Every finding on record at Life Care Center of Wichita

The facility reported a census of 117 residents. The sample included 24 residents. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program related to improper hand hygiene care by facility staff during incontinent care and catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care. The facility staff also failed to follow infection control policies for respiratory care and failed to follow proper enhanced barrier precautions (EBP- a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms (MDRO) in nursing homes). This deficient practice had the potential to spread possible infections to the residents in the facility. Findings included: - During an observation on 03/18/25 at 09:33 AM, Resident (R)18 was in her bed. Her wheelchair had an oxygen tank on the back of it with tubing wrapped around it and not in a bag. She had a cough and reported she thinks she may need to go to the hospital. During an observation on 03/18/25 at 02:09 PM, R93's oxygen tubing nasal cannula was hung on the wheelchair and touched the wheel. During an observation 03/19/25 10:35 AM, R72 received incontinent care by Certified Nurse Aide (CNA) T and Certified Medication Aide (CMA) X. CNA T and CMA X failed to complete hand washing prior to applying gloves when donning personal protective equipment (PPE- gowns, face shields and/or eyeglasses/goggles, and gloves). CNA T and CMA X used their gloved hands to close the blinds on the window, opened the closet door, and opened the drawer on the nightstand and neither aide changed gloves and then CMA X provided peri care to R72's perineum (the area between the genitals and the anus) she used one disposable wipe three strokes before disposing the wipe. CMA X did not change the area of the wipe when she washed perineum front to back. With the first stroke CMA X pulled the wipe back and a noted light brown colored spot was on the wipe. CMA X used the same area on the wipe for two more strokes. R72 was assisted onto her left side, CNA T provided care to R72's buttocks, CNA T removed her glove on her right hand applied a new glove then applied barrier cream to R72's buttocks. CMA X removed her gloves and applied new gloves, but the staff did not perform hand hygiene between doffing and donning gloves. During an interview on 03/19/25 at 11:05 AM, CNA T reported that she should have removed both gloves and performed hand hygiene, she also reported she did not realize she had touched surfaces in R72's room with gloves before she performed peri care. During an interview on 03/19/25 at 11:10 AM, CMA X reported that she should have washed her hands each time after she removed her gloves. CMA X reported that she knew to not use a wipe more than one stroke when peri care was provided CMA X reported that she thought the light-colored brown area on the wipe after the first stroke was barrier cream. She reported that R72 did have a smear of soft bowel movement in her brief. During an observation on 03/20/25 at 08:19 AM, R18 was in bed with the call light on. Her bilevel positive airway pressure (BiPAP-medical device which helps with breathing) mask was laying on top of items on the bed side table. Her incentive spirometer was on the overbed table with the mouthpiece laying on the table adjacent to two dried spots of coffee and other items. During an interview on 03/19/25 at 10:41 AM, CNA U stated oxygen tubing should always be placed in a bag when not in use. During an interview on 03/19/25 at 01:29 PM, Licensed Nurse (LN) M stated oxygen tubing and BiPAP masks should always be in a bag when not in use. LN M said the nebulizer should be washed out and laid open on a paper towel when a treatment is completed. During an observation on 03/20/25 at 08:27 AM, CNA F entered the room and put on gloves. LN M and the therapy aide were in the room with gloves on. She put on a gown and handed a gown to LN M. The therapy OT aide went over and got one and put it on. The OT aide lowered the head of the bed, but the legs of the bed would not lower. CNA F wiped the front of R18's peri area with several swipes with the same wipe, then rolled R18 to her side and wiped with a new wipe every wipe on the bottom. Took off her soiled gloves and put on clean gloves without hand hygiene. CNA F applied cream and again removed soiled gloves and applied new gloves without hand hygiene. CNA F placed the catheter drainage bag on the bed beside R18's legs that were raised at least 6 inches above her bladder. CNA F picked up the catheter several times lifting it far above the foot of the bed to adjust the covers off R18's feet. This Nurse reminded her to keep the bag below the bladder. She stated she was worried it would pull on the tubing if she left it down, but she did attach it to the bed below the level of the bladder. CNA F lifted the catheter drainage bag up again over the level of the bladder several more times in the process of dressing R18, also lifted it up and handed it over the other staff member to the other side of the bed at her shoulder height. CNA F and LN M removed their gown to transfer R18 to her wheelchair. CNA F attached the catheter drainage bag to the sling but removed it prior to the transfer. During the transfer with the hoyer lift, CNA F handed the catheter drainage bag to LN M, who then kept the bag below the level of the bladder. Then CNA F went to the bed and remade the bed by spreading out the bed pad and taking off the soiled turn sheet. LN M took the sling out of the room as CNA F got R18 set up for breakfast. During an interview on 03/20/25 at 08:52 AM, LN M stated the Foley catheter drainage bag should be kept below the level of the bladder. Also, hand hygiene should be performed prior to putting on gloves and between glove changes. During an observation on 03/20/25 at 01:25 PM R71 was assisted off unit with other facility staff for activities. Leg bag was not emptied, and pant leg was soiled with urine. During an interview on 03/19/25 at 02:04 PM, CNA DD revealed that R71's catheter had been leaking and that she had fixed it to stop the leak. CNA DD revealed that R71 was able to change her clothes when it is needed. During an interview on 03/19/25 at 01:52 PM, Certified Medication Aide (CMA) R revealed staff are responsible for R71's catheter care and switching it from the night drainage bag to the leg bag for daytime use as well as the emptying of the catheter. During an observation on 03/20/25 at 09:09 AM, LN N prepared R93's medications. During the medications preparation LN N dropped the cap off the Lactulose (a synthetic sugar used to treat constipation) bottle onto the ground. LN N picked the cap back up off the floor with her left hand applied a glove to her right hand and retrieved a sanitation wipe from the cart. LN N wiped the cap off and placed it back onto the bottle. LN N removed the glove off her right hand and finished the medication preparation for the remainder of six more medications. LN N failed perform hand hygiene after she cleansed the cap. During an interview on 03/20/25 at 10:05 AM, LN N reported that there was no hand sanitizer on the medication cart, and she should have washed her hands. She reported that she normally would not wash her hands every time she removed her gloves. During an interview on 03/24/25 at 10:03 AM, Administrative Nurse D expected staff to perform hand hygiene after they pick up an object off the floor before they provide resident care or tasks. During an interview on 03/24/25 at 11:29 AM, Administrative Nurse E stated that it was her expectations for nursing staff to empty R71's leg bag prior to her leaving the unit to attend activities. R71 was reported to be able to notify the nurse on shift if this care had been completed or not when asked. During an interview on 03/24/25 at 02:48 PM, Administrative Nurse B stated that it was her expectations for CNA to be completing catheter care. When the Nurse documents the completion of the task on the medications administration record (MAR) that verified that nurse confirmed the CNAs preformed the catheter care. Administrative Nurse B revealed she expected staff to complete catheter care at least once a shift and more if necessary. During an interview on 03/20/25 at 01:23 PM, Administrative Nurse F stated she expected staff to perform hand hygiene prior to applying gloves and when taking off gloves prior to putting them back on. Administrative Nurse F IC nurse stated that she expected the oxygen tubing and BiPaP mask to be in a bag when not in use. The nebulizers were to be washed out with water and left to air dry on a paper towel. Administrative Nurse F expected staff to follow the EBP guidelines by wearing proper PPE when performing ADL care. They do not have to wear PPE when going in to ask a question, but if they were going to touch the resident or their items in their room. Staff were expected to wear PPE if transferring, toileting, toileting, anything that is body contact, or changing sheets. Administrative Nurse F had not had a chance to spot check staff on catheter care or incontinent care. She expected staff to perform hand hygiene and don gloves to provide incontinent care or catheter care. Perform hand hygiene and don new gloves before touching clean items. She expected staff to only wipe one time with a cloth then throwing it away and getting a new cloth. During an interview on 03/24/25 at 02:48 PM, Administrative Nurse B stated that it was her expectations for CNA to be completing catheter care. When the Nurse documents the completion of the task on the MAR that verified that nurse confirmed the CNAs preformed the catheter care. Administrative Nurse B revealed she expected staff to complete catheter care at least once a shift and more if necessary. During an interview on 03/24/25 at 02:49 PM, Administrative Nurse B stated it was her expectation that staff use good infection control measures including hand hygiene before and between gloving, use proper infection control measures with Foley catheter including using the proper PPE according to the EBP policy, and cleaning the nebulizers and taking them apart to dry on a paper towel. The facility's Enhanced Barrier Precautions policy dated 06/03/24 documented EBP was required during high- contact care activities for residents with wounds, indwelling medical devices including urinary catheters. Examples of high-contact resident care activities requiring gown and gloves include dressing, transferring, changing linens, and device care. The facility lacked a policy of Incontinent Care The facility failed to maintain an effective infection control program related to improper incontinent care, improper hand hygiene after removal of soiled gloves and failed to wear the proper PPE when staff cared for residents on EBP to prevent cross contamination in the facility.

The facility reported a census of 117 residents with 24 in the sample. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food to prevent possible food-borne illness among the facility's residents. Findings included: - On 03/18/25 at 07:55 AM, during the initial tour of the central kitchen and refrigerator storage areas, the following areas of concern were identified: One undated opened one-gallon jug of honey mustard dressing, one undated gallon jug of base BBQ sauce, approximately 33 slices of cheese in cellophane wrap undated, a five-pound tub of sour cream is opened and undated. And one pitcher with an orange substance in it that is undated and unlabeled in the walk-in refrigerator. Four unsealed opened and undated bags of food stuff, one bag of Italian zucchini in the freezer. The tour also documented the freezer temperature logs had nothing noted for 03/17/25, the refrigerator temperature log had blanks for 03/15/25, 03/16/25, and 03/17/25. The sanitizer log documents blank from 03/12/25 through 03/17/25. On 03/18/25 at 08:04 AM, an interview with Dietary staff J revealed the facility policy was to reseal and date all opened foods. She confirmed the above as not being properly dated, sealed, and labeled. Dietary staff J stated the logs should be filled out each shift each day and confirmed the open areas were not correct. On 03/19/25 at 04:15 PM, three cutting boards noted with many scratches making an uncleanable surface. On 03/19/25 at 04:15 PM, Certified Dietary Manager (CDM) I confirmed the scratches and reported that she would buy new ones. On 03/20/25 at 12:00 PM, noted that there was an unidentified man on a ladder with a roof tile open by the dishwashing room that was several feet away from the tray line, while staff were starting the tray line for lunch. There was then water noticed leaking from a ceiling tower approximately eight feet away from the meal line prep area. The water intensified the maintenance man came over to that area with an outside vendor, as water was pouring out of the ceiling above the sink area where a microwave and small freezer were plugged in, and tray caddy with six trays set up for meal pass with silverware wrapped in a paper napkin and the dessert cup that was covered on the trays were noted to be sprayed with the water that came out of the ceiling as the dark blue trays had several water spots on them, CDM I unplugged the microwave, moved a large dish storage container, that was covered, towards the dishwasher room and told Dietary staff J to take the one tray caddy that was splashed with the water to the dishwasher room, another dietary staff moved that tray caddy and it sat out of the way and never made it to the dishwasher. Those trays were used on the last trays set up for the meal that the test tray was on. The divided dishes that were set up on a table where the temperature base was placed on were splashed with the water from the ceiling also and they were used to serve the food to the residents. On 03/20/25 at 12:07 PM, Maintenance Staff EE reported that there was a leak noted above that area earlier today and this was the first time the outside worker could get to the facility to fix the leak and reported this was not his call, to do the job during a meal service. On 03/20/25 at 12:30 PM, CDM I reported that maintenance staff did not normally work in the kitchen during the meal prep and pass time. On 03/20/25 at 12:34 PM, Administrative Staff A reported that maintenance should not have been working in the kitchen during mealtimes and reported that the outside vendor shut off the wrong valve and that was what caused the water to leak. The facility's Food Safety Requirements dated 04/26/23 documented that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The facility's Food Safety policy dated 04/26/23 documented food would be stored and maintained in a clean, safe, and sanitary manner following federal, state, and local guidelines to minimize contamination and bacterial growth. The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety to prevent possible food borne illness in the facility's resident population.

The facility census totaled 117 residents, eleven medication carts and three medication storage rooms. Based on observation, interview, and record review, the facility failed to ensure the staff had dated multiple dose vials of injectable medication. This deficient practice placed residents at risk of receiving outdated injectable medication. Findings included: - On 03/20/25 at 01:49 PM, observation in the medication room revealed a multiple dose vial of Purified Protein Derivative (PPD) solution (substance used in a skin test to diagnose tuberculosis [TB] infection) had been opened and was not marked with the opened date. During an interview on 03/20/25 at 01:50 PM, Administrative Nurse G replied that she believed multiple-dose vials are good for 28 days and that some insulin pens could be good for use longer than 28 days. Administrative Nurse G replied that the opened pen or vial should have been dated once it had been opened with the open date; labeled on the pen, box or vial. During an interview on 03/20/25 at 02:30 PM, Administrative Nurse B reported that PPD solutions should have been labeled when it was opened. Administrative Nurse B stated the PPD solution was good for 28 days and it had now been disposed of. Administrative Nurse C provided the undated facility policy Omnicare Medication Storage Guidance. The facility policy guidance indicated that multiple-dose vials for injection are to be dated when opened. It also indicated that the unused portion were to be discarded after 28 days or in accordance with the manufacturer's recommendations. The facility failed to ensure the safe and secure storage of multiple-dose injectable medication when observation onsite revealed staff had failed to date multiple-dose injectable medication once it had been opened.

