based on interviews and record review, the facility failed to ensure staff provided a written notice of transfer or discharge to residents or their responsible parties and the reasons for the transfer in writing and in a language they understood. The notice should include the effective date of discharge or transfer; the location to which there resident is transferred or discharged ; a statement of the resident's appeal rights, including the name, address (mailing and electronic mail), telephone number of the entity which receives requests and information on how to obtain the appeal form and assistance in completing and submitting it; the name, address (mailing and electronic mail) and telephone number of the Office of the State Long-Term Care Ombudsman; and for residents with a mental disorder or related disabilities, the mailing, electronic mail (e-mail) address and telephone number of the agency for protection and advocacy for individuals with mental disorders established under the Protection and Advocacy for Mentally Ill Individuals Act. This affected three of 15 sampled residents, ( Resident #21, #29 and #34). The facility census was 59. Review of the facilities policy for transfers and discharges, reviewed 8/9/23, showed, in part: - The facility will follow the limited conditions under which Centers for Medicare and Medicaid Services (CMS) has outlined how the facility may initiate transfer or discharge of a residence, the documentation that must be included in the medical record, and who is responsible for making the documentation. Additionally, the facility will ensure the information that must be conveyed to the receiving provider for residents being transferred or discharged to another healthcare setting is provided in accordance with federal guidance; - When the facility transfers or discharges a resident under any of the circumstances, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider; - Documentation in the resident's medical record must include: the basis for the transfer; - Information provided to the receiving provider must include a minimum of the following: contact information of the practitioner responsible for the care of the resident; resident representative information including contact information; advance directive information; all special instructions or precautions for ongoing care; comprehensive care plan goals and all other necessary information, including a copy of the resident's discharge summary and any other documentation to ensure a safe and effective transition of care; - Facility initiated transfers or discharges: in the following circumstances, facilities may initiate transfers or discharges: the discharge or transfer is necessary for the resident's welfare and the facility cannot meet the resident's needs; the resident's health has improved sufficiently so that the resident no longer needs the care and/or services of the facility; the resident's clinical or behavioral status (or condition) otherwise endangers the health of individuals in the facility; the resident has failed, after reasonable and appropriate notice to pay, or have paid under Medicare or Medicaid, for his/her stay at the facility; or the facility ceases to operate; - Emergency transfers to acute care: when residents are sent emergently to an acute care setting these scenarios are considered facility-initiated transfer, NOT discharges, because the resident's return is generally expected. Residents who are sent emergently to an acute care setting, such as a hospital, should be permitted to return to the facility. 1. Review of Resident #21's electronic medical record on 1/5/24 at 9:21 A.M., showed: - 12/7/23 at 6:29 P.M., Certified Nurse Aide (CNA) reported the resident was not acting right. Resident had left facial drooping and her face was twitching. Resident was not able to speak, she would move her lips and no sound would come out. Vital signs were blood pressure 110/54, respirations 18, pulse 78, oxygen saturation ( amount of oxygen in the blood) was 93% on room air, temperature 98.5. Primary care physician contacted and gave the order to send to the emergency room for evaluation and treatment. The resident was sent to the emergency room at 1:00 P.M. The hospital called and the resident was admitted to the hospital; - 12/8/23 at 2:56 P.M., The resident arrived back from the hospital at 10:15 A.M., this morning in a wheelchair with facility transport. Vital signs blood pressure 135/80, pulse 83, respirations 18, temperature 97.5 and oxygen saturation 98% on room air. The primary care physician and family were notified. - The medical record did not have a copy of any discharge letter that would have been issued to the resident. Review of the resident's significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/11/24 showed: - Cognitive skills intact; - Upper and lower extremity impaired on both sides; - Dependent on the assistance of staff for eating, toileting, dressing, transfers and personal hygiene; - Had a catheter (sterile tube inserted into the bladder to drain urine); - Always incontinent of bowel; - Diagnoses included neurogenic bladder ( the name given to a number of urinary conditions in people who lack bladder control due to a brain, spinal cord or nerve problem), stroke, quadriplegia (paralysis of all four limbs), obstructive uropathy, and Parkinson's disease ( a progressive, degenerative neurological condition that affects a person's control of their body movements), diabetes mellitus, congestive heart failure (CHF, accumulation of fluid in the lungs and other parts of the body), anemia (not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues) and depression. 2. Review of Resident #29's electronic medical record on 1/3/24 at 11:24 A.M., showed: - 6/15/23 at 1:50 P.M., at approximately 12:30 P.M., the Activity Director informed the nurse the resident reported he/she was having pain between his/her shoulder. At 12:35 P.M., the assessment showed the resident with inspiratory ( wheezing sound when you inhale) and expiratory wheezing ( wheezing sound when you exhale) throughout and expiratory rub (sound that results from the movement of inflamed and roughened pleural surfaces against one another during movement of the chest wall) throughout. Vital signs: blood pressure 128/61, temperature 97.9, pulse 106, respirations 22, oxygen saturation 89% with oxygen at 5 liters/ nasal cannula. Primary care physician texted above information and called back and gave order to send to the emergency room for evaluation and treatment. Resident informed of the order and he/she was getting ready to go. Facility van driver notified of need for transfer to the emergency room at approximately 1:05 P.M. The Director of Nursing (DON) notified of above. Van driver here at 1:20 P.M. Report called to the emergency room . Resident left facility at 1:35 P.M. Attempted to contact the durable power of attorney (DPOA) and message left related to above. Resident's sister called and will meet the resident at the emergency room . - 6/15/23 at 4:02 P.M., received a call from the hospital and the resident was admitted for exacerbation of chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing). - The medical record did not have a copy of any discharge letter that would have been issued to the resident. Review of the resident's quarterly MDS, dated [DATE], showed;- Cognitive skills intact; - Independent with eating, oral hygiene, toilet use, dressing, and transfers ; - Always continent of bowel and bladder; - Diagnoses included seizure disorder (a disorder in which nerve cell activity in the brain is disturbed), anxiety and depression. 3. Review of Resident #34's quarterly MDS, dated [DATE], showed: - Cognitive skills intact; - Independent with eating; - Dependent on staff for toilet use, dressing, and transfers; - Had a catheter; - Had an ostomy ( a surgery to create an opening from an area inside the body to the outside); - Diagnoses included anemia, neurogenic bladder, depression, multiple sclerosis ( a long-lasting (chronic) disease of the central nervous system). Review of Resident #29's electronic medical record on 1/5/24 at 10:33 A.M., showed: - 11/23/23 at 7:30 P.M., the nurse went to check on the resident at 6:45 P.M., resident noted to have rapid breathing. This nurse tried to awaken resident and the resident barely opened his/her eyes and started to talk but was not making sense. Assessed resident: temperature 105.0, blood pressure 238/107, pulse 126, respirations 22, oxygen saturation on room air 94%. Contacted the physician at 6:50 P.M., and ordered to send resident to the emergency room . This nurse called 911 at 6:55 P.M. Called report to the hospital at 7:00 P.M. and called the DPOA at 7: 17 P.M. Emergency Medical Services (EMS) said the resident was being life flighted to the hospital. - The medical record did not have a copy of any discharge letter that would have been issued to the resident. During an interview on 1/3/24 at 11:19 A.M., the infection preventionist (IP) said: - When a resident is transferred to the emergency room , they send a copy of the resident's face sheet, the medication administration record (MAR), a transfer sheet and a bed hold policy; - If the resident is their own person, they give a copy to the resident; - The transfer form is just the basic information, resident's name, vital signs, emergency contact, and advance directives; - The transfer form did not have all the information it should have on it. During an interview on 1/5/24 at 9:03 A.M., the Social Services Director (SSD) said: - He/she gave the resident or the responsible party a copy of the bed hold policy; - He/she sent a monthly report to the Ombudsman. During an interview on 1/5/24 at 4:44 P.M., the DON said: - She was not aware until today that all that information was supposed to be included on the transfer form.