The facility reported a census of 117 residents. The 24 sampled residents included four dependent residents reviewed for activities of daily living (ADLs). Based on observation, interview, and record review the facility failed to provide scheduled baths in accordance with the residents scheduled bathing schedule to ensure necessary services to maintain good personal hygiene for Resident (R) 47. Findings included: - Review of Resident (R) 47's Electronic Health Records (EHR) Physician Orders (POS), dated 02/25/25 documented diagnoses which included hemiplegia (paralysis or complete loss of movement on one side of the body), hemiparesis (muscle weakness on one side of the body) following cerebral infarction (stroke-when blood flow to the brain is blocked causing tissue death in the brain) affecting the non-dominant side, lack of coordination and need for assistance for personal care. The 10/08/24 Minimum Data Set (MDS) documented a brief interview for mental status (BIMS) score of 14 indicating intact cognition. She reported choosing her bath type was very important to her. The resident required partial/moderate assistance of staff with bathing. The resident had no functional limitations in range of motion for upper or lower extremities. The Quarterly MDS dated [DATE] documented an improved BIMS score of 15, indicating intact cognition. The Care Plan dated 01/28/25 documented the resident had an activities of daily living (ADL) self-care performance deficit related to her need for one staff assistance in part of bathing activity. The care plan lacked direction to the staff regarding the resident's bathing schedule and/or the resident's preferences. Review of the resident's Electronic Medical Record (EMR) for Tasks revealed the residents bathing preferences included the use of a whirlpool two days a week on Monday and Thursday during the day shift. The staff offered the resident four bathing opportunities during the 30-day period of 02/24/25 through 03/23/25. Review of the resident's bath sheets, and task bathing indicated the resident was offered bathing 2/24/25 thorough 3/24/25 and on 02/27/25 the resident had a shower, on 03/03/25 she refused, on 03/16/25 a shower was given, and on 03/17/25 the resident refused. The documentation lacked indication of any baths offered at any other time during the 30-day period reviewed. On 03/18/25 01:51 PM revealed R47 in her chair, in her room and she stated she did not get the baths like she wanted. The staff gave her showers, but they were not given as scheduled. On 03/20/25 at 09:53 AM, Certified Nurse Aide (CNA) GG confirmed the resident required assistance of staff for all of her ADLs. CNA GG reported the resident should receive at least two baths a week, but she could have a bath as she preferred. The facility had a bath schedule that was based on the resident's preferences. The preferences and schedule should be listed in the resident's care plan to guide the staff on the resident's preferences a well. CNA GG reported the CNAs completed a bath sheet when they offered the resident a shower or when they give a them a bath. The nurse should be notified if resident's refused their baths. Then the nurse would check with a resident to determine if there was a scheduling problem and try to work it out. On 03/24/25 at 02:39 PM, Administrative Nurse E confirmed the above findings. She confirmed the staff did not offer bathing opportunities for the resident in accordance with her preference. Additionally, the resident's preferences were not documented in the care plan to guide the staff in providing cares for the resident. On 03/24/25 at 02:03 PM, Administrative Nurse B confirmed the above findings and stated she would expect the staff to offer bathing opportunities in accordance with the bathing schedule and resident's preferences which should be noted in the resident's care plan. On 03/24/25 at 02:37 PM, Administrative Nurse B confirmed preferences were not on the resident's care plan. The facility policy titled Comprehensive Care Plans and Revisions, dated 09/11/24, documentation included the facility will ensure that the comprehensive care plan is developed to include the resident's requests and preferences. The facility failed to develop a comprehensive care plan to direct the staff in the provision of care and services in accordance with the resident's preferences in accordance with the resident's bathing preferences.

The facility reported a census of 117 residents with 24 residents sampled. Based on observation, interview, and record review revealed the facility failed to hold hypotension (low blood pressure) medication for Resident (R)11. Findings included: - Review of Resident (R)11's Electronic Medical Record (EMR) revealed a diagnosis of hypotension (low blood pressure BP). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS indicated R11 had a diagnosis of hypotension. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 09/27/24, did not trigger. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of 15, indicating intact cognition. She had a diagnosis of hypotension. The care plan, revised 04/26/25, lacked staff instruction regarding the use of Midodrine (hypotension medication) medication. Review of the resident's EMR revealed the following physician's order: Midodrine (medication used to treat low blood pressure/hypotension), 5 milligrams (mg), by mouth (po), twice daily (BID), for a diagnosis of hypotension. Staff were to monitor the resident's BP and hold the medication if her systolic blood pressure (SBP-the top number) was greater than 110 millimeters of Mercury (mmHg), BID, ordered 02/28/25. Review of the resident's blood pressures in her EMR, from 02/15/25 through 03/20/25, revealed the following instances where staff administered R18's Midodrine when the resident's SBP was greater than the ordered parameter of 110 mmHg: On 02/12/25, the resident's SBP was 112 mmHg, and staff administered the medication. On 02/21/25, the resident's SBP was 113 mmHg, and staff administered the medication. On 02/26/25, the resident's SBP was 114 mmHg, and staff administered the medication. On 03/06/25, the resident's SBP was 112 mmHg, and staff administered the medication. On 03/20/25, the resident's SBP was 157 mmHg, and staff administered the medication. On 03/22/25, the resident's SBP was 131 mmHg, and staff administered the medication. On 03/24/25 at 02:49 PM, Administrative Nurse B stated it was the expectation for staff to hold medications when the vital signs were outside of the ordered parameters. The facility policy, Administration of Medications, dated 09/16/24, included: Staff will follow the 10 rights of medication administration while administering medications to the residents. The facility failed to ensure staff held the hypotension medication, as ordered, for R18 on multiple occasions.

The facility reported a census of 117 residents with 24 residents selected for review. Based on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set for three Residents (R), which included R11's pressure injury and R18's use of a foley catheter. Findings included: - Review of the Electronic Health Record (EHR) documented R11 had pertinent diagnoses of dependence on dialysis treatment, end-stage renal disease (ESRD-a terminal disease of the kidneys), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), morbid obesity, unspecified malnutrition, and hypotension (low blood pressure. The 09/27/24 Annual Minimum Data Set (MDS) documented a brief interview for mental status (BIMS) score of 15, indicating intact cognition. R11 did not have a risk for pressure ulcers. The 09/27/24 Pressure Ulcer/Injury Care Area Assessment CAA documented R11 had impaired bed mobility. The 03/02/25 Quarterly MDS documented a brief interview for mental status (BIMS) of 15, indicating intact cognition. The assessment documented R11 as on a parenteral/IV feeding (administration of nutritional products directly into the bloodstream, bypassing the usual process of eating and digestion). The assessment also documented R11 did not have any pressure ulcers. During an interview on 03/20/25 at 09:57 AM, Licensed Nurse (LN) Q stated R11 had a wound on her buttock that was identified as a stage three pressure area. During an interview on 03/20/25 at 09:07 AM, Administrative Nurse H confirmed R11 did not get intravenous (IV-administered directly into the bloodstream via a vein) fluid or nutrition while she was in the facility. Administrative Nurse H stated it was incorrect and she would complete a correction of the MDS. Administrative Nurse H stated there was some confusion about the resident's pressure ulcer. She coded that there was a pressure ulcer, but there was not one at any stage. She stated the pressure ulcer questions were incorrect and would be corrected. Administrative Nurse H reported the facility followed the Resident Assessment Instrument (RAI) for instructions on how to complete the MDS. During an interview on 03/24/25 at 02:49 PM, Administrative Nurse B stated she expected the MDS to be completed correctly. The facility's Certification of Accuracy of the MDS policy dated 09/05/24 documented the MDS assessment must accurately reflect the resident's status. - Review of the Electronic Health Record (EHR) documented R18 had pertinent diagnoses of acute renal failure (sudden onset of severe inability of the kidneys to excrete wastes, concentrate urine and conserve electrolytes that can be treated) and urinary retention (lack of ability to urinate and empty the bladder). The 02/28/25 Admission Minimum Data Set (MDS) documented R18 had a brief interview for mental status (BIMS) of 11, indicating moderately impaired cognition. The MDS lacked documentation regarding R18's urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). During an observation on 03/20/25 at 08:27 AM revealed the resident had an indewlling urinary catheter. During an interview on 03/24/25 at 01:11 PM, Administrative Nurse H confirmed R18 did have a foley catheter that she was admitted with. She stated the MDS was incorrect, and she would complete a correction of the MDS. Administrative Nurse H reported the facility followed the Resident Assessment Instrument (RAI) manual for instructions on how to complete the MDS. During an interview on 03/24/25 at 02:49 PM, Administrative Nurse B stated she expected the MDS to be completed correctly. The facility's Certification of Accuracy of the MDS policy dated 09/05/24 documented the MDS assessment must accurately reflect the resident's status.

The facility had a census of 117 residents, the sample included 24 residents. Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan with interventions to address R47's preferences for bathing on the resident's comprehensive care plan. Findings included: - Review of Resident (R)47's Electronic Health Records (EHR) Physician Orders (POS), dated 02/25/25 documented diagnoses which included hemiplegia (paralysis or complete loss of movement on one side of the body), hemiparesis (muscle weakness on one side of the body) following cerebral infarction (stroke-when blood flow to the brain is blocked causing tissue death in the brain) affecting the non-dominant side, lack of coordination and need for assistance for personal care. The 10/08/24 Minimum Data Set (MDS) documented a brief interview for mental status (BIMS) score of 14 indicating intact cognition. She reported choosing her bath type was very important to her. The resident required partial/moderate assistance of staff with bathing. The resident had no functional limitations in range of motion for upper or lower extremities. The Quarterly MDS dated [DATE] documented an improved BIMS score of 15, indicating intact cognition. The Care Plan dated 01/28/25 documented the resident had an activities of daily living (ADL) self-care performance deficit related to her need for one staff assistance in part of bathing activity. The care plan lacked direction to the staff regarding the resident's bathing schedule and/or the resident's preferences. Review of the resident's Electronic Medical Record (EMR) for Tasks revealed the residents bathing preferences included the use of a whirlpool two days a week on Monday and Thursday during the day shift. The staff offered the resident four bathing opportunities during the 30-day period of 02/24/25 through 03/23/25. Review of the resident's bath sheets, and task bathing indicated the resident was offered bathing 2/24/25 thorough 3/24/25 and on 02/27/25 the resident had a shower, on 03/03/25 she refused, on 03/16/25 a shower was given, and on 03/17/25 the resident refused. The documentation lacked indication of any baths offered at any other time during the 30-day period reviewed. On 03/18/25 01:51 PM revealed R47 in her chair, in her room and she stated she did not get the baths like she wanted. The staff gave her showers, but they were not given as scheduled. On 03/20/25 at 09:53 AM, Certified Nurse Aide (CNA) GG confirmed the resident required assistance of staff for all of her ADLs. CNA GG reported the resident should receive at least two baths a week, but she could have a bath as she preferred. The facility had a bath schedule that was based on the resident's preferences. The preferences and schedule should be listed in the resident's care plan to guide the staff on the resident's preferences a well. CNA GG reported the CNAs completed a bath sheet when they offered the resident a shower or when they give a them a bath. The nurse should be notified if resident's refused their baths. Then the nurse would check with a resident to determine if there was a scheduling problem and try to work it out. On 03/24/25 at 02:39 PM, Administrative Nurse E confirmed the above findings. She confirmed the staff did not offer bathing opportunities for the resident in accordance with her preference. Additionally, the resident's preferences were not documented in the care plan to guide the staff in providing cares for the resident. On 03/24/25 at 02:03 PM, Administrative Nurse B confirmed the above findings and stated she would expect the staff to offer bathing opportunities in accordance with the bathing schedule and resident's preferences which should be noted in the resident's care plan. On 03/24/25 at 02:37 PM, Administrative Nurse B confirmed preferences were not on the resident's care plan. The facility policy titled Comprehensive Care Plans and Revisions, dated 09/11/24, documentation included the facility will ensure that the comprehensive care plan is developed to include the resident's requests and preferences. The facility failed to develop a comprehensive care plan to direct the staff in the provision of care and services in accordance with the resident's preferences in accordance with the resident's bathing preferences.

The facility reported a census of 117 residents. The facility failed to provide the appropriate vegetarian diet selection sheet for a resident (R)13 who was vegetarian with orders for a vegetarian diet. Findings included: - Review of R13's diagnoses from the Electronic Health Record (EHR) documented, anemia due to enzyme disorder (occurs when red blood cells break down faster than the body can replace them, often due to inherited enzyme deficiencies like G6PD or pyruvate kinase deficiency), schizophrenia ( a chronic brain disorder that affects how a person thinks, feels, and behaves, often characterized by disruptions in thought processes, perceptions, and emotional responsiveness, leading to hallucinations, delusions, and disorganized thinking). The 10/02/24 Annual Minimum Data Set (MDS) documented a BIMS score of 15, which indicated intact cognition. R13 was independent for eating and had no weight loss indicated on the assessment. The 01/02/25 Quarterly Minimum Data Set (MDS) documented a BIMS score of 15, which indicated intact cognition. R13 was independent for eating and had no weight loss indicated on the assessment. Review of R13's Care Area Assessment (CAA) revealed no concerns to dietary needs. An observation on 03/20/25 revealed R13 received the same dietary selection sheet as the other residents to select her meals for the day. Administrative Nurse E assisted R13 to cross out the non-vegetarian protein options and write in her vegetarian selections. The dietary sheet had only and egg protein option for breakfast and there were not any additional protein selections for the lunch or supper meals. During an interview on 03/18/25 at 11:52 AM, R13 stated she was a vegetarian and the facility had not provided many options for her dietary requirements. R13 reported the facility told her they would provide her protein choices, and they have not done so and R13 stated she has had to spend part of her monthly income to buy groceries. During an interview on 03/19/25 at 11:05 AM, Administrative Nurse E reported R13's diet was on a regular vegetarian dietand stated R13 crossed out menu items on the dietary sheet provided to her. R13 wrote in her vegetarian choices and often did not eat or order breakfast. During an interview on 03/20/25 at 09:25 AM, Dietary Staff I stated some vegetarian options were provided on the daily dietary sheet that the residents filled out. Alternate protein options were available, and the residents were allowed to write their choices. She reported that the same dietary sheet was provided to all of the residents. During a phone interview on 03/20/25 at 10:54 AM, with Dietitian KK she stated it was not appropriate for a vegetarian resident to receive the same dietary meal selection list as the other residents. He reported a vegetarian resident should have received a dietary selection list that was specific to their diet. He further stated that it was not appropriate for a resident to have to spend their own money on groceries to ensure they received necessary protein. Dietitian KK also indicated that there should have been protein options available for a vegetarian at every meal. The facility policy Food and Nutrition Services Manual dated 03/05/24, has nothing documented in it with regards to meeting requirement for alternative ordered diets. The facility failed to follow the ordered alternative menu to ensure proper nutrition for resident 13 that had a vegetarian diet ordered.