Based on observations, interviews, and record review, the facility failed to ensure staff followed professional standards of practice when they did not clean the port of two insulin pens, which affected two of 15 sampled residents, (Resident #21, and #45 ), failed to clean the port on the vial of insulin for Resident #45, and failed to appropriately change a water humidification system for one resident (Resident #17) . The facility census was 59. Review of the facility's policy, for guidance for using insulin products, dated 2021, showed, in part: - Use an alcohol wipe to clean the top of the insulin vial. 1. Review of Resident #45's care plan, revised 4/6/22, showed: - The resident had diabetes mellitus; - Blood sugar check as ordered; - Medication as ordered. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/27/23, showed: - Cognitive skills intact; - Lower extremities impaired on both sides; - Had seven insulin injections in the last seven days; - Diagnosis included diabetes mellitus. Review of the resident's physician order sheet, (POS), dated January, 2024, showed:- Order date: 8/24/23 - Humalog (fast acting insulin), 45 units with meals for diabetes mellitus. Hold for blood sugar less than 120; - Order dated: 6/2/21 - Humalog insulin per sliding scale before meals and at bedtime related to diabetes mellitus. Blood sugar 111- 150 - give two units; - Order date: 5/30/23 - Lantus (long-acting) insulin, 50 units twice daily for diabetes mellitus. Review of the resident's medication administration record (MAR), dated January 2024, showed: - Humalog insulin, 45 units with meals for diabetes. Hold for blood sugar less than 120; - Humalog insulin per sliding scale before meals and at bedtime related to diabetes. Blood sugar 111- 150 - give two units; - Lantus insulin, 50 units twice daily for diabetes mellitus. Observation on 1/4/24 at 7:03 A.M. showed: - Licensed Practical Nurse (LPN) A did not clean the port of the Humalog insulin pen and attached the needle, did not prime the insulin pen and dialed the pen to 47 units; - LPN A did not clean the port on the vial of Lantus insulin and drew up 50 units; - At 7:18 A.M., LPN A administered the Humalog insulin in the resident's right abdomen; - At 7:18 A.M., LPN A administered the Lantus insulin in the resident's left abdomen. During a telephone interview on 1/5/24 at 11:42 A.M., LPN A said: - He/she should have cleaned the port of the insulin pen and the port on the vial of Lantus insulin with an alcohol wipe before administering the insulin. During an interview on 1/524 at 2:56 P.M., the Director of Nursing (DON) said: - Staff should make sure they clean the port of the insulin pens and the port on the vials of insulin with an alcohol wipe. 2. The facility did not provide a policy for nasal sprays. Review of the leaflet for Flonase nasal spray, revised March 2016, showed, in part: - Shake the bottle gently; - Blow your nose to clear the nostrils; - Close one side of the nostril. Tilt your head forward slightly and carefully insert the nasal applicator into the other nostril; - Start to breathe in through your nose, and while breathing in press firmly and quickly down one time on the applicator to release the spray; - Repeat in the other nostril; - Wipe the nasal applicator with a clean tissue and replace the cap. Review of Resident #21's significant change in status MDS, dated [DATE], showed: - Cognitive skills intact; - Upper and lower extremities impaired on both sides; - Diagnoses included stroke, respiratory failure ( serious condition that makes it difficult to breathe on your own), and quadriplegia (paralysis below the neck that affects all four limbs). Review of the resident's POS,dated January, 2024, showed: - Order date: 12/4/23 - Flonase allergy relief nasal suspension 50 micrograms (mcg.), one spray alternating nostrils daily for allergies. Review of the MAR, dated January, 2024, showed: - Flonase allergy relief nasal suspension 50 micrograms (mcg.), one spray alternating nostrils one time a day for allergies. Observation on 1/4/23 at 9:23 A.M., showed: - LPN B did not shake the Flonase bottle; - LPN B did not have the resident blow his/her nose beforehand; - LPN B administered one spray in each nostril and did not close either side of the nostril during administration. During an interview on 1/5/24 at 2:56 P.M., the DON said: - Staff should follow the manufacturer's guidelines for the administration of Flonase ( shake the bottle, have the resident blow their nose, close one side of the nostril when administering in the opposite nostril and repeat in other nostril.) During a telephone interview on 1/9/23 at 4:08 P.M., LPN B said: - He/she should have followed the manufacturer's guidelines for administering Flonase, shake the bottle, have the resident blow their nose, close one side of the nostril and administer in the opposite nostril and repeat in the other nostril. 44395 The facility did not provide a policy for use or care of the Arivo 2 Nasal High Flow system (a portable warmed and humidified high flow oxygen delivery system: used to deliver high levels of respiratory gases to a patient.) Review of the manufacturer, [NAME] and Paykel, use and care guide showed the Airvo is not a closed system. Follow infection control guidelines to prevent cross contamination. Daily care: run the drying mode and rinse the patient interface and water chamber. Review of the manufacturer guidelines showed: the cannula is to be changed weekly and all tubing and chamber kits are to be changed every 2 weeks. The filter is to be changed every 3 months, 1000 hours or if discolored. These are all recommendations for a single use patient machine. Review of Continuous Positive Airway Pressure (CPAP) talk national website shows that the water used in the Arivo 2 should be changed every day to prevent bacteria from collecting in stagnant water, and chambers should be cleaned weekly to prevent bacteria buildup. 3. Review of Resident #17 Annual MDS dated [DATE] showed: - No cognitive defecits; -Need for moderate assistance with personal hygiene; -Use of Oxygen (O2); -Diagnoses of heart failure (a condition in which the heart does not pump enough blood and cannot carry adequate oxygen to, or carry waste away from the body), Chronic Obstructive Pulmonary Disease (COPD: a group of diseases that cause airflow blockage and breathing-related problems) and respiratory failure (a serious condition that makes it difficult to breathe on your own). Review of the resident's POS for January 2024 showed: - Arivo 31 Liters high pressure humidified with 3 cm of peep (positive expiration and pressure) every night shift for acute respritory failure. Order date of 8/3/23. -Check Distilled water level every four hours for shortness of breath, or low O2 saturation. Review of the resident's Comprehensive Care Plan dated 12/14/23 showed: -The resident has COPD. He/She will display optimal breathing patterns daily. -Arivo at night. He/She had been refusing. Review of the resident's January 2024 Treatment Administration Record (TAR) showed the resident refused the Arivo on January 1, 2 and 3. Observation and interview on 1/2/24 at 3:25 P.M. showed the Arivo machine at the bedside, with a clear bag hanging from a medication administration pole, connected by tubing to the machine. The bag showed over 1000 milliliters (ml) of clear liquid and a date of 12/21/23. The clear chamber on the Arivo machine had a moderate amount of condensation in it. The resident said he/she did not get the Arivo applied, because staff do not know how to use it. Observation on 1/3/24 at 11:01 A.M. showed the Arivo clear bag had over 1000ml of fluid and was dated 12/21/23. The clear chamber on the Airvo machine had a moderate amount of condensation. During an interview on 1/5/23 at 11:43 A.M. LPN C said he/she assumed the company that brought the Arivo in did education on it. He/She did not know how to use the Arivo. He/She had not recieved education on the Arivo. During an interview on 1/5/23 at 11:46 A.M. LPN D said he/she did not know how to set up, use or clean the Arivo. He/She had not recieved education on the Airvo. During an interview on 1/5/24 at 11:50 A.M. the Physical Therapy Assistant/Therapy Program Director said he/she did not know if a Respiratory Therapist came to the facility. There was not a Respiratory Therapist in the Therapy Department. During an interview on 01/05/24 at 2:56 P.M. the DON said the Arivo, and CPAP machines were the nurses responsibility to apply. He/She was unfamiliar with the Arivo. He/She was unsure how often the Arivo would need to be cleaned or parts changed but would assume at least weekly . He/She had not recieved eduction on the use, cleaning or standards for the Arivo.

44395 Based on observation, interview and record review, the facility failed to ensure facility staff provided two of 15 sampled residents (Resident #2 and Resident #21), that was unable to complete his/her own activities of daily living, the necessary care and services to maintain good personal hygiene. The facility census was 59. Review of the facility provided policy Activities of Daily Living (ADL's) Reviewed 8/23/23 showed: -The resident will receive assistance as needed to complete ADL's; -A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, personal and oral hygiene; -Assist residents with bed/wheelchair positioning as necessary to promote good body alignment and to prevent skin breakdown. 1. Review of the resident #2's Quarterly Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff) dated 11/6/23 showed: -Brief Interview of Mental Status (BIMS) of 99, indicated severe cognitive deficits; -Severely impaired decision making ability; -Long term and short term memory problems; -Dependency on staff for completion of ADLs'; -Always incontinent of bowel and bladder; -Diagnoses of Epilepsy (abnormal electrical brain activity, also known as a seizure,) Profound intellectual disabilities, legal blindness, psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality) and anxiety (a feeling of fear, dread and uneasiness). Review of the resident's Comprehensive Care Plan initiated 6/18/19, with no updates, showed: -The resident was dependent on staff for meeting emotional, intellectual, physical, and social needs related to immobility and physical limitations; -He/She has an ADL self-care performance deficit; - Right elbow splint to be applied 4-6 hours per day. Apply when getting resident up each morning; -The resident was totally dependent on two staff for repositioning and turning in bed; -The resident was totally dependent on 1 staff for personal hygiene and oral care. Continuous observation starting on 1/03/24 at 9:48 A.M. showed; -The resident was sitting in his/her wheelchair in his/her bedroom. - He/She had his/her feet curled up and crossed in the seat of the wheelchair. -At 11:34 A.M. Staff assisted the resident to the dining room via wheelchair. -At 11:56 A.M. He/She was sitting at the dining room table, feet crossed and under him/her. -At 12:12 P.M. his/her meal was delivered to the table. At 12:14 P.M. staff sat to assist the resident with his/her meal. Continuous observation starting on 1/04/24 at 5:01 A.M. showed; - The resident in bed, privacy curtain pulled, covers tucked snugly around him/her. - At 6:03 A.M. he/she remained in bed, no staff had entered his/her room. - At 6:37 A.M. Certified Nurse Aide (CNA) A and CNA D stood at the resident's room door. CNA A said the resident was fine, then CNA A and CNA D went to the next room. - At 7:30 A.M. CNA D entered the resident's room, pulled the resident's blankets back, left the resident uncovered, washed his/her hands then applied gloves. - CNA D removed the resident's saturated incontinent brief and provided incontinent care. CNA D applied a new incontinent brief, and dressed the resident in pajama pants and a sweatshirt. CNA D placed a mechanical lift sling under the resident. CNA E entered the room with a mechanical lift. The resident's roommate asked CNA D to put on the resident's wrist splint. -CNA D and CNA E used the mechanical lift to transfer the resident to his/her wheelchair. -CNA D and CNA E did not straighten the resident's legs and the resident was seated in the wheelchair with his/her legs bent at the knee, legs crossed underneath him/her and sitting on his/her feet. During an interview on 1/4/23 at 7:35 A.M. CNA D said; - He/she had worked for the facility more than four months. -Residents who are incontinent need to be checked, cleaned up, or repositioned at least every two hours. -He/She was not sure why it was longer than two hours to assist Resident #2. -He/She was not aware the resident had a splint to apply. -He/She did not know how to apply the brace. -He/She did not know if stretches or exercises were done when providing care for dependent residents. -The resident always sits on his/her legs. -He/She was not sure what would happen if staff attempted to place the resident in the chair not sitting on his/her feet. 2. Review of Resident #21's care plan, revised 12/13/21 showed: - The resident had an ADL self-care performance deficit related to limited mobility, generalized pain and stroke; - The resident was totally dependent on one staff for personal hygiene and oral care. He/She had a full set of dentures. Review of the resident's significant change in MDS, dated [DATE], showed: - Cognitive skills intact; - Upper and lower extremities impaired on both sides; - Dependent on the assistance of staff for toileting; - Dependent on staff for oral hygiene; - Had a Foley catheter (a tube inserted into the urethra); - Always incontinent of bowel; - Diagnoses included neurogenic bladder ( the name given to a number of urinary conditions in people who lack bladder control due to a brain, spinal cord or nerve problem), stroke, quadriplegia (paralysis of all four limbs), obstructive uropathy, and Parkinson's disease ( a progressive, degenerative neurological condition that affects a person's control of their body movements). Observation on 1/4/24 at 7:21 A.M., showed: - CNA B and CNA C provided catheter (sterile tube inserted into the bladder to drain urine) care, dressed the resident for the day and used the mechanical lift and transferred the resident into his/her wheelchair; - CNA C wiped the resident's face with a wipe, applied deodorant, brushed the resident's hair and used body spray per the resident's request; - CNA B and CNA C did not offer or provide oral care. During an interview on 01/04/24 at 8:04 A.M. Licensed Practical Nurse (LPN) A said he/she is the charge nurse, passing medications and completing treatments for the 400 hall. He/she cannot get to everything. Residents should be checked and changed every two hours, but staff are not always able to get that done. During an interview on 1/9/24 at 4:14 P.M., CNA B said he/she should have offered or provided oral care to the resident. During an interview on 1/9/24 at 4:30 P.M., CNA C said he/she should have offered or provided oral care to the resident. During an interview on 1/05/24 at 2:56 P.M. the Director of Nursing (DON) said: -She expected residents to be cleaned, changed, dressed, offered to brush teeth/hair, and do anything we would do to get ourselves ready for the day. -She expected incontinent care to be done every 2 hours. -She would not expect a dependent resident to go longer than two hours for a check and change or repositioning. -She expected staff to apply splints as ordered and know how to apply the splint.

Based on observations, record review and interviews, the facility staff failed to provide activities to four (Resident #49, #25, #40 and #44) out of 15 sampled residents. The facilty census was 59. Review of the activites policy dated 9/21/23 showed: - The activities will be directed by a qualified Activities Director (AD); - The AD develops, implements, and supervises the resident activities; - The faciliy should implement an ogoing resident-centered activity program that incorpaortes the resident's interests and prefernces; - The activity porgram should improve the resident's physical and psychosocial well being; - The acitivity program should create opprotunities for the residents to have a meaningful life. 1. Reveiw of Resident #49s quarterly Minimum Data Set, (MDS, a federally mandated assessmet completed by the facility staff), dated 10/3/23 showed: - The resident had a brief interview for mental status (BIMS) score of 15, indicating no cognitive impairment; - He/She required assistance of one staff to get dressed, take a shower and use the toilet; - Diagnoses included: Parkinson's Disease (a progressive disorder that affects the nervous system and can cause uncontrolled shaking and tremors), Dementia (a disease that affects the brain, causes confusion and can affect reasoning), and phsychotic disorder (a mental disorder that is charachterized by a disconnect from reality). Review of the resident's activity care plan dated 10/28/22 showed: - The staff were supposed to invite the resident to all facility activities; - The resident enjoyed doing crafts; - The resident enjoyed visiting with other residents and staff; - The resident will voice satisfaction with type and amount of activity involvement. During an interview on 1/2/24 at 11:27 A.M. the resident said: - He/SHe liked to participate in Bingo; - He/SHe would like to go to other activities but the staff do not ask him/her to go; - The staff do not help him/her to other activities. Observation on 1/3/24 at 10:00 A.M. showed: - A puzzle activity was on the calendar to be completed; - No activity was offered to the residents of the Memory Care Unit. During an interview on 1/3/24 at 10:12 A.M. the resident said: - He/SHe did not get to go to the movie night activity last night becuase no staff helped him/her to the activity; He/She really wanted to go to the movie. 2. Review of Resident #25's quarterly MDS dated [DATE] showed: -He/She had a BIMS score of 0, indicating severely impaired cognitive function; - He/SHe had no behaviors; - He/She was dependent on the staff for all cares; - He/she was non verabl and did not make his/her needs known; - Diagnoses included: Dementia and depression. Review of the resident's activity care plan dated 7/12/22 showed; - The resident would attend at least one activity per week; - The staff were supposed to invite the resident to all activities; - The staff were supposed to offer and assist the resident to activities. Review of the resident's activity assessment dated [DATE] showed: - The resident enjoyed things of the past and cooking; - The resident liked to watch television (TV). - There was no type of activity documented. Review of the Activity logs dated October, Noveber and Decemer 2023 showed: - The resident had participation of an activity six times in October; - Participation in an activity nine times in November; - Participation in an activity eight times in December. Observation's on 1/2/24 through 1/5/24 at 10:00 A.M. and 2:00 P.M. showed: - The resident did not participate in any scheduled activity; - The resident did not recieve any individual activities; - The staff did not offer to take the resident to an activity; - The staff did not offer an individual activity. Observation on 1/3/24 at 10:00 A.M. showed: - The staff laid the resident into bed; - The staff did not offer to provide an activity for the resident or take him/her to an activity. 49808 3. Review of resident # 40 Minimum Data Set (MDS), (A federally mandated assessment completed by facility staff), dated 10/19/23 showed: -Resident is dependent on staff for all activities of daily living; -Resident does not have the ability to discuss needs or wants; -Diagnosis included dysphagia (swallowing problems), unspecified dementia(a condition characterized by progressive or persistent loss of intellectual functioning especially with impairment of memory and abstract thinking), and cognitive communication deficit (difficulty with thinking and how someone uses language). Review of resident # 40 Care Plan revised 6/1/23, showed: -Resident is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t cognitive deficits and physical limitations. -Staff to invite resident to scheduled activities; -Resident appears to like music activities: -Resident has several stuffed animals he/she enjoys keeping with them; -Care plan did not indicate how frequent resident should be offered activities or how staff is to recognize/meet social needs of resident. 4.Review of resident # 44 quarterly Minimum Data Set (MDS) dated [DATE], showed: -Brief Interview of Mental (BIMS) score of 7 consistent with severe cognitive impairment; -Resident requires a Hoyer lift for all transfers; -Resident requires staff assistance with all Activities of Daily Living (ADL). Review of resident # 44 Care Plan, revised on 12/18/23, showed: -Activity director to provide 1:1 visits with the resident as needed; -Resident enjoys outdoor activities; -Resident enjoys painting; -Resident enjoys activities involving music; -Resident enjoys watching TV. Observation on 01/02/24 at 2:37 P.M., showed: -Activity schedule for the month of January posted on hallway bulletin board of memory unit. -Daily activities for memory unit residents at 10:00 A.M., 2:00 P.M. and 7:00 P.M -Activities include: -Sundays-10:00 A.M. hand massage, 2:00 P.M. reading aloud, 7:00 P.M. movie time -Mondays-10:00 A.M. ball games, 2:00 P.M. trivia, 7:00 P.M. movie time -Tuesdays-10:00 A.M. Yoga/exercise, 2:00 P.M. Bingo, 7:00 P.M. movie time -Wednesdays-10:00 A.M. puzzles, 2:00 P.M. craft, 7:00 P. M. movie time -Thursdays-10:00 A.M. bean bag toss, 2:00 P.M. card houses, 7:00 P.M. movie time -Fridays-10:00 A. M. music, 2:00 P.M. Bingo, 7:00 P.M. movie time -Saturdays-10:00 A.M. balloon battle, 2:00 P.M. audio books, 7:00 P.M. movie time Observation on 01/03/24 at 10:03 A.M. and 10:24 A.M., showed: -No activities noted on memory unit or in the rooms of residents. Observation on 01/04/23 at 10:00 A.M., showed: -No resident activities at this time in memory care unit (MCU). Observation on 1/5/23 at 10:10 A.M., showed: - Activity of music was scheduled at 10 A.M. five of the 15 residents on the unit were in the common area listening to music playing on the TV. Three of the five residents had their head down and eyes closed. Interview with the Activities director on 1/4/23 at 4:00 P.M. Activities director said: -He/She does not have enough help to make sure each resident has his/her activity requirement; -He/ She was depending on the nursing staff to help with activities on the MCU but recently discovered they did not have time to complete activities with the residents; -There was not always enough staff to get the resident to activities, especially on the MCU; -He/ She had not been working one on one with the residents on the MCU, but does offer puzzle pages for the residents to complete and hallway bowling; -The evening movie time was the residents watching television in the their rooms. -Activities are supposed to be documented on an individual activity log; -He/She did not have anything logged for resident's #25, #40 or #44 because he/she had not completed individual activities with those residents; - Resident #49 had said he/she would like to participate in more activities, but the staff do not get him/her to them. Interview with Director of Nursing (DON) on1/5/23 at 3:10 P.M., DON said: -She expected residents to recieve an activity opprtunity twice daily seven days per week; -He/She would also expect church services on Sunday; -He/She would expect individualized activities for persons that cannot verbalize and would expect staff to help residents to the activities and encourage residents to attend activities.