The facility identified a census of 108 residents. The sample included three residents reviewed for hot liquid accidents. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 1, who required staff assistance with meals, remained free from preventable accidents when she spilled hot tea on herself on 12/12/23. This deficient practice resulted in a second degree burn second degree burn (potentially painful burn which affects the first and second layer of the skin and blisters) to her left thigh. This also placed the resident at risk for increased pain. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of lack of coordination, generalized muscle weakness, glaucoma (abnormal condition of elevated pressure within an eye caused by obstruction to the outflow), and cognitive communication deficit. The Significant Change Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of two, which indicated severe cognitive impairment. R1 required extensive assistance with one staff for bed mobility, eating, and personal hygiene; total dependence with two staff for transfers; and extensive assistance with two staff for toileting. The Quarterly MDS dated [DATE], documented R1 had a BIMS score of seven, which indicated severe cognitive impairment. R1 required partial/moderate assistance with eating. The Cognitive Loss/Dementia (progressive mental disorder characterized by failing memory, confusion) Care Area Assessment (CAA) dated 05/08/23, documented R1 had confusion, disorientation, or forgetfulness and a decreased ability to make herself understood. The Nutritional Status CAA dated 05/15/23, documented R1 required assistance with eating, and she had good intake. R1's Care Plan, revised 10/09/23, documented she had an activity of daily living (ADL) self-care performance deficit related to a need for assistance with ADLs, glaucoma, cognitive impairment, and muscle weakness. The care plan documented an intervention, dated 01/18/23, that directed R1 required one staff assistance with eating and setup. R1's Care Plan, revised 01/25/24, documented R1 was at risk for a break in skin integrity related to the need for assistance with bed mobility and repositioning, incontinence (lack of voluntary control over urination or defecation), and history of skin impairment. The care plan documented interventions, dated 12/12/23, that directed occupational therapy to screen R1 for safety with hot liquids and hot tea was to be served to R1 with a lid to reduce the risk of burns. R1's Care Plan did not address hot liquids safety before 12/12/23. The facility's investigation dated 12/12/23 at 12:44 PM documented R1 sat in the dining room at the table and had lunch. She lifted her cup of hot tea, dropped it in her lap, and on the floor. Staff took R1 to her room and assessed her for injury. Staff called R1's provider and left a message. Staff notified R1's daughter in person. R1 was assessed by the wound nurse and had a reddened area that measured 0.9 centimeters (cm) by 0.2 cm. R1 was to have hot beverages covered and her family was to be there for all lunches in her room. An investigation note, dated 12/13/23, documented the root cause analysis of the spill was recent pain in R1's hands and swelling in her right hand. Staff were in the dining room and observed the event. R1's care plan was updated, and staff were to serve R1 hot tea in a cup with a lid. Therapy reported increased edema and pain in hands as causative factor in dropping her cup resulting in a burn on her left thigh. The Assessments tab of R1's EMR revealed the following: A NRSG: Wound Observation Tool on 12/12/23 at 01:56 PM documented first observation of left thigh blister that measured 0.9 by 2 cm with a plan for Skin Prep (a solution that when applied forms a protective waterproof barrier on the skin) every shift. A NRSG: Wound Observation Tool on 12/19/23 at 12:01 PM documented the left thigh blister, that measured 0.8 by 1.3 cm, had popped and an abrasion was noted to the area. Upon request, the facility was unable to provide evidence the facility assessed the resident's ability to safely manage hot liquids prior to the incident on 12/12/23. The Notes tab of R1's EMR revealed the following: A Health Status Note on 12/12/23 at 01:07 PM documented R1 in the dining room having lunch and she picked up her cup of hot tea and spilled it in her lap. She was immediately taken to her room and her skin was assessed for injury. R1 had a reddened intact area noted to her upper left thigh. Her family arrived at 12:44 PM and were notified of the incident. R1's family did not want her eating in the restorative dining room for lunch and wanted her to eat in her room where they would be there daily to assist her. An Event Note on 12/14/23 at 05:52 PM documented R1 was to have lids on all of her drinking cups. R1 continued to take the lids off and was educated. On 01/25/24 at 12:42 PM, R1 sat in her wheelchair in her room with her family present. She lifted her mug with a lid and drank independently. On 01/25/24 at 12:42 PM, R1's representative stated her concern was if the facility handed R1 hot liquids, staff should have made sure she did not spill it. On 01/25/24 at 12:55 PM, Licensed Nurse (LN) G stated R1 was sat at a table in the restorative dining room and went to take a drink of hot tea then spilled it on her lap and on the floor. She stated she took R1 to her room and she had a light pink area from the spill. LN G stated R1's family came in and wanted her to eat in her room with them. She stated R1 fed herself and received hot tea with meals for a long time per her family's request. LN G stated she did not think there was a hot liquid screening. On 01/25/24 at 01:26 PM, Certified Nurse Aide (CNA) M stated staff knew how to care for residents by reviewing the Kardex (nursing tool that gives a brief overview of the care needs of each resident) and from report. She stated the residents who needed assistance or were at risk of choking, ate in the restorative dining room and there were two CNAs to oversee the residents. CNA M stated R1 fed herself. On 01/25/24 at 01:34 PM, LN H stated staff knew how to care for residents by looking at the care plan and Kardex. She stated if a resident needed assistance with eating then they ate in the restorative dining room. LN H stated if R1's care plan directed she needed staff assistance with eating then that meant staff cut her food up, helped with her condiments, and completely set up her meal then sat between her and another resident. She stated hot liquids should be served with a lid on it. She was not sure if the facility screened for hot liquid safety. On 01/25/24 at 01:38 PM, Administrative Nurse D stated the Kardex informed staff how to care for a resident and included ADLs, fall interventions, behaviors, and was individualized for each resident. She stated one assistance with eating varied and could be setup help or actual help with eating. Administrative Nurse D stated the facility did not s specifically assess for hot liquid safety, but staff reported if a resident looked shaky or needed to be looked at for safety with hot liquids. The facility's Area of Focus: Incident and Reportable Event Management policy, last reviewed 12/01/23, directed the facility strived to provide an environment that was free from accident hazards over which the facility had control and provided supervision and assistive devices to each resident to prevent avoidable accidents. The facility failed to ensure R1, who required staff assistance with meals, remained free from preventable accidents when she spilled hot tea on herself on 12/12/23. This deficient practice resulted in a burn to her left thigh. This also placed the resident at risk for increased pain.

The facility reported a census of 112 residents. The facility identified one central kitchen with four dining areas. Based on observation, interview, and record review, the facility failed to provide sanitary food preparation and storage of food to prevent the spread of food borne illness to the residents of the facility. Findings included: - The initial environmental tour of the kitchen, on [DATE] at 08:05 AM, with Dietary Staff BB revealed the following items/areas of concern: 1. Dietary Staff DD standing at the warming table while serving resident food lacked a hair net that covered all hair, when approximately 18 inches of hair hung free below a hair net. 2. Observed Dietary Staff DD standing at the warming table serving the residents breakfast, wearing artificial fingernails approximately one inch long and painted. Staff DD failed to wear gloves or utilize utensils to serve the biscuits and breakfast meat to residents. 3. In dry storage: a box of dry hot cereal was open to air and lacked both open and/or expiration dates. 4. In dry storage: a large can of tomatoes contained a dent along the side. 5. The door from the kitchen into the utility hallway held a sign that indicated the door was to always remain closed. However, it was observed held open with a magnetic lock. 6. The walk-in refrigerator held a metal pan of hot dogs, and they were only partially covered with clear plastic wrap, leaving them open to air and undated. 7. The walk-in refrigerator held a large container of an unknown white cheese which was open to air and undated. 8. The walk-in refrigerator held a large transparent container with an unknown red liquid which was open to air, undated and not identified. 9. The walk-in refrigerator held a large transparent container with an unknown brown liquid which was open to air, undated and not identified. 10. The walk-in freezer held a large box of raw hamburger patties, which were observed open to air and undated. 11. The walk-in freezer held a large box of pre-cooked pork fritters, which were observed open to air and undated. 12. On the back prep table, a large mixer with a dried unknown white substance noted on the bowl guard and underside of the motor. 13. A cart next to the warming table contained a stack of divided plates and two stacks of regular plates that were uncovered. The cart observation revealed it contained an unknown debris over it. On [DATE] at 10:45 AM, observation revealed two unknown persons walking in the kitchen food areas wearing ball caps and lacked hair nets or coverings. On [DATE] at 11:10 AM, observed Dietary Staff DD preparing to serve the residents noon meals. When asked what the temperature of the pizza was, Dietary Staff DD replied, I'm not the cook. When asked how Dietary Staff DD knew the if the pizza was fully cooked, Dietary Staff DD replied, Because it's burned. Observation revealed pizza, chicken pot pie, broccoli, and tater tots all on the warming table lacked any blackened or burned areas. Dietary Staff DD began plating and serving the residents food items and failed to perform any temperature checks before serving the foods to the residents. Per request that Dietary Staff DD obtain the temperature readings of the foods on warming table, Dietary Staff DD failed to locate a food thermometer. Dietary Staff BB obtained the requested food temperature checks. On [DATE] at 11:45 AM, Dietary Staff BB and Dietary Staff CC stated that the expectation was for all persons in the kitchen area to be wearing hair nets regardless of other headgear, and all hair must be restrained. Further, Dietary Staff BB and Dietary Staff CC stated that whoever was cooking or serving the food should have easy access to a food thermometer. Additionally, Dietary Staff BB and Dietary Staff CC stated that all foods should be temperature checked prior to being placed on the warming table to ensure appropriate doneness, and again before being served to residents to ensure the foods are safe for consumption. Furthermore, Dietary Staff BB and Dietary Staff CC stated that fingernails were supposed to be natural, short and unpainted. Finally, Dietary Staff BB and Dietary Staff CC stated that all foods in the kitchen should be dated with when they were received, dated when they were opened, and dated when they expired or were otherwise unusable. The facility's policy Associate Conduct and Dress Code, dated [DATE], documented that all dietary staff must wear hair restraints that covers all unpinned hair. Further documents fingernails are to be kept short and clean and artificial nails and/or polished nails are not permitted. The facility's policy Food Procurement, dated [DATE], documents that food products are inspected upon delivery for safe transport and quality. The facility's policy Food Safety, dated [DATE], documents foods are to be placed in a leak-proof sanitary container with a tight-fitting lid and labeled with name of the contents with date and use-by date noted. Further documents that dented cans are to be returned to vendor and stored in a designated area away from other food and will not be used. The facility's policy Food Service/Meal Service, dated [DATE], documents that foods are to be prepared with clean tongs, scoops, forks, spoons or other suitable instruments to avoid manual contact with prepared foods. The facility's policy Food Temperature Control, dated [DATE], documented that food temperatures are checked at completion of cooking. The facility failed to provide sanitary food preparation and storage of food to prevent the spread of food borne illness to the residents of the facility.