Based on observations, interviews, and record review, the facility failed to assure staff provided catheter (a sterile tube inserted into the bladder to drain urine) care in a manner to prevent urinary tract infections (UTIs) or the possibility of a UTI when staff failed to clean the drainage spout appropriately and placed the graduate ( a clear plastic container with markings used to collect and measure fluids) directly on the floor which affected two of 15 sampled residents, ( Resident #21 and #39). The facility census was 59. Review of the facility's policy for indwelling urinary catheter (Foley) management, reviewed 8/24/23, showed, in part: - The facility will ensure that residents admitted with a urinary catheter, or determined to need a urinary catheter for a medical indication will have the following areas addressed: insertion , ongoing care and catheter removal protocols that adhere to to professional standards of practice and infection prevention and control procedures. 1. Review of Resident #39's care plan, revised 7/31/23 showed: - The resident had an activities of daily living (ADL) self-care performance deficit related to amputation of both legs, fatigue, impaired balance, and limited mobility; - The resident is incontinent of bowel and dependent upon staff to cleanse after bowel movement. Review of the resident's urinalysis (UA, a test to analyze urine contents) dated 10/21/23, showed the presence of bacteria indicative of a possible UTI. Review of the resident's urine culture and sensitivity (UA with C & S, identifies the amount and type of bacteria present and the medications appropriate to treat the infection), dated 10/21/23, showed the presence of organisms indicative of a possible UTI. Review of the physician's order, dated 10/23/23, showed: -Bactrim DS twice daily for five days for UTI. Review of the physician's order, dated 10/27/23, showed: - Change to Cipro 500 milligrams (mg.) twice daily for five days for UTI. Review of the resident's significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/17/23, showed: - Cognitive skills moderately impaired; - Lower extremity impaired on one side; - Had a Foley catheter; - Always incontinent of bowel; - Diagnoses included obstructive uropathy ( a disorder of the urinary tract that occurs due to obstructed urinary flow), stroke, benign prostatic hyperplasia (BPH, age-associated prostate gland enlargement that can cause urination difficulty) and peripheral vascular disease (PVD, a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Review of the resident's care plan, revised 1/2/24, showed: - The resident had a Foley catheter related to scrotal edema and obstructive uropathy; - Catheter care every shift; - Position catheter bag and tubing below the level of the bladder; - Observe and document for pain/discomfort related to the catheter. Observation on 1/4/24 at 5:09 A.M., showed: - Certified Nurse Aide (CNA) A placed a paper towel on the floor and placed the graduate on it. He/she removed the spout from the sleeve, unclamped it and emptied 700 milliliters (ml.) of yellow urine from the drainage bag. He/she clamped the spout and placed it back in the sleeve and did not clean it. - CNA H did not separate and clean all the frontal skin folds and used the same area of the wipe to clean different areas of the skin; - CNA A and CNA H turned the resident on his/her side; - CNA H wiped the rectal area with fecal material on the wipe, used a new wipe and wiped the rectal area with a smear of fecal material then folded the wipe and dabbed at both sides of the buttocks with the same area of the wipe; - CNA A applied peri guard ( house barrier) to the buttocks; - CNA A and CNA H placed a clean incontinent brief on the resident. During a telephone interview on 1/9/24 at 6:20 P.M., CNA H said: - He/she should have separated and cleaned all areas of the skin where urine or feces had touched; - Should wipe front to back, not back in forth; - Should not use the same area of the wipe to clean different areas of the skin; - Should clean the spout of the drainage bag with an alcohol wipe. During a telephone interview on 1/9/24 at 6:36 P.M., CNA A said: - He/she did not need to clean the spout of the drainage bag; - Should wipe from front to back, not back and forth; - Should not use the same area of the wipe to clean different areas of the skin; - Should separate and clean all areas of the skin where urine or feces had touched. 2. Review of Resident #21's care plan, revised 3/18/22, showed: - The resident was at risk for UTIs due to indwelling Foley catheter; - Catheter care every shift and as needed; - Encourage adequate fluid intake; - Keep catheter below the level of the bladder; - Monitor for signs and symptoms of UTI and report to the primary care physician as needed; - Monitor urine output for color, clarity and amount. Report any changes to the primary care physician as needed. Review of the resident's significant change in MDS, dated [DATE], showed: - Cognitive skills intact; - Upper and lower extremities impaired on both sides; - Dependent on the assistance of staff for toileting; - Had a Foley catheter; - Always incontinent of bowel; - Diagnoses included neurogenic bladder ( the name given to a number of urinary conditions in people who lack bladder control due to a brain, spinal cord or nerve problem), stroke, quadriplegia (paralysis of all four limbs), obstructive uropathy, and Parkinson's disease ( a progressive, degenerative neurological condition that affects a person's control of their body movements). Observation on 1/4/24 at 7:21 A.M., showed: - At various times from 1/2/24 to current date, the drainage bag hung on the side of bed facing the door and did not have a dignity cover; - CNA C did not separate and clean all of the front perineal folds; - CNA C turned the resident on his/her side and and wiped the rectal with fecal material noted and used a different wipe for each swipe. CNA C did not clean all areas of the buttocks; - CNA B and CNA C place a clean incontinent brief on the resident; - CNA C did not have a clean barrier and placed the graduate directly on the floor, removed the spout from the sleeve, unclamped it, emptied 700 ml of yellow urine into the graduate, cleaned the spout with an alcohol wipe, clamped the tubing and replaced the spout in the sleeve. During a telephone interview on 1/9/24 at 4:14 P.M., CNA B said: - All the drainage bags should have a dignity cover; - Should place the graduate on a paper towel; - Should separate and clean all areas of the skin where urine or feces has touched. During a telephone interview on 1/9/24 at 4;20 P.M., CNA C said;- Drainage bags should have a dignity cover; - Should separate and clean all areas of the skin where urine or feces has touched; - Should have a clean barrier to place graduate on. During an interview on 1/5/24 at 2:56 P.M., the Director of Nursing (DON) said: - Staff should place a barrier on the floor before placing the graduate on it; - Staff should clean the drainage spout with an alcohol wipe; - Staff should not use the same area of the wipe to clean different areas of the skin; - Staff should separate and clean all areas of the skin where urine or feces had touched. - Drainage bags should have a dignity cover.