The facility reported a census of 112 residents with 23 selected for review which included four residents reviewed for pressure ulcers. Based on observation, interview and record review, the facility failed to ensure pressure ulcer dressing care for one Resident (R)108, of the four residents reviewed for pressure ulcers. Findings included: - Review of Resident (R)108's Physician Record, dated 05/03/23, revealed diagnoses included chronic myeloid leukemia (a type of cancer of the bone marrow and blood), osteomyelitis (infection in the bone) and pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) of the sacrum (large triangular bone between the two hip bones). The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with normal cognitive function, required extensive assistance with bed mobility and transfer, with no impairment of the upper or lower extremities. The resident was always incontinent of bowel and had one unstageable pressure ulcer and a surgical incision. The Pressure Ulcer Care Area Assessment (CAA), dated 02/16/23, assessed the resident was dependent on staff for bed mobility, was always incontinent of bowel, and had an actual pressure injury. The Feeding Tube CAA, dated 02/16/23, assessed the resident had a feeding tube due to severe protein calorie malnutrition and the inability to take in enough calories for healing after back surgery. The Quarterly MDS, dated [DATE], assessed the resident with normal cognitive function, required extensive assistance of two staff for bed mobility and transfer, was always incontinent of bowel, and had an unstageable pressure ulcer present upon admission. (The resident readmitted to acute care on 02/16/23 through 02/27/23 and again from 04/17/23 through 04/26/23). The Care Plan, reviewed 05/03/23, instructed staff the resident required extensive assistance of two staff for incontinence care and to turn and reposition the resident while in bed. It instructed staff to keep the resident's skin clean and dry. The resident had a low air loss mattress. The resident transferred with staff assistance with a slide board (a board used to slide across from the wheelchair to bed). The Physician's Order, dated 04/26/23, instructed staff to cleanse the sacral pressure ulcer with normal saline and gauze, place Medi honey (a substance that contains honey to decrease inflammation in wounds), pack lightly with calcium alginate (a dressing that absorbs drainage to minimize bacteria in the wound), apply skin prep to the skin surrounding the wound and apply a bordered foam dressing on Monday, Wednesday and Friday and as needed. Observation, on 06/05/23 at 09:15 AM, revealed the resident seated in his wheelchair in his room eating breakfast. Observation, on 06/05/23 at 10:53 AM, revealed Certified Nurse Aide (CNA) O and CNA P transferred the resident from his wheelchair to the bed utilizing the sliding board. Observation, on 06/05/23 at 11:05 AM, revealed Licensed Nurse (LN) H and LN I proceeded to position the resident onto his left side, removed the resident's brief to provide wound care to the resident's sacral pressure ulcer. The resident lacked a dressing to cover the sacral wound and was incontinent of stool. LN H confirmed the resident lacked a dressing to the wound and searched the incontinent brief for the dressing. LN H stated she would expect staff to notify the charge nurse of the resident's need for a dressing to his sacrum before getting him up in his chair and would need to determine what staff got the resident up in his wheelchair this morning. LN H provided incontinence care, washed hands, and donned clean gloves and cleanse the wound with normal saline, and measured the wound as 2.3 by 2.2 centimeters (cm) with a depth of 0.3 cm. The wound contained dark red tissue. LN H stated the original wound worsened after the resident's frequent admissions to acute care and at one time the resident had a wound vac (a device that removes pressure over a wound and removes drainage to aid in healing). Interview, on 06/07/23 at 09:30 AM, with Administrative Nurse D, revealed she would expect staff to notify the charge nurse to apply a dressing to the resident's sacral pressure ulcer if the dressing was soiled or absent. Administrative Nurse D stated she questioned the staff but did not realize the resident had been sitting up in his wheelchair and then later transferred into the bed when staff observed the lack of a dressing to cover the area. The Facility Policy Skin Integrity and Pressure Ulcer/Injury Prevention and Management revised 08/25/21, instructed staff to report to the nurse if staff identified a topical dressing as soiled, saturated, or dislodged. The facility failed to ensure application of a sacral pressure ulcer dressing for this resident with bowel incontinence to prevent infection and promote wound healing.

The facility reported a census of 112 residents with 23 selected for review which included one resident reviewed for intravenous therapy. Based on observation, interview and record review, the facility failed to ensure timely dressing change for one Resident (R)15 with a peripherally inserted central catheter (PICC- a long thin tube that is inserted into a vein in the arm and ends in a vein near the heart) for intravenous infusion of antibiotics. Findings included: - Review of Resident (R)15's Physician Order Sheet, revealed diagnoses included chronic respiratory and heart failure, blood stream infection due to central line infection and wound infection. The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with normal cognitive function. The Quarterly MDS, dated [DATE], assessed the resident with normal cognitive function. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 11/23/22, assessed the resident required assistance with ADL due to weakness. The Care Plan, reviewed 05/24/23 instructed staff the resident was at risk for rehospitalization due to chronic kidney failure and resistance to starting dialysis. The resident refused cares and treatments and had poor decision making. Staff instructed to assist the resident to develop more appropriate methods of coping and interacting. The Physician's Order, dated 05/23/23, instructed staff to insert a PICC line for intravenous access, maintain the line per protocol, and to administer Daptomycin intravenous solution reconstituted, 350 milligrams (MG,) intravenously, at bedtime, one time only. The Physician's Order, dated 05/25/23, instructed staff to administer Daptomycin intravenous solution, 350 mg, intravenously, every other day, for wound infection for two weeks. Observation, on 06/05/23 at 10:08 AM, revealed the resident positioned in bed. The resident had a peripherally inserted central catheter (PICC) dressing with loose edges on her left upper arm with a date of 05/23/23 (14 days prior). Interview with the resident at that time revealed she received intravenous antibiotics for MRSA in an abdominal wound. The resident stated an infectious disease physician directed the care for this and she saw this physician on 05/31/23 when the physician directed staff to continue with the antibiotic administration. The resident stated that during that visit, the physician noted the dressing on her left upper arm (dated 05/23/23) and voiced concern to her that staff should change the dressing. The resident stated she informed staff at least twice to change the dressing since that time. Observation, on 06/06/23 at 08:30 AM, revealed the PICC line to the resident's left arm removed and the resident now had a dressing on her right upper arm with a dressing dated 06/05/23. Interview at that time with the resident revealed staff inserted a new line as the one on her left arm came out when staff tried to change the dressing. Interview, on 06/06/23 at 02:15 PM, with Licensed Nurse (LN) J, revealed the registered nurses on night shift change the PICC line dressings. LN J stated she thought the staff replaced the resident's PICC line because the previous line was not in correct position. Interview, on 06/06/23 at 03:30 PM, with LN G, revealed registered nurses on third shift change the PICC line dressing changes. LN G stated the physician originally ordered one dose of daptomycin IV, and then reordered it on 05/25/23 for once a day every other day. LN G confirmed staff did not change the PICC line dressing which was placed on 05/23/23. Interview, on 06/07/23 at 09:15 AM, with Administrative Nurse D revealed she would expect staff to change the PICC line dressing every seven days as ordered by the physician and as per professional standards. Administrative Nurse D confirmed staff did not change the dressing since placement on 05/23/23. The facility policy Peripherally inserted central catheter (PICC) dressing change dated August 19, 2022, instructed staff to change the transparent semipermeable dressing over a peripherally inserted central catheter (PICC) at least every seven days. The facility failed to ensure staff changed this resident's PICC line dressing every seven days as instructed by the physician to prevent infection.

The facility reported a census of 112 residents with 23 residents sampled, including one resident reviewed for notification of change. Based on observation, interview and record review, the facility failed to notify the physician of pulses being outside of parameter, as ordered, for one Resident (R)77. Findings included: - Review of Resident (R)77's electronic medical record (EMR) revealed a diagnosis of hypertension (HTN-elevated blood pressure (BP)). The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. He had a diagnosis of HTN. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 12/01/22, documented the resident was not able to accurately provide answers to questions. The quarterly MDS, dated [DATE], documented the resident's BIMS score of 14, indicating intact cognition. He had a diagnosis of HTN. The care plan, revised 03/03/23, instructed staff the resident took medications which included Lisinopril (a medication used to lower BP). Review of the resident's EMR revealed the following physician's orders: Amlodipine 2.5 milligrams (mg), by mouth (po), every day (QD), for HTN, ordered 12/06/22. Staff were to notify the physician if the resident's BP was less than 90/40 or greater than 170/110 or if the resident's pulse was less than 60. Lisinopril 40 mg, po, QD, for HTN, ordered 12/06/22. Staff were to notify the physician if the resident's BP was less than 90/40 or greater than 170/110 or if the resident's pulse was less than 60. Review of the resident's Medication Administration Record (MAR) revealed the resident had a pulse less than 60 on 06/02/23, 06/03/23, 06/06/23, 05/26/23, 05/29/23 and 04/26/23. The facility failed to notify the physician of the pulse less than 60, on those dates, as ordered, in case the physician determined the need for a change in the blood pressure medications. On 06/07/23 at 07:57 AM, Certified Medication Aide (CMA) R stated some residents had physician ordered parameters for medications. If the pulse of BP are outside of parameters, CMA R stated she would notify the nurse immediately. On 06/07/23 at 08:01 AM, Licensed Nurse (LN) G confirmed the staff failed to notify the physician of the pulses being outside of parameter on those dates. On 06/07/23 at 09:16 AM, Administrative Nurse D stated the facility identified an issue with the physician not being notified of pulses being outside of parameters in January and were working on correcting the issue. The facility policy for Physician Orders, revised 03/10/23, included: The facility is obligated to follow and carry out the orders of the prescribe. The facility failed to notify the physician of pulses being outside of parameters for this resident as ordered in case the physician needed to determine a change in the blood pressure medications was necessary.

The facility reported a census of 112 residents with 23 residents sampled including two residents reviewed for activities of daily living (ADL). Based on observation, interview and record review, the facility failed to provide adequate ADL cares for one dependent Resident (R)20, regarding clean clothing. Findings included: - Review of Resident (R)20's electronic medical record (EMR) revealed a diagnosis of rheumatoid arthritis (chronic inflammatory disease that affected joints and other organ systems). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. He had no rejection of care and required extensive assistance of two staff for dressing. The Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 02/22/23, documented the resident required assistance with all ADLs due to weakness. The care plan for ADLs, dated 02/15/23, instructed staff the resident required assistance with dressing. Review of the resident's EMR revealed he required extensive to total assistance of one staff for dressing from 05/08/23 through 06/05/23. On 06/05/23 at 12:09 PM, the resident propelled himself in his wheelchair from his room to the assisted dining room for lunch. The resident wore a clean dark blue shirt. On 06/06/23 at 08:00 AM, the resident sat up at the side of his bed. The resident had on the same dark blue shirt which had dried food substance on the front. On 06/06/23 at 12:27 PM, the resident sat up at bedside eating lunch. The resident continued to wear the same dark blue shirt with dried food substance on the front. On 06/07/23 at 07:53 AM, the resident rested in his bed. He continued to wear the same dark blue shirt with dried food substance on the front. On 06/05/23 at 11:40 AM, the resident stated the staff did not change his clothes every day. He stated he feeds himself and tends to get food on his shirt, but the staff do not change his clothes when they are dirty. The resident stated he would like to have his clothes changed when they are dirty. On 06/06/23 at 11:25 AM, Certified Nurse Aide (CNA) N stated the resident required staff assistance with dressing. The resident eats either in the assisted dining room or his room and was able to feed himself. He does not refuse cares; he was cooperative with staff. On 06/06/23 at 02:22 PM, Certified Medication Aide (CMA) M stated the resident was very kind and had no rejection of cares. He was able to feed himself but required assistance with dressing. Sometimes in the evening he would fall asleep and staff do not always get his clothes changed. On 06/07/23 at 09:51 AM, Licensed Nurse (LN) G confirmed the resident's shirt was dirty. On 06/07/23 at 09:16 AM, Administrative Nurse D stated the resident would refuse cares. The facility policy for Activities of Daily Living (ADLs), reviewed 08/22/22, included: A resident who is unable to carry out activities of daily living receives the necessary services to maintain good personal hygiene. The facility failed to provide adequate assistance in dressing for this dependent resident, who continued for days to wear soiled clothing.

The facility had a census of 97 residents. The sample included 22 residents. Based on observation, record review, and interview, the facility failed to store, prepare, and serve food under sanitary conditions for 94 residents who resided in the facility and received meals from the facility kitchen. This placed the residents at risk for foodborne illness. Finding included: - On [DATE] at 08:26 AM, during initial tour of the facility kitchen, observation revealed: Four 32-ounce (oz.) cartons of Sysco Imperial Thickened Dairy drink with a use by date of [DATE]. Six 24 oz. packets of Reliance Biscuit Gravy mix with a use by date of [DATE]. Three 11.3 oz. packets of Imperial Turkey Gravy mix with a use by date of [DATE]. Eleven four oz. Imperial Nectar Thickened Lemon-Flavored Water with a use by date of [DATE]. On [DATE] at 11:22 AM, observation of the kitchen during the meal preparation and serving revealed Dietary Staff (DS) CC plating food for the midday meal. He washed his hands and placed gloves on and sorted through the resident meal sheets. DS CC retrieved a loaf of white sandwich bread, brought it to the serving table, opened the bag, reached inside and took out two slices of bread. DS CC proceeded to scoop a serving of turkey salad, placed it on the bread then covered the turkey salad with another slice of bread using the soiled gloves. DS CC had not changed gloves after touching the meal sheets, after retrieving bread and reaching in for two slices of bread, and touching the scoop handle in the turkey salad. On [DATE] at 11:30 AM, observation revealed DS DD wearing gloves preparing/cutting lettuce and tomatoes for a salad. DS DD touched his arm in a scratching type motion with his left hand to right forearm, then with same gloves, placed lettuce and tomatoes on a plate, without changing gloves. DS DD also observed with gloved hands peeled a banana, placed the banana on the cutting board used to prepare lettuce and tomatoes, then cut banana into bite size pieces. DS DD placed the bite size banana pieces into a bowl without changing gloves between tasks. On [DATE] at 12:30 PM, a review of food temperature logs revealed no temperature recorded for cold foods/desserts or drinks served [DATE] through [DATE]. On [DATE] at 12:35 PM, observation revealed the front of the steam cooker and temperature control dial and the Vulcon oven doors and handles with built up deposits of yellow to dark brown debride. The weekly cleaning schedule had not been completed from [DATE] to [DATE]. On [DATE] at 12:35 PM, a review of the Hydrion QT testing strips used to measure the sanitizer solution concentration with an expiration date of [DATE]. On [DATE] at 08:32 AM, DS BB stated foods and drinks should be removed from dry storage if not used by the use by date, and staff should wash hands and change gloves between tasks or touching contaminated surfaces. DS BB verified different cutting boards should be used between fruits and vegetables. DS BB also verified the lack of cold food temperature readings, cleaning schedule not completed, and the testing sanitation strips had expired [DATE]. The facility's Food Safety policy, dated [DATE], recorded all food purchased, stored and distributed is handled with accepted food-handling practices and per federal, state and local requirements. Dry food storage safety 'Use by Date' is noted on the label or product when applicable. The 'Use by Date' guide is easily accessible to all associates involved with resident food storage. The policy further documented a danger zone of cold food temperature above 41 degrees Fahrenheit (F) which allows the rapid growth of pathogenic microorganisms that can cause foodborne illness outbreak if consumed. Food temperatures are checked at before being placed on the serving line and issues are identified, they are corrected, or the food discarded. The facility's Hand Washing for Food and Nutrition Services Department policy, dated [DATE], recorded staff washes hands and exposed portions of arms necessary to remove contamination and after the following: handling soiled utensils or equipment, switching between raw food and working with ready-to-eat food, and during donning gloves for working with foods. Gloves are to be changed between serving task or if soiled. The facility's Safe Food Handling policy, dated [DATE], recorded all working surfaces, utensils, and equipment are cleaned and sanitized appropriately after each use and if contaminated. Upon request the facility failed to provide a cleaning schedule and sanitation policy. The facility failed to store, prepare, and serve food under sanitary conditions for 94 residents who received food from the facility kitchen, placing the residents at risk for foodborne illness.

The facility reported a census of 89 residents with five selected for review of unnecessary medications. Based on observation, record review, and interview the facility contracted pharmacist failed to identify the lack of physician notifications for blood glucose of less than 60 mg/dL (milligrams per deciliter, a measurement that indicates the amount of a particular substance (such as glucose) in a specific amount of blood) or greater than 350 mg/dL for Resident (R) 40 per physician order. Findings Include: - Review of R40's signed physician orders [REDACTED]. Review of R40's Admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00 indicating severly impaired cognition. R40 had a [DIAGNOSES REDACTED]. Review of R40's Care Plan dated 02/03/20 revealed the resident had a [DIAGNOSES REDACTED]. Review of the Physicians Order Sheet dated 08/19/20 revealed as of 06/09/20, blood sugar levels were to be obtained before meals and at bedtime. Staff was to call the physician if the results were less than 60 mg/dLor greater than 350 mg/dL for further orders. Review of the July and August 2020 Electronic Medication Administration Record [REDACTED] July 5 at 10:00 AM the reading was 369 mg/dL, July 6 at 02:00 PM the reading was 416 mg/dL, July 13 at 02:00 PM the reading was 358 mg/dL, July 27 at 10:00 AM the reading was 351 mg/dL, August 3 at 10:00 AM the reading was 413 mg/dL, August 7 at 08:00 PM the reading was 400 mg/dL August 11 at 10:00 AM the reading was 365 mg/dL. Interview on 08/13/20 at 09:47 AM with Licensed Nurse (LN) D revealed that R40 had orders to call the physician if blood sugars are less than 60 mg/dLor greater than 350 mg/dL. LN C stated that if the blood sugars were outside of the parameters, staff should call the residents doctor for further instructions or new orders, and the LN should document in the resident's medical record. Interview on 08/13/20 at 12:29 PM with Administrative Nursing Staff B revealed that if a blood sugar fell outside of parameters, the nurse should notify the physician and documented in the nursing progress notes. Administrative Staff B stated she expected that the consultant pharmacist would inform the facility if the nursing staff were not notifying the physician for blood sugars outside of parameters. Interview on 08/17/20 at 08:50 AM consultant staff E stated that he does review the parameters to ensure that the facility is following up with them and would note discrepancies in his report. He also stated that he has however been unable to enter the facility due to COVID-19 and that the facility is changing some things from paper to computer. Review of the Medication Regimen Review dated 11/28/16 documented that the consultant pharmacist will conduct medication regimen reviews if required under a pharmacist consultant agreement and will make recommendations based on the information available in the residents' health record. The facility failed to ensure the consultant pharmacist identify physicians' notifications for blood sugars out of physician-ordered parameters to ensure this resident stay free from medication side effects.

The facility reported a census of 89 residents with five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to adequately monitor the results of blood sugar checks for Resident (R) 40 who received insulin injections. Findings Include: - Review of Resident (R) 40's signed physician orders [REDACTED]. Review of R40's annual Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00 indicating they could not determine the resident's cognition. R40 had a [DIAGNOSES REDACTED]. Review of R40's Care Plan dated 02/03/20 revealed the resident had a [DIAGNOSES REDACTED]. Review of the Physicians Order Sheet dated 08/19/20 revealed as of 06/09/20 Accuchecks (blood glucose measuring system used for the monitoring of glucose) were to be obtained before meals and at bedtime for blood sugar levels. Staff were to call the physician if the results were less than 60 mg/dL (milligrams per deciliter), or greater than 350 mg/dL for further orders. Humalog (fast-acting insulin) 100 unit/ml, inject three units subcutaneously three times a day for diabetes. Review of the July and August 2020 Electronic Medication Administration Record [REDACTED] July 5 at 10:00 AM the reading was 369 mg/dL, July 6 at 02:00 PM the reading was 416 mg/dL, July 13 at 02:00 PM the reading was 358 mg/dL, July 27 at 10:00 AM the reading was 351 mg/dL, August 3 at 10:00 AM the reading was 413 mg/dL, August 7 at 08:00 PM the reading was 400 mg/dL and August 11 at 10:00 AM the reading was 365 mg/dL. Observation of R40 on 08/11/20 at 12:16 PM revealed him sitting on the edge of his bed with his bedside table pulled up in front of him with his lunch meal. Interview on 08/13/20 at 01:13 PM with direct staff C revealed that the nurse obtained the Accuchecks. Interview on 08/13/20 at 09:47 AM with Licensed Nurse (LN) D revealed R40 had orders to call the physician if blood sugars are less than 60 mg/dLor greater than 350 mg/dL. LN C stated that if the blood sugars were outside of the parameters staff should call the resident's doctor for further instructions or new orders and this should be documented in the nursing notes. Interview on 08/13/20 at 12:29 PM with Administrative Nurse B revealed that if a blood sugar fell outside of parameters the nurse should notify the physician. This notification should be documented in a nursing progress note. Administrative Nurse B stated it was her expectation that the consultant pharmacist would notify the facility if nursing staff were not notifying the physician for blood sugars outside of parameters. The facility was unable to provide a policy which addressed blood sugar parameters and physician notification specifically. The facility failed to adequately monitor blood sugar results for this resident who received daily insulin injections and had elevated blood sugars outside of physician ordered parameters with failure to notify the physician.

The facility census totaled 113 residents. Based on observation, interview, and record review the facility failed to ensure residents could file a grievance anonymously. This had the ability to affect all residents in the facility. Findings included: - Observation on 12/05/19 at 09:27 AM revealed a box at the corner of the nurse's station with no card grievance cards in it. The 400 hall had a locked plastic bin, which read Have you seen great customer service? Tell us about it Submit your nomination here. Further review of both nurse's stations lacked any evidence of grievance forms or a way for residents to submit the forms anonymously. Review of the Concern and Comment Form located near the facility Social Service office revealed a notice to residents to leave the completed form with supervisor on duty. A facility manager will contact you as soon as possible to discuss the concern, any subsequent investigation and measures to resolve the concern. The form lacked any direction to residents wanting to file the grievance anonymously. An interview with Licensed Nurse (LN) D on 12/06/19 at 02:21 PM revealed she didn't know if there was a box to place grievance forms in besides the ones at the nurse's stations. LN D thought there might be a box up front. An interview with Administrative Staff A on 12/05/19 at 09:10 AM revealed the residents knew they could put the grievances under her door or in her mailbox. (Further review of the facility lacked any direction to residents to place grievance forms under Administrative Staff A's door and/or in Administrative Staff A's mailbox). The facility did not provide a policy on grievances. The facility failed to ensure residents had a way to file grievances in writing, anonymously.

The facility census totaled 113. Based on observation, interview and record review the facility failed to ensure administration followed up on resident concerns, by the failure to contact Resident (R)2's family member when she knew the family member had a lot of the facility Concern and Comment Forms, which were filled out, but did not contact them to resolve the concerns. Findings included: - An interview with Administrative Staff A on 12/05/19 at 09:10 AM revealed she knew who called in the complaints the surveyors were in the facility on because she saw R2's family member walking around the weekend prior (four days earlier) with a lot of Concern and Comment Forms. When asked if the felt like a she should have reached out to the family member about the forms, Administrative Staff A stated she had been busy and in/out of the facility so did not have a chance to reach out to the family member. The facility did not provide any Concern and Comment Forms, which were filled out by R2's family member dated the weekend prior to 12/05/19 or any correspondence with the family member regarding the stack of completed Concern and Comment Forms Administrative Staff A reported R2's family member had during her weekend observations. The facility policy Performance Improvement Program revised 06/26/09 revealed the facility involved all departments and included monitoring, evaluation, and follow up action. The facility failed to ensure administration effectively followed up on R2's family member concerns.

The facility reported a census of 113 residents. Based on observation, interview, and record review the facilty failed to have an effective infection control program by the failures observed during survey which included failure to ensure the housekeeping staff cleaned a contact precaution room in a sanitary manner, failure of staff to sanitarily store oxygen tubing for a resident when not in use, failure to post information regarding Personal Protective Equipment (PPE) required before entering resident rooms which required PPE, failure to ensure a resident identified as requiring a private room due to contact precautions from [MEDICAL CONDITION] (a highly contagious opportunistic pathogen infecting the colon of individuals on antibiotic therapy and can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon) did not have a roommate, and the failure to ensure the facility staff informed the housekeeping staff of the infectious organism in each room to ensure effective/appropriate cleaning. These failures had the potential for affect all residents in the facility. Findings included: - Observation on 12/03/19 at 01:45 PM revealed Housekeeping Staff K cleaned a room occupied by R4 (identified as on isolation precautions for [MEDICAL CONDITION]) and R1 (identified by her minimum data set as receiving [MEDICAL CONDITION] while a resident). HS K wore a mask and gloves but did not wear a gown. Further observation revealed HS K mopped the side of the room inhabited by R4 and then continued to mop through R1's side of the room. HS K did not red bag the trash from either side of the room. HS K said she would red bag the trash on R4's side of the rom but could not produce a red bag to show the surveyor. Further observation revealed HS K did not remove her gloves prior to exiting the room and did not wash her hands with soap and water. Review of the Care Plan for R4 revealed a 10/03/19 interventions which instructed staff the resident had [MEDICAL CONDITION] and required contact isolation (wear gowns and masks when changing contaminated linens. Place soiled linens in bags marked biohazard. Bag linens and close bag tightly before taking to laundry. Disinfect all equipment before it leaves the room. Educate resident/family/staff regarding preventative measures to contain the infection.) Interview with HS K (through an interpreter) on 12/03/19 at 01:45 PM revealed she only wore a gown when she needed to, but could not describe what conditions warranted the use of a gown. HS K confirmed she did not red bag R4's bathroom trash. Interview with Administrative Nurse I on 12/03/19 at 02:25 PM revealed R4 did not leave her bed and would always have runny stools and was colonized for [MEDICAL CONDITION]. Administrative Nurse I confirmed the resident had an order for [REDACTED]. Interview with Consultant Nurse J on 12/04/19 at 01:45 PM revealed the facility moved R1 out of R4's room and stated according to the policy anyone with [MEDICAL CONDITION] would be in a private room. Consultant Nurse J confirmed R4 should be on contact precautions. Interview with Administrative Nurse I on 12/06/19 at 12:09 PM revealed she was the infection preventionist for the facility since about (MONTH) 2019. Administrative Nurse I said she had completed the infection preventionist information through the online Centers for Disease Control (CDC) a couple of months ago. When asked how she ensured facility staff donned PPE appropriately, Administrative Nurse I said they would know to do it since they cover it upon hire but stated she did not go over it again after hire. When asked how Administrative Nurse I ensure staff knew the correct way to remove and dispose of PPE, Administrative Nurse said she did not know. When asked how she ensured housekeeping staff (included non-English speaking housekeeping staff) knew what infectious organism was in a room, Administrative Nurse I stated she could not tell the housekeeping staff because it would be a Health Information Portability and Accountability Act (HIPAA) violation. Review of the facility policy regarding ,[MEDICAL CONDITION]. (Clostridioides) Difficile reviewed 07/25/19 revealed contact precautions for those residents with diarrhea caused by [MEDICAL CONDITION] and noted those residents should be assigned a private room. The policy further stated those residents with fecal incontinence were preferentially assigned to private rooms. The policy noted staff were required to wear a gown to enter the room of a resident who had diarrhea caused by [MEDICAL CONDITION] if substantial contact with the resident or environmental surfaces were anticipated and gloves were required to enter the room. Review of the facility Transmission-based Precautions and Isolation Procedures policy revised 07/25/19 revealed when a resident was placed on transmission-based precautions the staff should clearly identify the type of precautions and the appropriate PPE used. The staff should place signage in a conspicuous place outside the resident's room such as the door or the wall next to the doorway identifying the CDC category of transmission-based precautions, instructions for use do PPE and/or instructions to see the nurse before entering. The facility failed to ensure housekeeping staff cleaned a contact precaution room sanitarily and failed to ensure a resident identified with [MEDICAL CONDITION] had a private room. - Observation on 12/05/19 at 08:59 AM revealed a Resident (R)2's nasal canula placed on the bed, with the tubing wrapped around the right upper hand rail of the bed and partially covered by the resident's blanket, but not stored in any bag to protect the nasal canula from contamination. Observation of R4's room on 12/05/19 at 09:00 AM revealed a small three drawer plastic container outside of her room (which contained PPE items) with no identification/instruction for staff and/or visitors of what PPE items were required to wear before entering the room. The area lacked information to alert visitors to stop and ask the nurse before entering the room. Observation on 12/05/19 at 09:10 AM revealed two staff at R26's room. Licensed Nurse (LN) G stopped and donned PPE (mask, gown, gloves) from a three-drawer plastic container while the other unidentified staff stood inside R26's room and only wore gloves. The area around R26's room lacked identification/instruction for staff and/or visitors of what PPE items were required to wear before entering the room. The area lacked information to alert visitors to stop and ask the nurse before entering the room. Observation on 12/05/19 at 09:21 AM revealed PPE in a small three-drawer plastic container which sat on the floor between R3 and R27's room with no identification of which room the PPE belonged and no identification/instruction for staff and/or visitors of what PPE items were required to wear before entering the room. The area lacked information to alert visitors to stop and ask the nurse before entering the room. Interview with LN H on 12/05/19 at 09:22 AM revealed the PPE between R3 and R27's room was intended for R3. LN H stated the R3 received heavy doses of [MEDICAL CONDITION] and staff needed to educate visitors to wear a mask before entering his room. LN H stated R3 wore a mask anytime he left his room. LN H stated she would have to look to see if there was a sign at his door but stated R3 was coherent and would stop anyone at the door and tell them to put on a mask. LN H did not know how she monitored for visitors and said she just watched, and most visitors asked, but sometimes she had to say wait and stop the visitor so they would put on the mask. Interview with Consultant Nurse J on 12/06/19 at 03:16 PM revealed the facility had issues with the signs on the door and removed them but verified the facility should have signs on the door to identify to stop and ask a nurse before entering the room and what PPE staff/visitors needed to where before entering. Review of the facilty policy regarding Oxygen Administration/Safety/Storage/Maintenance reviewed 04/15/19 lacked information regarding storage of oxygen tubing for a resident when not in use. Review of the facilty policy regarding Personal Protective Equipment (PPE) reviewed 07/25/19 revealed the facility must establish an infection prevention and control program (IPCP). The policy lacked direction to staff in regard to PPE notifications on resident rooms. Review of the facility 'Transmission-based Precautions and Isolation Procedures policy revised 07/25/19 revealed when a resident was placed on transmission-based precautions the staff should clearly identify the type of precautions and the appropriate PPE used. The staff should place signage in a conspicuous place outside the resident's room such as the door or the wall next to the doorway identifying the CDC category of transmission-based precautions, instructions for use do PPE and/or instructions to see the nurse before entering. The facilty failed to ensure staff stored oxygen tubing for resident in a sanitary manner and failed to ensure staff posted signs to alert staff and visitors of the PPE required before entering resident rooms which required a form of PPE.