Based on observations, interviews, and record review, the facility failed to ensure staff administered medications with a less than five percent medication error rate (5%). Staff made seven errors out of 25 opportunities for error, which resulted in an error rate of 28%. This affected 2 out of 15 sampled residents, ( Resident #26 and #45). The facility census was 59. Review of the facility's policy for guidance for using insulin products, dated 2021, showed, in part: - Use an alcohol wipe to clean the top of the insulin vial; - Meal time administration - Humalog insulin may be given within 15 minutes before or immediately after a meal; - To minimize air bubbles in pen-like devices prime the pen prior to each and every injection by pushing two units into the air until a drop of insulin is seen at the top of the needle. 1. Review of Resident #45's care plan, revised 4/6/22, showed: - The resident had diabetes mellitus; - Blood sugar check as ordered; - Medication as ordered. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/27/23, showed: - Cognitive skills intact; - Lower extremities impaired on both sides; - Had seven insulin injections in the last seven days; - Diagnosis included diabetes mellitus. Review of the resident's physician order sheet, (POS), dated January, 2024, showed: - Order date: 8/24/23 - Humalog (fast acting insulin), 45 units with meals for diabetes mellitus. Hold for blood sugar less than 120; - Order dated: 6/2/21 - Humalog insulin per sliding scale before meals and at bedtime related to diabetes mellitus. Blood sugar 111- 150 - give two units; - Order date: 5/30/23 - Lantus (long-acting) insulin, 50 units twice daily for diabetes mellitus. Review of the resident's medication administration record (MAR), dated January 2024, showed: - Humalog insulin,45 units with meals for diabetes. Hold for blood sugar less than 120; - Humalog insulin per sliding scale before meals and at bedtime related to diabetes. Blood sugar 111- 150 - give two units; - Lantus insulin, 50 units twice daily for diabetes mellitus. Observation on 1/4/24 at 7:03 A.M. showed: - Licensed Practical Nurse (LPN) A did not clean the port of the Humalog insulin pen and attached the needle, did not prime the insulin pen and dialed the pen to 47 units; - LPN A did not clean the port on the vial of Lantus insulin and drew up 50 units; - At 7:18 A.M., LPN A administered the Humalog insulin in the resident's right abdomen; - At 7:18 A.M., LPN A administered the Lantus insulin in the resident's left abdomen; - At 8:11 A.M., showed the resident was in his/her wheelchair in his/her room dozing off at intervals. No meal has been served; - At 8:15 A.M., the dietary staff propelled the resident to the dining room for breakfast; - At 8: 20 A.M., the staff placed the resident's breakfast tray in front of him/her; - At 8:22 A.M., the resident took the first bite of his/her breakfast. During a telephone interview on 1/5/24 at 11:42 A.M., LPN A said: - He/she should have cleaned the port of the insulin pen with an alcohol wipe before he/she attached the needle; - He/she should have cleaned the port on the vial of Lantus insulin with an alcohol wipe before drawing up the insulin; - He /she should have primed the insulin pen with one or two units of insulin before administering it; - The resident should have had a meal within 15 - 20 minutes of receiving the Humalog and Lantus insulin. 2. Review of the facility's policy for general dose preparation and medication administration, revised 1/1/22 showed, in part: - Facility should crush oral medications only in accordance with pharmacy guidelines. Review of the website, www. webmd.com for multivitamin with minerals showed: - Swallow the tablets whole. Do not crush or chew the tablets. Review of the website, www.drugs.com for ferrous sulfate tabs showed: - Swallow the iron tablets and capsules whole: do not crush, open or chew. 3. Review of Resident #26's care plan, revised 5/19/21 showed: - The resident has anemia (not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues): - Give medications as ordered. Review of the Resident's quarterly MDS, dated [DATE] showed: - Cognitive skills intact; - Diagnoses not addressed. Review of the resident's POS, dated January, 2024, showed: - Order date: 8/11/23 - Ferrous Sulfate oral tablet 325 milligram (mg.) one tablet by mouth one time a day every two days for iron deficiency anemia; - Order date 1/20/22 - Multivitamins-minerals tablet one tablet by mouth daily for supplement. Review of the resident's MAR, dated January, 2024, showed: - Ferrous Sulfate oral tablet 325 mg. one tablet by mouth one time a day every two days for iron deficiency anemia; - Multivitamins-minerals tablet one tablet by mouth daily for supplement. Observation on 1/4/24 at 8:55 A.M., showed LPN B: - Placed the Multivitamins with minerals tablet and the Ferrous Sulfate tablet in a plastic bag and crushed the medications, placed the crushed medication in a medication cup with applesauce and administered to the resident. During an interview on 1/5/24 at 11:42 A.M., LPN A said: - Multivitamins with minerals and Ferrous Sulfate should not be crushed. During an interview on 1/524 at 2:56 P.M., the Director of Nursing (DON) said: - Staff should make sure they clean the port of the insulin pens and the port on the vials of insulin with an alcohol wipe; - She would expect staff to prime the insulin pen with one or two units of insulin, then dial it to the amount to be administered; - The resident should have a meal within 30 minutes of receiving a fast acting insulin; - Should not crush a multivitamin with minerals and was not for sure about the ferrous sulfate. During an interview on 1/9/24 at 4:08 P.M., LPN B said: - He/she thought you could crush Multivitamins with minerals and could crush Ferrous Sulfate.

Based on interviews and record review, the facility failed to provide assessments and interventions to prevent falls for one resident (Resident #5) who fell three times within a 24 hour period while at the facility and sustained significant injuries. The facility census was 57. 1. Review of the facility policy for fall management dated 11/16 showed: -The purpose is to promote patient safety and reduce patient falls by proactively identifying, care planning and monitoring of patients' fall indicators; -Based on the comprehensive assessment of a patient, the facility must ensure that patients receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the patient's choice; -The patient environment remains as free of accident hazards as possible and each patient receives adequate supervision and assistive devices to prevent accidents; - All patients will be assessed for fall indicators upon admission, readmission, quarterly, change in condition and with any fall event; -An individualized fall management care plan will be developed and initiated upon all patient admissions and readmissions; -The interdisciplinary team will review and revise all patients fall management care plans upon completion of each comprehensive, significant change and quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, upon a fall event and as needed. Care plan revisions will be made at the time as indicated; -With the event of a patient fall, a complete nursing assessment will be performed by the nurse. The nurse will communicate with other staff members and caregivers regarding the patient's fall event, assessment findings and fall indicators. The patient's fall management care plan will be revised as indicated; -Upon the event of a patient fall, the patient will be reviewed by the interdisciplinary team members for any indicated additional assessment and care plan revisions, during the next clinical rounds. 2. Review of the facility policy for neurological assessment (an evaluation of a person's nervous system) dated 9/08 showed: -Purpose is to provide a mechanism to ensure a uniform procedure for neurological assessment and to provide guidelines for observation and communication of trends and changes over a period of time; -The neurological assessment flow sheet shall be initiated by a written physician's order for neurological checks or when indicated by a resident assessment (head injury, post fall, neurological decompensation). Neurological assessments shall be performed at least every four hours for the first 24 hours then at least every eight hours, unless ordered more or less frequently by the physician or when the resident is determined to be at risk for neurological decompensation; -Neurological assessment and documentation on the flow sheet shall include the date and time of the assessment, eye opening, verbal response, motor response, pupillary response and limb response; -The nurse shall document and report any pertinent changes in the resident's neurological status immediately to the physician. 3. Review of Resident #5's MDS dated [DATE] showed: -[DIAGNOSES REDACTED]. -Unable to make own decisions; -No behaviors or wandering; -Activity preferences are reading books and newspapers, listening to music, snacks, prefers to stay up past 8:00 P.M.; -Extensive assistance of one staff member for activities of daily living (ADL's); -History of falls prior to admission and two falls since admission; -Seven days of antipsychotic (a medication used to treat mental illness), seven days of antianxiety and seven days of an antidepressant. Review of the fall risk evaluation dated 4/22/17 showed the resident was at high risk for falls. Review of the interim care plan for falls dated 4/24/17 showed: -At risk for physical injuries from falls related to unsteady ambulation, dementia, recent falls and non-compliance with safety instructions; -Goal to minimize risk for a fall related injury; -Interventions included staff assistance with transfers and ambulation, monitor and encourage use of proper foot wear, wear non-skid socks while out of bed, physical therapy to evaluate and treat, remind resident to sit for a few minutes before standing and to stand slowly due to drop in blood pressure. Review of the fall care plan dated 5/12/17 showed: -At risk for falls due to history of falls at home, and fall risk score of 20 and use of psychotropic medications; -Goal was to be free from injuries related to falls; -Approaches included to monitor frequently for needs being met, fall risk assessment per protocol, monitor for changes in gait or balance; assist to the bathroom before and after meals and before bedtime, physical therapy as ordered, monitor for proper footwear, encourage the resident to sit for a few minutes prior to standing to prevent orthostatic hypotension (a condition when the blood pressure will drop upon coming to a sitting or standing position); check on resident frequently. The resident has a monitor at bedside with a speaker in the nurse's office (a device used to monitor a baby's movement while in a bed or crib) and at times may require one assistance to transfer and ambulate. Review of the undated care directives (a guide used by the Certified Nurse Aides (CNA) to use to give care) showed no approaches for prevention of falls. Review of the facility incident follow up and recommendation form dated 5/12/17 at 4:20 P.M. showed: -Resident found sitting on the floor of the dayroom. Resident stated he/she did not know how he/she fell . Laceration to the back of the head. Review of the nurses' notes dated 5/12/17 showed no documentation of the fall or post fall care and assessments. Review of the care plan for falls and the care directives showed no new approaches after the fall. Review of the nurses' notes dated 5/13/17 at 4:07 P.M. showed: -On 