The facility reported a census of 106 residents with 24 residents included in the sample. Based on observation, record review, and interview the facility failed to provide supervision to ensure the safety of cognitively impaired resident #26, who experienced continuous wandering behaviors. Findings included: - Review of resident #26's pertinent [DIAGNOSES REDACTED]. and irrational fear), and major [MEDICAL CONDITION] (major mood disorder). Review of the admission minimum data set ((MDS) dated [DATE] revealed a severely impaired cognition, inattention and disorganized thinking. The resident wandered daily with no significant risk of intruding on others privacy. The resident required supervision with walking in room and corridor. Review of the Quarterly minimum data set ((MDS) dated [DATE] revealed a BIMS score of 0, indicating severely impaired cognition with inattention and disorganized thinking noted. The resident wandering occurred 1-3 days with no significant risk of intruding on others privacy. The resident required extensive assistance of 1 staff with locomotion on unit and limited assistance of 1 staff with walking in his/her room and corridor. The resident did not used a mobility device. Review of the care area assessment (CAA) dated 6/8/18 revealed the resident had severe cognitive impairment and was unable to complete a BIMS assessment. The resident had severe long and short-term memory loss, was alert and required the locked dementia unit due to exit seeking behavior, wandering with no purpose, and was a high elopement risk. The resident exhibited frequent behaviors, was unable to sit still, and continuously wandered in and out of other residents' rooms. The resident needed continuous re-direction and distraction and was in continuous motion throughout locked unit. The resident required supervision with ambulation. The staff were to intervene with activities such as folding clothes, working with blocks and taking walks with staff. Review of the elopement/wandering review dated 6/2/18, indicated the resident went out the door the first day of admission and was identified as at risk for elopement. On 9/28/18 and 10/2/18 the review indicated the resident had poor decision-making skills, ambulated independently but staff must walk with her, wandered aimlessly, but the summary was marked as not at risk for elopement. The medical record revealed no further elopement reviews completed and the elopement risk notebook at nurse's station indicated the resident was an elopement risk. Review of the 4/8/19 significant change elopement risk assessment revealed the resident wandered aimlessly without purposeful or goal directed movement. The resident had a history of [REDACTED]. The resident ambulated independently with or without the use of an assistive device. Review of Care Plan dated 6/1/18 revealed the resident was an elopement risk as evidenced by exit seeking related to his/her [DIAGNOSES REDACTED]. 9/8/18: Staff to involve the resident in activities. 4/8/19: Staff to evaluate exit-seeking behaviors to determine cause or pattern. 4/9/19: The resident required the locked dementia unit to stay safe and was added to the elopement book. 4/9/18: The staff placed a wanderguard (electronic device used to monitor residents at risk of wandering) on the resident and the staff were to check and ensure its placement each shift, and night shift were to ensure it was working, daily. Staff were to use visual barriers such as stop sign, ribbons, and tape as needed. Observation on 4/3/19 at 2:48 PM revealed the resident wandered in and out of 3 other resident room. During this time licensed nursing staff O and direct care staff L were watching other residents. Observation of the resident on 4/4/19 at 1:33 p.m. revealed the resident walked about the unit, pushed on exit doors, then turn and walk to the chair and sit. The resident would stand back up within seconds of sitting down and begin walking around the unit again. The resident continued to walk around the unit and looked out the windows. The staff did not walk with the resident. Observation on 4/4/19 at 1:47 PM revealed the resident went to the north exit door with a stop sign on it, opened it and the alarm sounded. The resident walked two to three steps out of the door and then came back in as staff were going to toward his/her. The resident returned back inside without issue. The staff were not walking with the resident, and the staff did not notice the resident's location until the alarm sounded. Observation of the resident on 4/8/19 at 7:32 AM revealed the resident walked around the unit, looked out the windows and did not go toward the exit doors. The direct care staff N did not walk with the resident and was observing residents in the day room. Interview with direct can staff N on 4/8/19 at 11:25 AM revealed the resident liked to wander around and had been more alert and moving more. Staff N stated the resident was okay to walk on his/her own and even walked faster than staff N walked. Staff N stated the staff have to keep an eye on the resident. Interview with direct care staff L on 4/10/19 at 1:20 p.m. revealed the resident was independent to walk and when the resident wen to his/her room or other resident room, the staff followed the resident. Staff L stated the staff took the resident to an activity, offered a snack, or re-direction when the resident wandered. Interview with licensed nursing staff K on 4/4/19 at 2:02 PM revealed the staff watched the resident, but stated the resident was so quick. Staff K stated the facility had to put up a stop sign to deter the resident from wandering, however, it did not deter the resident today. Staff K stated the resident did not need the wanderguard, since all doors on the unit were alarmed. Interview with licensed nursing staff K on 4/9/18 at 1:28 PM revealed the staff put a wanderguard on the resident yesterday due to the residents increased wandering in the last few days. Staff K stated the resident ambulated independently and staff watched the resident. Staff K stated the residents care plan was updated as well. Review of the facility policy on wandering and elopement dated 12/13/18 revealed residents wound be assessed for unsafe wandering and elopement indicators upon admission, readmission, change in condition, quarterly, and with any unsafe wandering or elopement event utilizing the Elopement /Wandering Monitoring form. The policy further revealed the interdisciplinary team would review and revise the residents unsafe wandering management care plan, if indicated, upon completion of each comprehensive, significant change and quarterly MDS and upon an unsafe wandering or elopement event. The facility failed to provide supervision to ensure the safety of cognitively impaired resident #26 who wandered continuously.