5/12/17 at approximately 9:20 P.M., the nurse was called to the memory care unit. The resident was just outside his/her door lying on the floor on his/her right side. He/she was alert and stated he/she fell and hit his/her head and asked for a family member to come to the facility. The nurse asked if the resident could sit up or stand and sit in the wheelchair. The resident was assisted to the wheelchair by two staff members. Noted dried blood to the back of the right side of the head. Noted a small laceration to the right upper eyelid. Physician notified. Family member called and asked for antipsychotic medication to be discontinued. Staff found the monitor at the nurses station was unplugged. A staff member plugged the monitor back in. Review of the fall risk assessment dated [DATE] showed: -Three or more falls in the last 90 days; -Resident displays behaviors of being easily distracted, periods of altered perception or awareness of surroundings, episodes of disorganized speech, periods of restlessness, periods of lethargy, mental function varies over the course of the day; -Incontinent of bowel and bladder; -Balance is not steady, only able to stabilize with physical assistance; -No drop in blood pressure while lying, sitting and one to three minutes after standing; -Psychiatric or cognitive problem; -Takes antipsychotic, antianxiety and antidepressant medication; -Score of a 20 for high risk for falls. During an interview on 5/15/17 at 3:45 P.M. Licensed Practical Nurse (LPN) A said: -He/she was the nurse on duty on 5/12/17 when the resident fell ; -The resident was alert and stated he/she hit his/her head; -The resident had an old laceration to the back of his/her head from earlier in the day that was closed with dried blood and a small laceration to the right eye; -The resident did not complain of any other pain; -There was no bruising to the right side of the face. Review of the nurses' notes dated 5/13/17 at 3:10 P.M. showed: -The resident was being assessed from a previous fall and staff noticed an area next to the right eye approximately one inch long, gaping open. The resident's right eye was black in color and he/she complained of pain in his/her cheek bone area. The right side of the resident's face was swollen and he/she had a bruise on the right jaw bone. Staff notified the resident's family. The family member said he/she was going to come in and take the resident to the emergency room . Staff notified the physician of the family member taking the resident to the emergency room . Staff notified the Director of Nursing (DON) of the transfer to the emergency room . During a telephone interview on 5/26/17 at 2:00 P.M. LPN B said: -He/she assessed the resident at 11:00 P.M. on 5/12/17; -The resident did not complain of any pain, there were bruising on the right side of the resident's face; -At 3:10 P.M. the resident complained of pain in the right eye, the right side of the resident's face had increased swelling; -He/she called the family and the physician, the family took the resident to the hospital; -There was a baby monitor in the nurses office to alert the staff when the resident moved in the bed; -At times there were no staff in the nurses office to hear the monitor; -Staff were supposed to sit outside the resident's room to monitor his/her movement; -At times there was only one aide working the unit so the aide was unable to sit and monitor the resident. Review of the nurses' notes dated 5/13/17 at 5:23 A.M. showed: -Resident returned from the emergency room with new orders and a [DIAGNOSES REDACTED]. Review of the emergency room radiology report dated 5/13/17 showed: -Blunt trauma (contusions or hematomas) and laceration to the upper right eyelid. Comminuted (a fracture in which a bone is broken, splintered or crushed into a number of pieces) displaced fractures involving the right zygomatic arch (cheek bone), the lateral orbital wall and the floor of the orbit (eye socket). There are comminuted displaced fractures involving the anterior (front), medial (middle) and lateral (outer) maxillary sinus walls (nose). Review of the nurses' notes dated 5/13/17 at 2:19 P.M. showed: -Nurse went into residents room to give scheduled medication and do 15 minute checks and resident was sitting on the bathroom floor with his/her feet out in front. The resident stated I did not fall, I just had to go to the bathroom. The CNA put a gait belt and shoes on the resident and helped the nurse assist the resident up off the floor and into the day room. The resident denied any new pain other than the bruise to the face rating it a six out of 10 (10 being extreme pain). The resident complained of feeling something in his/her eye. The right side of his/her face continues to be swollen and bruised. The resident denied hitting his/her head during the fall. The nurse educated the resident to rise slowly and ask for assistance when needing to transfer. The nurse notified the physician and the physician changed the resident's Care plan and fall assessment updated. Review of the care plan for falls dated 5/12/17 showed an intervention dated 5/13/17 for staff to educate the resident to ask for assistance with transfers. Review of the undated care directives showed no interventions for the CNA's to use to prevent falls. Review of the care plan for falls dated 5/12/17 showed no new interventions for the prevention of the falls that occurred on 5/12/17 or 5/13/17. During an interview on 5/15/17 at 11:00 A.M. Registered Nurse (RN) A said: -The resident fell on [DATE] on his/her right side and went to the emergency room and was diagnosed with [REDACTED]. -The resident has orthostatic hypotension and when he/she stood up he/she could fall; -The resident was supposed to ask for assistance when he/she wanted to get up, but he/she was not cognitively aware to ask for help. During an interview on 5/15/17 at 3:45 P.M. Licensed Practical Nurse (LPN) A said: -The resident has a history of orthostatic hypotension; -The family brought in a baby monitor for the facility to use to watch the resident when he/she was in his/her room; -The monitor was unplugged at the nurses station on 5/12/17; -There is not enough staff on the unit for one person to sit at the nurses station and watch the monitor; -The resident's falls occurred on the evening and midnight shifts; -One staff member was supposed to sit outside the resident's door and monitor the resident, but if another resident needed assistance, then no one was able to observe the resident. During an interview on 5/15/17 at 11:30 A.M. CNA A said: -The resident's blood pressure would drop when he/she stood up; -The resident was unsteady when he/she walked; During an interview on 5/15/17 at 4:15 P.M. the DON said: -She was aware of the fall on 5/12/17; -The nurse on 5/12/17 reported there was no bruising or swelling at the time of the fall; -The resident had frequent falls, his/her blood pressure would drop when he/she stood up; -The resident was not aware to ask for assistance before standing up; -The family brought in a baby monitor for the staff to use to monitor the resident when he/she was in his/her room; -When the resident was out of his/her room, the staff were to monitor every 15 minutes; -She would expect the nurses to send a resident to the hospital if the nurses felt there was injuries requiring emergency medical treatment. MO 5

Based on observations, interviews, and record review, the facility failed to ensure staff assessed skin for the development of pressure ulcers (PU) and failed to develop and implement measures to prevent the formation of PUs which affected two of 13 sampled residents (Resident #3 and #8). The facility census was 61. Review of the facility's Evaluations, Screenings, and Assessments for PU Prevention policy, dated 2/25/15, showed: - All residents are evaluated at the time of admission for skin care needs. - All residents received weekly skin integrity checks by licensed personnel. - Ulcers that are present on admission or develop after admission are treated according to medical orders. - Staff should perform weekly wound assessments and record the assessments on the Pressure Ulcer Status Record. - Staff should record each resident's PU description on the Weekly PU Tracking Report and submit the information to the director of nursing (DON) for the Risk Committee to review. - Staff should notify the physician, family, and staff if skin breakdown was found or if the resident was at risk for breakdown. - Staff should implement preventive measures for resident's considered at risk for skin breakdown. - Staff should provide medically directed treatment for [REDACTED]. Review of the facility's Preventative Measures policy, dated 10/7/10, showed: - Staff should cleanse the resident's skin at the time of soiling with urine or fecal material and at routine intervals. - Skin exposure to moisture due to incontinence, perspiration, or wound drainage should be minimized. - Topical ointments and creams that act as barriers to moisture should be used. - Staff should use proper positioning, transferring and turning techniques to prevent friction and shearing of the skin. - Staff should not turn the resident onto a red body surface. - Staff should monitor and document outcomes of treatments and interventions. Review of the facility's treatment of [REDACTED]. - Staff should provide a comprehensive treatment plan to meet the needs of each resident's goals. - Staff should provide the necessary treatment of [REDACTED]. - Staff should assess the entire resident to include wound assessment, comorbid (the presence of one or more diseases or disorders occurring with a primary disease or disorder) conditions and risk factors. - Staff should perform a nutritional assessment to promote healing. - Staff should assess pain related to the wound or treatment of [REDACTED]. - Staff should reduce the effects of pressure, shearing, and friction of the tissue. - Reposition the resident every two hours with the use of positioning devices as necessary. - Use pressure reduction seating surfaces and mattresses for pressure reduction. - Staff should provide care of wounds as ordered by the physician. - Staff should care plan the treatment and preventive care of skin issues. 1. Review of Resident #3's significant change in condition Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/31/15, showed: - A Brief Interview for Mental Status (BIMS) score of two which indicated severely cognitively impaired; did not make daily decisions; - Extensive assist of two staff for bathing and hygiene; - No PUs; - Always incontinent of bowel; - Urinary catheter (a sterile tube inserted into the bladder to drain urine). Review of the resident's care plan, reviewed on 9/2/14, showed: - At risk for PU development due to impaired mobility, stroke, and incontinence of bowel; - History of skin breakdown; - Monitor skin during routine care and report any problems; - Weekly skin assessments by charge nurse; - Reposition frequently; - Perineal care after each incontinent episode; - Pressure relief cushion for wheelchair; - Did not show wounds to buttocks or medial (inside) knee. Review of a physician's telephone order, dated 8/12/15, showed Licensed Practical Nurse (LPN) D documented: - Cleanse open areas to left proximal (center) knee with normal saline, apply Triple Antibiotic Ointment, and a dressing daily and as needed for 10 days Review of the Weekly Skin Integrity Data Collection Sheet showed staff did not document a wound to the left knee on 8/12/15. Review of nurse's progress notes, dated 8/12/15 through 8/16/15, showed: - No licensed staff documented any redness or open areas to the buttocks or open, scabbed, or abraised areas to the left medial knee. Review of the Weekly Skin Integrity Data Collection sheets showed staff did not conduct an assessment for wounds on 8/16/15. Review of nurse's progress notes, dated 8/17/15 through 8/25/15, showed: - No licensed staff documented any redness or open areas to the buttocks or open, scabbed, or abraised areas to the left medial knee. Review of the Weekly Skin Integrity Data Collection Sheet, dated 8/25/15, showed: - Redness to buttocks; - No licensed staff documented any open, scabbed, or abraised areas to the left medial knee. Review of nurse's progress notes, dated 8/26/15/15 through 9/2/15, showed: - No licensed staff documented any redness or open areas to the buttocks or open, scabbed, or abraised areas to the left medial knee. Review of a shower sheet, dated 9/2/15, showed: - Certified Nurse Aide (CNA) E did not document any skin issues on the diagram or in the visual assessment column. - LPN G and the wound nurse (WN) signed the shower sheet. Review of a nurse's progress note, dated 9/3/15, showed: - No licensed staff documented any redness or open areas to the buttocks or open, scabbed, or abraised areas to the left medial knee. Review of the resident's medical record showed staff did not document any nurse's progress notes from 9/4/15 and 9/5/15. Review of a shower sheet, dated 9/5/15, showed: - CNA F did not document any skin issues on the diagram or in the visual assessment column. - LPN F and the WN signed the shower sheet. Review of the resident's medical record showed staff did not document any Nurse's Progress notes for 9/6/15 and 9/7/15. Review of the Braden Scale for Predicting Pressure Ulcer Risk, dated 9/7/15, showed: - A score of 12 which indicated high risk for PU formation. Review of a nurse's progress note, dated 9/8/15, at 3:05 P.M., showed LPN A documented: - Treatment to the left knee discontinued. - Apply skin prep (a liquid film-forming skin barrier to help heal wounds) to left knee, apply Duoderm (a soft, flexible foam adhesive dressing to cover skin to help prevent friction or PU formation) and change every seven days and as needed. Review of a nurse's progress note, dated 9/9/15 through 9/12/15, showed: - No licensed staff documented any redness or open areas to the buttocks or open, scabbed, or abraised areas to the left medial knee. Review of a shower sheet, dated 9/12/15, showed: - CNA B did not document any skin issues on the diagram or in the visual assessment column. - LPN D and the WN signed the shower sheet. Review of a nurse's progress note, dated 9/13/15 through 9/16/15, showed: - No licensed staff documented any redness or open areas to the buttocks or open, scabbed, or abraised areas to the left medial knee. Review of a shower sheet, dated 9/16/15, showed: - CNA C did not document any skin issues on the diagram or in the visual assessment column. - LPN G and the WN signed the shower sheet. Review of a nurse's progress note, dated 9/17/15 through 9/19/15, showed: - No licensed staff documented any redness or open areas to the buttocks or open, scabbed, or abraised areas to the left medial knee. Review of a shower sheet, dated 9/19/15, showed : - CNA A documented sore area in the visual assessment column and circled the left medial knee on the diagram. - LPN F and the WN signed the shower sheet. Review of a nurse's progress note, dated 9/20/15 through 9/23/15, showed: - No licensed staff documented any redness or open areas to the buttocks or open, scabbed, or abraised areas to the left medial knee. Review of a shower sheet, dated 9/16/15, showed: - CNA G did not document any skin issues on the diagram or in the visual assessment column. - The WN signed the shower sheet. Review of the Weekly Skin Integrity Data Collection sheet, dated 9/24/15, showed Registered Nurse (RN) A documented: - Redness to inner buttocks, skin intact; - No documentation related to open, scabbed, or abraised areas to the left medial knee. Review of a nurse's progress note, dated 9/24/15, showed: - No licensed staff documented any redness or open areas to the buttocks or open, scabbed, or abraised areas to the left medial knee. Review of the resident's medical record from 9/25/15 through 9/30/15, showed no staff documented any notes related to wounds to the buttocks or left medial knee. Review of a shower sheet, dated 9/30/15, showed: - CNA H did not document any skin issues on the diagram or in the visual assessment column. - LPN A and the WN signed the shower sheet. Review of the resident's medical record for 10/1/15, showed no staff documented any notes related to wounds to the buttocks or left medial knee. Review of a shower sheet, dated 10/3/15, showed: - CNA I did not document any skin issues on the diagram or in the visual assessment column. - LPN F and the WN signed the shower sheet. Review of the Weekly Skin Integrity Data Collection sheet, dated 10/1/15, showed LPN C documented the following: - Abrasion to the left buttock. Review of the resident's medical record from 10/2/15 through 10/4/15, showed no staff documented any notes related to wounds to the buttocks or left medial knee. Review of the Care Directive (used by direct care staff to determine care needs), dated 10/5/15, showed: - Notify nursing staff of any skin integrity issues (redness, open areas, abrasions). - Did not mention any interventions to keep the resident from crossing his/her legs or to prevent pressure to the resident's left medial knee. Observation on 10/5/15, at 11:50 A.M., showed: - Resident #3 sat in a wheelchair with a special wheelchair cushion abductor device specifically made for the resident at the dining room table. - The abductor device was intended to keep the resident from crossing his/her legs. - His/her right leg was rigid and crossed over the left leg with the knees pressed tightly against each other. - No padding lay between the knees to prevent pressure to the left medial knee. Observation on 10/5/15, at 2:00 P.M., showed: - Resident #3 sat in his/her room in a wheelchair with a special wheelchair cushion abductor device specifically made for the resident at the dining room table. - The abductor device was intended to keep the resident from crossing his/her legs. - His/her right leg was rigid and crossed over the left leg with the knees pressed tightly against each other. - No padding lay between the knees to prevent pressure to the left medial knee. Observation on 10/5/15, from 3:00 P.M. until 4:30 P.M., showed: - Resident #3 sat in his/her room in a wheelchair with a special wheelchair cushion abductor device specifically made for the resident at the dining room table. - The abductor device was intended to keep the resident from crossing his/her legs. - His/her right leg was rigid and crossed over the left leg with the knees pressed tightly against each other. - No padding lay between the knees to prevent pressure to the left medial knee. Observation on 10/6/15, at 5:50 A.M., and 6:30 A.M. until 7:30 A.M. showed: - Resident #3 lay in bed asleep with his/her right leg crossed over the left leg with knees pressed tightly together and no padding lay between the knees. Observation on 10/6/15, at 8:05 A.M., showed: - The resident sat in a wheelchair with a special wheelchair cushion abductor device specifically made for the resident at the dining room table. - The abductor device was intended to keep the resident from crossing his/her legs. - The resident sat with no padding between his/her knees and the right leg crossed over the left leg with the knees pressed tightly together. Observation on 10/6/15, at 8:30 A.M., showed: - The resident yelled out I hurt, I hurt. Observation on 10/6/15, at 12:10 P.M., showed: - The resident sat in a wheelchair with a special wheelchair cushion abductor device specifically made for the resident at the dining room table. - The abductor device was intended to keep the resident from crossing his/her legs. - The resident sat with no padding between his/her knees and the right leg crossed over the left leg with the knees pressed tightly together. - The resident yelled out in the dining room that he/she hurt. - Nurse's Aide (NA) A wheeled the resident back to his/her room to eat his/her noon meal. Observation on 10/6/1/5, at 12:15 P.M., showed: - CNA B and NA A provided perineal care to the resident. - A large amount of soft semi-liquid stool lay against the resident's buttocks and rectal area. - CNA B and NA A to pulled the buttocks apart to see the resident's skin. - Two small open areas and redness of the skin were noted to the left buttock near the coccyx and between the gluteal fold (where the buttocks come together). - Both CNA B and NA A identified the open areas and redness on the resident's skin. - NA A cleaned the resident's buttocks and rectal area and said he/she was still passing fecal material and they needed to come back later to finish cleaning the resident. - Both CNA B and NA A placed a brief on the resident. - CNA B placed a small folded blanket between the resident's knees and left the room. - The resident continued to yell out he/she hurt. - LPN A entered the room and said he/she needed to give the resident some medication to calm him/her. - LPN A did not know why the resident yelled out with pain. Observation on 10/6/15, at 1:30 P.M., showed: - LPN A administered medication to the resident and received an order to collect a urine specimen. During an observation and interview on 10/6/15, at 2:30 P.M., showed: - LPN A removed the old Duoderm dressing from the left medial knee and said the resident now had two Stage II (a partial thickness loss of skin presenting as a shallow open ulcer without slough (dead tissue) and a red pink wound bed) PUs. - LPN A said the wounds were over the bony prominence of the knee. - Redness extended approximately one centimeter out from the wounds, encircling both wounds. - LPN A said on 10/1/15, when he/she last saw the wound, the resident had one black scab covered wound that he/she painted with skin prep and covered with Duoderm. - LPN A said the original wound to the left knee started as an abrasion and was found sometime in August, 2015. - LPN A said the resident now had two open wounds and both were covered with yellow slough so they were unable to stage. - LPN A left the room to summon the WN. During an observation and interview on 10/6/15, at 2:45 P.M., NA A and NA C did and said: - NA C and NA A provided perineal care to the resident. - The resident lay in a large amount of liquid brown fecal material. - NA C said the resident had two open areas to the buttocks and he/she needed to tell the nurse. - NA C said they had care directives that were printed on every resident but he/she did not know if Resident #3's directive said to place padding between the knees. - NA C said the resident did not have padding between his/her knees while up in the wheelchair today. - NA A said he/she did not know if the care directive instructed staff to place padding between the resident's knees. During an interview on 10/6/15, at 2:55 P.M., LPN A said: - Another LPN found the wound to the knee on 8/16/15. - He/she thought the wound started out as an abrasion. - He/she did not know why a wound notification sheet was not filled out concerning the wound to the knee. - When he/she saw the wound on 10/1/15, the wound was covered with a black scab. - He/she did not remember if he/she told the wound nurse about the wound, but he/she thought he/she did. - He/she changed the treatment to Skin Prep and Duoderm when he/she saw the black scab. During an observation and interview