The facility reported a census of 106 residents, with 24 residents included in the sample. Based on observation, interview, and record review the facility failed to assess, document, and monitor for pressure injuries for 4 residents reviewed. (#15, #30, #68, #75) Findings included: - Review of resident #15's [DIAGNOSES REDACTED]. Review of the 7/12/18 admission minimum data set (MDS) revealed a brief interview for mental status (BIMS) score of 12, which indicated moderately impaired cognition. The resident required total dependence of 2 staff for bed mobility, transfers, dressing, and toilet use and used a wheelchair for mobility. The resident did not have pressure ulcers, was at risk for pressure ulcers and did not receive skin and ulcer treatments. Review of the 1/12/19 quarterly MDS revealed the resident's short and long-term memory were intact. The resident required extensive assistance of 2 staff with bed mobility, toilet use, and total dependence of 2 staff with transfers. The resident used a wheelchair for mobility. The resident had no pressure ulcers, was at risk for pressure ulcer development, and received a pressure reducing device to his/her chair and bed. Review of the 7/12/18 care area assessment (CAA) revealed the following: Cognitive loss/dementia: The resident experienced some difficulty making him/herself understood and required extensive assistance with activities of daily living (ADL). ADL CAA: The resident triggered for extensive assistance with ADLs for mobility, toileting and transfers. The resident required extensive assist of 1 staff with dressing, personal hygiene and he/she required a lift for transfers. The resident was at risk for further decline in ADLs due to complications of immobility. Review of the facility care plan dated 7/16/18 revealed the following interventions: 7/16/18: The staff were to assist /remind the resident as needed (PRN) to reposition/shift weight to relieve pressure. 7/16/18: The staff were to complete weekly skin assessments. Review of the wound observation tool dated 2/25/19 revealed an unidentified direct care staff reported a new skin tear to the resident's left hip, unknown cause, stage 1 (intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED] (redness)), and the staff were able to cover the tear back up with some of the skin leaving two spots about 3 centimeters (cm) in diameter in which staff cleansed and covered with a dressing. The note revealed a previous coccyx wound reopened, stage 1, three separate open areas measured close to 3 cm in diameter were cleansed and dressing placed. The note revealed the staff needed the wound nurse or provider to review for treatment orders. The note addressed the area as an acquired pressure ulcer, stage one on 2/25/19, as a first observation. Review of the 3/4/19 at 1:55 a.m. (locked (when staff completed the charting) on 3/24/19 at 4:12 a.m.) wound observation tool revealed the resident's wounds were cleansed with normal saline and staff applied a dressing. The family requested the staff turn the resident every 45 minutes, offloaded coccyx when turning, and protective boots applied to the resident's feet. The wound measured 3-4 cm long on gluteal fold/coccyx stage 2 (partial thickness skin loss with exposed dermis) with no drainage. The staff cleansed the secondary wound and applied a dressing. The wound on inner left thigh appeared to be from sheering stage 1, and measured less than 3 cm in diameter, with no drainage. The noted listed the area as an acquired pressure ulcer dated 3/24/19, in the gluteal fold from pressure, stage 2, unchanged, with granulation tissue present (beefy red) with serous (clear) drainage and measured 4 cm in length by 0.25 cm in width, and no depth. Review of the wound observation tool (2 weeks later) on 3/18/19 at 1:55 A.M. revealed the resident used an air mattress, was repositioned every 2 hours and as needed (PRN) and had an acquired pressure ulcer on his/her coccyx stage III (full-thickness loss of skin) unchanged and which measured 3.9 cm in length by 0.8 cm in width and 0.1 cm in depth. Review of the 3/25/19 at 1:55 a.m. wound observation tool revealed the resident used an air mattress, staff repositioned every 2 hours and PRN, and the resident had an acquired pressure ulcer on his/her coccyx, stage III, unchanged and which measured 3.9 cm in length, 0.8 cm in width, an 0.1 cm in depth. Review of the 3/25/19-3/30/19 weekly pressure ulcer tracking report revealed the facility identified the resident had a coccyx wound, stage III, which measured 3.9 cm in length by 0.8 cm in width and was new. The tracking report revealed the resident had a suspected deep tissue injury (SDTI- persistent non-blanchable deep red, maroon or purple discoloration) to right and left heel which were new (no measurements recorded) and noted the description of each as eschar (dead tissue). The care plan did not address further pressure ulcer prevention measures until 4/2/19 which included the following: 4/2/19: The staff provided a pressure reducing mattress to the resident. 4/2/19: The staff were to provide treatments as ordered. 4/4/19: The staff were to offload the resident's heels while he/she was in bed. 4/4/19: The staff were to administer supplements as the physician ordered. 4/4/19: The staff were to administer treatments as ordered. 4/4/19: The staff were to teach the resident/family the importance of changing positions for prevention of pressure ulcers and encourage small frequent position changes. 4/4/19: The staff were to treat the resident's pain as per orders prior to treatment/turning etc. 4/4/19: The resident needed assistance to turn/reposition every 2 hours, more often as needed or requested. 4/4/19: The resident often refused to be repositioned and/or will reposition self to positions that were not beneficial for wound healing. Review of the resident's chart on 4/9/19 revealed there were no further measurements of the resident's wounds between 3/25/19 and 4/9/19, a gap of 15 days. Observation on 4/8/19 at 8:00 a.m. revealed the resident laid in his/her bed (air mattress in place) with head of bed and foot of the bed elevated. The resident displayed no signs of distress or pain. Interview with the resident on 4/10/19 at 10:43 a.m. revealed the resident stated the staff did not reposition him/her every 2 hours and had not measured his/her wounds this week and could not remember the when the wounds were measured last. Interview with direct care staff Z on 4/10/19 at 5:42 AM revealed the staff looked to the Kardex to know the cares required for each resident. Staff Z stated the licensed nursing staff let the direct care staff know if a resident had a pressure ulcer and if he/she saw a new skin area on the resident he/she would tell the licensed nurse. Staff Z stated the resident did have pain on his/her bottom and the direct care staff turned and repositioned the resident every 2 hours and stated the resident had an air mattress. Staff Z reported the resident did not have an open wound on his/her bottom and stated it was a previous wound which was a shallow area and the staff used pillows and propped up his/her feet to offload pressure and used protective boots when the resident allowed. Interview with licensed nursing staff BB on 4/10/19 at 6:24 A.M. revealed the unit managers followed up on resident skin conditions. Interview with licensed nursing staff AA on 4/8/19 at 10: 50 A.M. revealed he/she did not always have time to get all treatments and dressing changes completed on his/her shift and would pass on to the next shift and stated the staff have to prioritize which wound is worse and ensure the worse one gets taken care of. Interview with administrative nursing staff CC at 9:25 AM on 4/10/19 revealed he/she recently started assessing resident wounds. Staff CC stated the last time he/she measured the residents wounds were on 3/26/19, 2 weeks prior, and stated the wound measurements should be completed weekly. Staff CC stated he/she had no training over assessing/staging wounds. If he/she had questions about the assessment he/she would ask another member of the management team. Staff CC stated he/she did not have a set day to do wound rounds, he/she tried for Fridays, however it varied based on how much other work they had and if he/she was pulled to the floor to work. Staff CC did not know who would perform the wound assessments if he/she were not in the facility and did not know the protocol for staff coverage of wound care when he/she were not in the facility. Interview with administrative nurse B on 4/10/19 at 10:18 a.m. revealed skin checks should be done with cares, daily. Staff B stated wound rounds were expected to be done weekly and he/she expected wounds to be measured weekly. Staff B expected administrative nursing staff to team up and do wound assessments. Staff B did not know if staff assessing wounds had competency checks or training related to assessment/measurements. Staff B stated the resident's physician extenders or him/her oversaw assessment of resident wounds, although he/she did not know when the resident's wounds were last assessed. Staff B stated he/she would have expected each of the resident's wounds to be assessed with [REDACTED]. Interview with physician Y on 4/11/19 at 12:04 p.m. revealed the facility used a wound protocol, where they sent resident's to wound clinics, so he/she didn't have an expectation regarding staff measurement/assessment of wounds. He/she stated his/her physician extenders did not measure wounds based on the facility protocol to send resident's to wound clinics and he/she was unaware of a licensed practical nurse measuring wounds. Staff Y stated he/she would expect interventions in place on the resident's care plan related to his/her pressure ulcers at least after they were identified. Review of the facility policy Pressure Ulcer/Injury Prevention and Management revealed the facility completed a comprehensive skin assessment on admission to identify damage already present when admitted to the facility. Staff would perform a skin assessment on the resident weekly. When skin breakdown occurred, it required attention and a change in the plan of care to appropriately treat the patient. The facility failed to provide treatment and services to include pressure ulcer preventative measures to prevent the development of a stage III pressure ulcer to resident #15's coccyx and 2 SDTI to both heels through lack of care planning interventions for a resident identified as at risk, who did not admit with the pressure ulcers and was dependent upon staff for activities of daily living (ADL) assistance. The staff failed to perform weekly wound assessments to include measurements and staging for the resident's wounds once identified. - Review of resident #30's signed order summary report dated 4/21/19 revealed the following Diagnoses: [REDACTED]. knee. Review of the admission 7/27/18 minimum data set (MDS) revealed a brief interview for mental status (BIMS) score of 15, indicating intact cognition. The resident required extensive assistance of 2 staff with bed mobility and transfers. The resident used a wheelchair for mobility. The resident was at risk for pressure ulcer development and had 1 stage 4 (full-thickness skin and tissue loss) pressure ulcer unhealed and 1 unstageable (obscured full-thickness skin and tissues loss), unhealed, both present upon admission. The resident received a pressure reducing device for chair and bed, pressure ulcer care, applications of nonsurgical dressings other than to feet, applications of ointments/medications other than to fee, and applications of dressings to feet. Review of the 1/26/19 quarterly MDS revealed the resident was at risk for pressure ulcer development and had 1 stage 4 pressure ulcer unhealed and 1 stage 3 (full-thickness skin loss) unhealed, both present upon admission. The resident received a pressure reducing device for chair and bed, pressure ulcer care, applications of nonsurgical dressings other than to feet, applications of ointments/medications other than to fee, and applications of dressings to feet. Review of the care plan, revised 4/3/19, revealed the resident had a pressure ulcer to his/her coccyx related to immobility and included the following interventions: 1/26/19: The resident utilized an air mattress and wheelchair cushion and may get up once a day. 1/26/19: The staff were to offload the resident's heels and put on pressure relieving boots while in his/her chair. 4/3/19: The staff were instructed to administer treatments per physician orders. 4/3/19: The resident was followed by a wound clinic. 4/3/19: Inform the resident /family/caregivers of any new area of skin breakdown. 4/3/19: The resident needed assistance to turn and reposition at least every 2 hours, more often as needed or requested. 4/3/19: The resident required pressure relieving/reducing mattress and special cushion on his/her bed/chair. 4/3/19: The staff were to follow the physician orders for the resident's [DEVICE]. Review of the information provided revealed the last wound clinic wound note was from 2/6/19 (signed on 3/14/19) and revealed the resident had 1 sacral wound (no measurements documented), used a negative pressure suction to 125 mmHg, and the vacuum was changed on clinic day. The resident was to be turned every 2 hours, avoid positions which put direct pressure to wound site, limit side lying to a 30-degree tilt, and limit head of bed (HOB) elevation to 30 degrees in bed. Review of the 3/22/19 physician progress notes [REDACTED]. The resident had a [DEVICE] in place and the physician noted the wound was healing. Review of the 3/26/19 skin/wound note read the resident had a coccyx wound stage 4 pressure ulcer which measured 2.4 centimeters (cm) by 7.0 cm by 1.3 cm, with a moderate amount of serosanguineous (semi-thick reddish drainage) drainage, no odor noted, and the resident denied pain. The wound was improving. The right posterior heel stage 2 pressure ulcer measured 0.4 cm by 0.4 cm by 0.1 cm, with a scant (sparse) amount of serosanguineous drainage noted, no pain reported, and the wound was improving. The right lateral ankle stage 2 pressure ulcer measured 0.5 cm by 0.4 cm by 0.1 cm, with a scant amount of serosanguineous drainage, no pain reported, and the wound was improving. The [DEVICE] to the resident's coccyx continued at 125mmHg and was changed every Monday, Wednesday, and Friday, and as needed (PRN) if soiled/removed. The resident continued to follow with the local wound clinic and had an appointment scheduled for 4/3/19. Review of the 4/5/19 health status note revealed that administrative nursing staff C had approached the administrative nursing staff CC and reported the resident's sister stated the residents [DEVICE] needed to be changed due to it was covered in feces and had been so for 4 hours. Staff CC reported the concern to unidentified staff nurse who subsequently changed the [DEVICE]. Review of the resident's medical record on 4/9/19 revealed the staff had not measured the wounds in 15 days, since 3/26/19. Observation on 4/8/19 at 8:04 a.m. revealed the resident lay in his/her bed with head of bed elevated and a [DEVICE] in place (tubing visible from under the blanket) and the tubing ran along the left side of the bed toward the floor. The resident did not display signs of pain or distress. Interview on 4/8/19 at 8:38 a.m. with the family member of the resident revealed the facility was short staffed and the staff do not give baths or reposition the resident as they are supposed to. The family member stated he/she had to wait for staff to assist the resident and had to go find staff a lot of the time. Per interview with the administrative nursing staff CC at 9:25 AM on 4/10/19 revealed he/she recently started assessing resident wounds. Staff CC stated the last time he/she measured the residents wounds were on 3/26/19, 2 weeks prior and stated the wound measurements should be completed weekly. Staff CC stated he/she had no training over assessing/staging wounds. If he/she had questions about the assessment he/she would ask another member of the management team. Staff CC stated he/she did not have a set day to do wound rounds, he/she tried for Fridays, however it varied based on how much other work they had and if he/she was pulled to the floor to work. Staff CC did not know who would perform the wound assessments if he/she were not in the facility and did not know the protocol for staff coverage of wound care when he/she were not in the facility. Interview with direct care staff Z on 4/10/19 at 5:42 AM revealed the staff looked to the Kardex to know the cares required for each resident. Staff Z stated the licensed nursing staff let the direct care staff know if a resident had a pressure ulcer and if he/she saw a new skin area on the resident he/she would tell the licensed nurse. Staff Z stated the resident had a [DEVICE] on his/her bottom and the resident admitted with the [DEVICE]. Staff Z reported to the nurse if the [DEVICE] was loose, contained air, and if it was soiled as it would require changing. Staff Z reported he/she reported redness to the nurse also. Interview with licensed nursing staff AA on 4/8/19 at 10: 50 a.m. revealed he/she did not always have time to get all treatments and dressing changes completed on his/her shift and would pass on to the next shift and stated the staff have to prioritize which wound is worse and ensure the worse one gets taken care of. Interview with administrative nursing staff D on 4/9/19 at 2:07 PM revealed staff did weekly skin assessment's on residents with baths. Staff D stated if a resident refused it would be documented on a progress note, family notified and on-call administrative staff notified. Staff D stated the facility had been short of staff, which made it difficult to check/change/reposition residents and complete treatments for residents to include a [DEVICE] change. Interview with licensed nursing staff BB on 4/10/19 at 6:24 a.m. revealed the unit managers followed up on resident skin conditions. Interview with administrative nursing staff CC at 9:25 AM on 4/10/19 revealed he/she recently started assessing resident wounds. Staff CC stated the last time he/she measured the residents wounds were on 3/26/19, 2 weeks prior and stated the wound measurements should be completed weekly. Staff CC stated he/she had no training over assessing/staging wounds. If he/she had questions about the assessment he/she would ask another member of the management team. Staff CC stated he/she did not have a set day to do wound rounds, he/she tried for Fridays, however it varied based on how much other work they had and if he/she was pulled to the floor to work. Staff CC did not know who would perform the wound assessments if he/she were not in the facility and did not know the protocol for staff coverage of wound care when he/she were not in the facility. Staff CC stated he/she was going to measure the wounds later today. Interview with administrative nurse B on 4/10/19 at 10:18 a.m. revealed skin checks should be done with cares, daily. Staff B stated wound rounds were expected to be done weekly and he/she expected wounds to be measured weekly. Staff B expected administrative nursing staff to team up and do wound assessments. Staff B did not know if staff assessing wounds had competency checks or training related to assessment/measurements. Staff B stated the resident's physician extenders or him/her oversaw assessment of resident wounds, although he/she did not when the resident's wounds were last assessed, but knew the resident went to the local wound clinic. Staff B stated he/she would have expected each of the resident's wounds to be assessed with [REDACTED]. Interview with physician Y on 4/11/19 at 12:04 p.m. revealed the facility used a wound protocol, where they sent resident's to wound clinics, so he/she didn't have an expectation regarding staff measurement/assessment of wounds. He/she stated his/her physician extenders did not measure wounds based on the facility protocol to send resident's to wound clinics and he/she was unaware of a licensed practical nurse measuring wounds. Staff Y stated he/she would probably expect interventions in place on the resident's care plan related to his/her pressure ulcers at least after they were identified. Review of the facility policy Pressure Ulcer/Injury Prevention and Management revealed the facility would completed a comprehensive skin assessment on admission to identify damage already present when admitted to the facility. Staff would perform a skin assessment on the resident weekly. When skin breakdown occurred, it required attention and a change in the plan of care to appropriately treat the patient. The facility failed to monitor the pressure ulcers for resident #30, who had a stage IV and a stage III pressure ulcer, and the facility did not assess/document on the wounds weekly. - Review of resident #68's signed interagency transfer record and admission orders [REDACTED]. Review of the admission minimum data set assessment ((MDS) dated [DATE] revealed the resident was rarely/never understood. The resident required extensive to total assist of 1-2 staff assistance for activities of daily living (ADLs). The resident had a risk of pressure ulcer development. The resident had no unhealed pressure ulcers and required pressure reducing devices for the chair and bed, a turning/repositioning program, nutrition/hydration interventions to manage skin problems, application of nonsurgical dressings to areas other than feet and applications of ointments/medications to areas other than to feet. Review of the activity of daily living (ADL) care area assessment (CAA) dated 2/12/19 revealed the resident required staff assistance with ADLs. The CAA identified the contributing factors included generalized weakness, and decreased safety awareness. The assessment noted other risk factors the resident had were related to ADL decline, falls, incontinence, skin breakdown, and pain. The facility would initiate a care plan to improve/maintain current ADL status and functional ability, maintain continence status, decrease pain, and decrease fall and pressure ulcer risk. Review of the pressure ulcer CAA dated 2/12/19 revealed the care area triggered secondary to potential for pressure ulcer development. The contributing factors to the resident's potential for pressure ulcer development included ADL/functional/mobility impairment and incontinence. The assessment identified the resident's risk factors as pain, development of pressure ulcer/skin condition and fluid deficit risk. A licensed nurse would assess the resident's skin each week and put proper interventions in place to prevent skin breakdown. The resident's skin would also be assessed by direct care staff with each bath and each time staff dressed the resident. The physician would be notified of any abnormal findings and treatment orders would be obtained. Direct care staff assisted the resident with repositioning at least every two hours and as needed for comfort. The resident's care plan would be initiated/reviewed to improve/maintain current ADL status and functional ability, maintain continence status, prevent pain, and decrease pressure ulcer risk. Review of the resident's care plan revealed the following: 2/20/19 - Focus: The resident had limited physical mobility related to stroke. 2/20/19 - Goal: The resident would remain free of complications related to immobility through the next review date. The care plan lacked any intervention related to the resident's limited physical mobility related to a stroke problem/goal. 2/28/19 - Focus: Activity of daily living assistance and therapy services needed to maintain or attain highest level of function. 2/28/19 - Goal: The care plan lacked measurable goals for the resident's ADL problem. 2/28/19 - The resident would have therapy services as ordered. The care plan lacked any other intervention related to the resident's ADL assistance. 2/6/19 - Focus: The resident had an ADL self-care performance deficit related to [MEDICAL CONDITION] (paralysis of one side of the body) The care plan lacked any intervention related to the resident's ADL self-care performance deficit. 3/19/19 - The resident had a break in skin integrity to his/her coccyx, left buttock, right inner thigh and left wrist. 3/19/19 staff would educate the resident and/or family regarding skin problems and treatment. 3/19/19 - The resident required a pressure reducing mattress. 3/19/19 - Staff would provide the resident treatment as ordered. 3/19/19 - Staff would perform weekly skin checks on the resident. 4/4/19 - The resident required assistance with repositioning every two hours and as needed. 4/4/19 - The resident was seen by the wound clinic. The resident's care plan lacked evidence the resident had a risk for pressure ulcer development and/or interventions related to any actual pressure ulcers the resident had until 3/19/19 even though the CAA dated 2/12/19 stated the resident's risk would be care planned and the resident started treatment for [REDACTED]. Review of the initial weekly skin integrity data collection form dated 2/5/19 revealed the resident and an old open area at his/her feeding tube site. The skin integrity form lacked any evidence the resident had any other skin conditions/concerns present upon admission to the facility. Review of the resident's progress notes from 2/5/19 through 2/26/19 lacked documentation, which would indicate the resident had wounds until the following note. Review of the order dated 2/26/19 revealed staff would clean the resident's coccyx with normal saline, pat the area dry, and apply protective covering Monday, Wednesday, Friday and as needed if soiled or removed. Review of the skin integrity data collection assessment dated [DATE] revealed the resident had a blister on his/her left wrist. The assessment lacked any measurement of the area. The assessment lacked any indication the resident had an area on his/her coccyx. Review of the order note dated 2/28/19 at 12:57 AM revealed staff cleaned the resident's coccyx with normal saline, patted the area dry, and applied protective covering Monday, Wednesday, Friday and as needed (PRN). If soiled staff would remove the dressing as needed. The note lacked any description of the area on the coccyx being treated, measurements or further indication for the treatment. Review of the skilled note dated 3/5/19 at 2:51 AM revealed staff turned the resident to offload pressure. Review of the order administration note dated 3/7/19 at 6:46 PM revealed staff cleansed the resident's coccyx with normal saline, patted dry and covered with a dressing Monday, Wednesday, Friday and as needed if soiled. The note lacked any description of the area on the coccyx being treated, measurements or further indication for the treatment. Review of the order administration note dated 3/8/19 at 12:40 AM revealed the resident's coccyx was cleansed with normal saline, patted dry and covered with a dressing Monday, Wednesday, Friday and as needed if soiled. The note lacked any description of the area on the coccyx being treated, measurements or further indication for the treatment. Review of the event note dated 3/12/19 at 11:17 AM revealed a physician extender and licensed nurse CC assessed the resident's skin at this time. The note stated the resident's bilateral lower extremity wounds had not improved. The physician extender wrote orders to do an arterial doppler (define)on the resident's lower extremities. The resident's heels would be elevated or floated off of the bed. The note identified license nurse CC as the wound nurse. Staff would not use boots on the resident when he/she was in the wheelchair and would apply skin prep two times a day. The note lacked evidence the resident's wrist and coccyx were assessed by the nurse. The note further lacked any measurement of the resident's wounds. Review of the skin integrity data collection assessment dated [DATE] revealed the resident did not have intact skin, he/she had blisters, open areas and other pressure ulcers. The assessment revealed staff notified the resident's physician extender of his/her skin assessment. The resident had the following identified on the assessment: Left heel-unstageable pressure ulcer (no measurement or description of the area), right heel - unstageable pressure ulcer (no measurement or description of the area), left hand - unstageable pressure ulcer (no measurement or description of the area, right foot and left foot calluses -intact and on his/her coccyx an unstageable pressure ulcer (no measurement or description of the area). Review of the skilled note dated 3/18/19 at 12:32 AM revealed the dressing to the resident's wound on his/her coccyx was changed as ordered and the resident had no signs of pain. The note lacked any evidence the resident's other wounds were assessed Review of the weekly skin integrity data collection assessment dated [DATE] revealed the resident did not have intact skin. The resident had a surgical incision, blanchable redness and an open area/wound. The resident's right and left heels had blanchable redness. The skin integrity data collection assessment lacked evidence the residents left hand wound and/or the resident's coccyx wound were assessed. Review of the skin/wound note dated 3/19/19 at 1:31 PM revealed the skin assessment was completed by the nurse writer and unit manager, the resident had a right lower abdomen area which appeared to be a blister that is dried/oozing yellow drainage 1.3 centimeters (cm) x 3.0 cm x 0.1cm (the resident admitted with an old area to his/her peg tube site). The resident had a left inner wrist wound (the resident wore a splint to his/her left extremity) which measured 1.2 cm x 1.7 cm, with dry eschar (dead tissue) to entire wound bed. The resident had a coccyx wound which measured 7.5 cm x 4.0 cm and the wound bed had pink granulation, the peri-wound had normal skin color. The resident had a wound to the right upper inner thigh (the resident's record lacked any indication of when or how the resident's right upper inner thigh wound occurred) which measured 0.7 cm x 1.2 cm with slough to the entire wound bed, the peri-wound had normal skin color. The resident had a wound to the left outer front of sole, which measured 2.3 cm x 2.3 cm with dry eschar present. The resident had a wound to the left heel which measures 4.8 cm x 3.6 cm with dry eschar and a right outer heel wound which measured 6.5 cm x 7.5 cm with dry eschar. The resident's treatment plan included skin prep to bo