on 10/6/15, at 3:15 P.M., the WN and Director of Nurses (DON) did and said: - The WN said the two wounds to the resident's buttock were Stage II wounds. - No staff reported the buttock wounds to him/her this morning. - The left inner mid buttock or upper wound measured 0.5 centimeter (cm) long x 0.3 cm wide x less than 0.1 cm deep with 100% pink tissue in the wound bed. - The left mid buttock wound measured 0.6 cm long x 0.5 cm wide x less than 0.1 cm deep with 100% red/pink tissue in the wound bed. - The left medial front knee wound measured 0.9 cm long x 0.9 cm wide with an immeasurable depth. - The wound bed was covered with 100% yellow slough. - The left medial back knee wound measured 0.5 cm long x 0.7 cm wide with an immeasurable depth. - The wound bed was covered with 100% yellow slough. - No staff reported any wounds to the resident's knee to her at any time since staff found the wound in August. - The DON said staff should have reported the wounds to the buttocks found earlier in the day to the charge nurse so treatment could have started promptly. - The DON said the charge nurse who found the scabbed wound to the knee should have reported the wound to the WN when the wound was first found. Review of a nurse's progress note, dated 10/6/15, at 7:17 P.M., showed: - The WN documented LPN A notified her of two Stage II PUs to the resident's upper buttock and two PUs to the left medial knee both covered with yellow slough. - Physician and family member notified. - Padding placed between knees at all times, low air loss mattress (used to keep pressure off of buttocks when in bed), abductor wedge (a raised area on the wheelchair cushion to help keep resident's legs separated to prevent pressure areas), reposition frequently, perineal care after each incontinent episode. Review of the care plan, dated 10/6/15, showed the WN documented: - Two Stage II PUs to the left inner buttock and left mid buttock; - Two PUs to the left medial knee related to contractures and impaired mobility; - Physical Therapy (PT) as ordered; - Treatments to wounds as ordered; - Vitamins and supplements as ordered to help with healing of wounds; - Keep padding between the knees when the resident sat in the wheelchair or lay in bed; - Specialty wheelchair with abductor device to keep legs apart; - Low air loss mattress; - Foam knee pads to knees at all times. Review of the Care Directive dated 10/7/15, showed: - Staff did not update the Care Directive to include new orders or changes in care received on 10/6/15. During an interview on 10/7/15, at 8:15 A.M., the Registered Physical Therapist (RPT) said: - Resident #3 was on PT service from May until August and was just discharged from PT service. - The resident had a special wheelchair cushion abductor device specifically made for him/her which was intended to keep his/her legs separated because he/she crossed his/her legs frequently. - The RPT learned of the two PUs on 10/6/15, and received a referral to evaluate and treat the resident. - The RPT said the resident should sit in the wheelchair for one hour then be placed in bed with a short abductor wedge (a wedge shape foam device) between his/her legs to keep the legs separated. - The resident had [DIAGNOSES REDACTED] (rigidness, involuntary movement) of his/her legs and took medication for the [DIAGNOSES REDACTED], but the medication was discontinued because insurance would not pay for the medication. - His/her muscle tone was getting worse. - The RPT worked to get a larger pummel or abductor device for the resident's wheelchair, but it had not been approved by insurance. - Staff needed to keep the resident's legs separated to prevent pressure and PU formation on the knees. Observation on 10/7/15, at 8:30 A.M., showed: - The resident sat in a wheelchair with a special wheelchair cushion abductor device specifically made for the resident at the dining room table. - The abductor device was intended to keep the resident from crossing his/her legs. - The resident with his/her legs crossed and knees pressed tightly together with no padding between the knees. During an interview on 10/7/15, at 8:40 A.M., NA A said: - He/she did not see the open areas to the resident's buttocks during perineal care on 10/6/15. - He/she said he/she heard about the open areas. - He/she did not report the open areas to the charge nurse. Observation on 10/7/15, from 9:00 A.M. until 9:45 A.M. showed: - The resident lay in bed on his/her side asleep with the knees pressed tightly together and with no padding between his/her knees. During an interview on 10/7/15, at 3:00 P.M., the WN said: - If a resident's wound worsens or if staff found a wound, then they should fill out a Wound Assessment Tool sheet and give the sheet to him/her. - No staff told him/her of the wound found on the left knee in August. - LPN C should have reported the black scabbed covered wound to the WN. - The WN never received a Wound Assessment Tool sheet for the knee wound. Observation on 10/8/15, at 8:10 A.M., showed: - The resident sat in a wheelchair with a special wheelchair cushion abductor device specifically made for the resident at the dining room table. - The abductor device was intended to keep the resident from crossing his/her legs. - The resident with his/her legs crossed and knees pressed tightly together and no padding was between the knees. Observation on 10/8/15, at 8:45 A.M., showed: - The resident sat in a wheelchair with a special wheelchair cushion abductor device specifically made for the resident at the dining room table. - The abductor device was intended to keep the resident from crossing his/her legs. - The resident sat with the catheter tubing between the knees and the knees were pressed tightly against the tubing. - The tubing rested in the area of the two PUs on the left knee. - The resident said his/her knee was sore. 2. Review of Resident #8 comprehensive MDS, dated [DATE], showed: -Able to make own decisions; -Requires assistance of one staff member for transfers, ambulation and hygiene; -Occasionally incontinent of bladder; continent of bowels; -No pressure ulcers or skin issues; -[DIAGNOSES REDACTED]. Review of the Care Area Assessment (CAAs) for Pressure Ulcers, dated 8/10/15, showed: -At risk for skin breakdown; -Proceed with care plan for pressure ulcer risk. Review of care plan, dated 8/28/15, showed no care plan for pressure ulcer risk. Review of nurse's notes written by LPN A, dated 9/17/15, at 4:35 A.M., showed: -Noted superficial open areas to left buttock and underside of genitalia; -Resident does complain of tenderness when areas are cleansed. Review of the Weekly Skin Integrity Data Collection Sheet completed by licensed staff, dated 9/21/15, showed no open areas documented. Review of nurses' notes written 9/30/15, at 3:34 P.M., showed: - New order written for [MEDICATION NAME] to buttock three times a day and as needed. Review of the physician's orders [REDACTED]. Review of treatment administration record (TAR), dated October 2015, showed an order to apply [MEDICATION NAME] to buttocks three times a day and as needed documented as done all three shift from 10/1/15 through 10/7/15. Review of the Weekly Skin Integrity Data Collection sheet, dated 10/3/15, showed open areas on left and right buttocks. No description of the open areas, no measurements documented. Review of the Weekly Skin Integrity Data Collection sheet, dated 10/5/15, showed on going treatment to the buttocks. Observation on 10/6/15, at 12:45 P.M., showed: -CNA C stood the resident to assist to the bathroom, removed the resident's brief; -The resident's brief was soiled with fecal material. -CNA C obtained wet wipes and removed the fecal material from the resident's buttocks. -The resident said that both buttocks were sore and to wipe the buttocks gently. -The surveyor noted a dime size open area to the right mid buttock with yellow tissue surrounded the open area and a two inch by one inch open area to the left inner buttock surrounded by yellow tissue. -CNA C applied Selvan Silver (a protective skin cream containing Silver salt) to both buttocks. Review of the Selvan Silver package insert showed the cream was not to be applied to open wounds. During an interview on 10/6/15, at 12:50 A.M., CNA C said the resident has had the open areas to both buttocks for a while. During an interview on 10/6/15, at 1:00 P.M., LPN B said: -The areas to the resident's buttocks were considered Moisture Associated Skin Damage (MASD) and were not measured. During an interview on 10/6/15, at 1:15 P.M., the WN said the areas to the resident's buttocks were MASD and she did not assess any open areas that are not PU. The WN said she was not aware of any yellow tissue around the open areas. Review of nurses' notes, dated 10/6/15, at 2:10 P.M., showed staff wrote the physician would be at facility on 10/7/15, to look at the resident's excoriation to the buttocks. During an interview on 10/6/15, at 3:00 P.M., LPN A said: -He/she wrote a note to the WN on 9/17/15, informing her of open areas to the resident's buttocks. During an interview on 10/6/15, at 3:15 P.M., the WN said she could not remember the note written by LPN A informing her of open areas to the resident's buttocks. Review of physician's progress notes, dated 10/7/15, showed: -Nursing reports Stage II to right and left buttocks since 9/17/15. -Incontinent of stool; -First left buttock wound measures 2 cm by 0.5 cm and second wound measures 0.5 cm by 2 cm by 0.1 cm in depth with slough; -Right buttock wound measures 0.6 cm by 0.3 by 0.1 cm in depth with slough; -Stage II pressure ulcers to right and left buttocks; -Stimulin powder to wound bed two times a day and as needed. Cleanse wound with saline prior to applying Stimulin powder; -Physical Therapy to evaluate for wheelchair pad. Review of Pressure Ulcer Status Record completed by WN, dated 10/7/15, showed: -Stage III (full thickness tissue loss) pressure ulcer to right buttock measuring 0.6 by 0.3 by 0.1 cm in depth with 80% slough; debridement required; -Left lower buttock pressure ulcer Stage III measuring 0.5 cm by 2 cm by 0.1 cm in depth with 50% slough; debridement required; -Left upper buttock pressure ulcer Stage II measuring 2 cm by 0.5 cm by 0.3 cm in depth; no debridement required. During an interview on 10/7/15, at 11:15 A.M. the WN said: -All the pressure ulcers were Stage III. -Should have assessed the areas to the buttocks on 9/17/15. 3. During an interview on 10/8/15, at 9:30 A.M., the DON said: - She expected staff to inform charge nurses if they found red or open areas on any resident's skin. - She expected licensed nurses to perform weekly skin assessments on all residents. - She expected staff to report all open areas, new abrasions, boggy (soft) heels, excoriation, or moisture associated skin issues. - She expected direct care staff to complete information on shower sheets, mark areas of concern, and give the shower sheets to the charge nurse. - She expected charge nurses to look at the shower sheets, sign the shower sheets, and report any skin issues marked to the DON and WN. - She expected licensed to document any skin issues on the 24 hour report sheet. - She expected licensed staff to document the location, approximate size, and description of the wound or skin issue on the weekly skin assessment and nurse progress notes. - She expected all staff to report any wounds immediately so that the WN could evaluate and treat appropriately. - She expected staff to prevent skin to skin contact, turn or reposition residents every two hours, and refer the resident to PT for evaluation and treatment if wounds occurred.