The facility census totaled 112 residents with 1 resident reviewed for skin issues non-pressure related and one resident reviewed for a surgical wound. Based on observation, interview, and record review, the facility the failed to ensure staff adequately monitored resident #8 for skin breakdown and provided appropriate interventions to prevent breakdown and worsening of a small open area on a sacral flap (Skin flap surgery is done to treat large wounds that cannot be closed by skin grafting. Skin flap surgery uses skin flaps, which are skin and tissue near the wound, to cover the wound), which required surgical debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue); and failed to routinely evaluate and monitor multiple skin ulcers (a sore on the skin) on resident #6's left lower leg. Findings included: - Review of resident #8's [DIAGNOSES REDACTED]. Review of the admission minimum data set ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 14, indicating no cognitive impairment. The resident required extensive assistance of two staff for bed mobility and toileting. He/she had an indwelling Foley catheter (tube inserted into the bladder to drain urine into an external collection bag) and was frequently incontinent of bowel. The facility assessed the resident at risk for development of pressure ulcers (soft tissue injury usually over a bony prominence or related to a medical or other device) and the resident had 1 unstageable (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough (dead tissue, usually cream or yellow in color or eschar (dead tissue)) which measured 1.5 centimeters (cm) x 0.5 cm x 0.3 cm. The facility implemented a pressure reduction device for the resident's chair and bed, applied nutrition/hydration interventions, and provided the application of dressings to the resident's feet along with pressure ulcer care. These interventions were added to the resident's comprehensive care plan dated 11/4/17. Review of the re-admission MDS dated [DATE] revealed a BIMS score of 11, indicating moderate cognitive impairment. He/she required extensive assist of two staff for bed mobility and toileting. The resident had a Foley catheter and was frequently incontinent of bowel. He/she was at risk for the development of pressure ulcers and currently had 1 stage IV pressure ulcer which measured 11 cm x 7.5 cm x 3.2 cm. The facility implemented a pressure reduction device for the resident's bed and chair, nutrition/hydration interventions, pressure ulcer care, and the application of non-surgical dressings. The activities of daily living (ADL) care area assessment (CAA), dated 1/25/18, revealed the resident needed extensive assistance with all ADLs, except for personal hygiene and eating. Review of the urinary incontinence CAA, dated 1/25/18, revealed the resident had a Foley catheter and he/she was frequently incontinent of bowel. He/she needed assist with toileting, peri care, and Foley care. Review of the nutrition CAA, dated 1/24/18 revealed the resident was at risk for altered nutrition. Review of the pressure ulcer CAA, dated 1/24/18, revealed the resident was at risk for skin breakdown. The facility had assessed the resident with the Braden Scale (a tool used to determine pressure ulcer risk) and determined the resident was a high risk for the development of pressure ulcers with a score of 11 on 10/19/17 and identified the resident responded to only painful stimuli, was very moist (his/her skin was damp), was chair fast with very limited mobility, probably inadequate food intake, and had a problem with friction (when the skin is rubbed against another object) and shearing (when forces moving in opposite directions are applied to tissues in the body). Review of the resident's care plan listed the following interventions: 10/19/17 - admission care plan included the use of a low air loss mattress. 10/31/17 - encourage resident to limit wheelchair time (this intervention was not placed on his/her care plan until 12 days after admission) 11/4/17 -Observe the resident's intake of meals and offer alternatives as needed (PRN) and refer to the registered dietitian PRN. Remind and assist the resident to reposition/shift PRN. Discuss any non-compliance issues with the resident and his/her responsible party as well as provide education about pressure ulcer etiology (the causes of pressure ulcers), risk factors, treatment, and prevention. Minimize pressure over boney prominences. Notify the licensed nursing staff of any new areas of skin breakdown, redness, blisters, bruises, or discoloration. Ensure the resident had a pressure relieving or reduction device for a specialty mattress and chair cushion. Provide wound care as ordered by the physician, and to see the current wound treatment and progress records. Limit his/her wheelchair time and offload pressure with side-to-side while in bed. 11/6/17- Use a turning system while the resident was in bed due to the resident having a sacral (large triangular bone between the two hip bones) pressure injury with a history of sacral flap (surgical procedure where additional skin is attached to close an open area) and provide treatment as ordered. The resident is only to be out of bed 2 hours per day utilizing the large split leg sling for full lift transfers. Staff were instructed to leave the sling in the wheelchair, making sure no part of the sling was under the resident's bottom. Review of the nurse's admission note, dated 10/19/17, revealed the resident admitted to the facility that day with a large area of scarring noted to the coccyx (small triangular bone at the base of the spine) area with a small opening to the middle of the scarring. The admission notes lacked evidence of any further assessment of the small opening, such as measurements of the opening, if there was any drainage, or what the wound bed looked like. Review of weekly skin integrity data collection revealed on 10/27/17 an open area to coccyx - tunnel (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound) under flap. The document lacked assessment of the wound or surrounding tissue. Review of the resident's clinical record from 10/19/17 to 10/27/17 revealed no further documentation of the resident having a sacral and/or coccyx wound. This was 12 days without documentation or assessment of the wound. Four days after the weekly skin integrity data collection, on 10/31/17, the physician instructed staff to apply barrier cream with incontinent care, encourage the resident to lay down during the day, and to limit wheelchair time due to his/her history of a sacral flap secondary to pressure injury. Review of the physician's progress note dated 11/2/18 noted the resident had a coccygeal skin breakdown. The physician noted the breakdown was at the site of a prior large ulceration and grafting. Review of a weekly skin integrity data collection revealed on 11/3/17 staff reported an open sore on the resident's coccyx. The resident's clinical record lacked any further description of the wound. Staff left a message for the physician and the resident was off loaded side-to-side every 2 hours and was on an air mattress. Review of a physician's orders [REDACTED]. A resident at risk note, dated 11/3/17, reported the resident had a new open area to his/her coccyx with preventive measures in place and to be evaluated by the facility wound nurse. Review of a nurse's note, dated 11/6/17, revealed new orders were obtained for the resident to not be out of bed more than 2 hours per day. The resident had a history of [REDACTED]. The right buttock had a black/brown area with yellow/brown drainage. The coccyx scar tissue was open with a small tunnel measuring 0.8 cm. Review of the pressure ulcer status record, dated 11/6/17, revealed the wound to the coccyx area measured 9 cm x 7 cm x 0.8 cm and was yellow/brown in color with moderate drainage. On 11/9/17, nurse's note revealed the resident had a new order to consult a physician specialist regarding the wound to the prior sacral flap. Review of a nurse's note, dated 11/10/17, revealed the consultant physician I saw the resident and planned a surgical debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue) of the wound with placement of a [DEVICE] (a device used to aid in closing a wound). Review of weekly skin integrity data collection revealed on 11/10/17 there was excoriation (damage to the skin) noted below the prior surgical scarring. The note lacked any other description or location of the excoriation. Review of a nurse's note, dated 11/10/17, revealed the resident was sent to the emergency room for treatment related to [MEDICAL CONDITION] (condition without enough healthy red blood cells to carry adequate oxygen to body tissues) Review of the hospital provided documents revealed the resident underwent [REDACTED]. After the procedure, the resident admitted to a specialized treatment facility, which focused on wound care, prior to being discharged back to the facility. The resident readmitted to the facility on [DATE]. Review of the pressure ulcer status record, dated 1/18/18, revealed the resident readmitted to the facility with a stage IV sacral pressure ulcer, which measured 11 cm x 8 cm x 3.3 cm with 30% of the wound being slough and exposed bone. The wound had moderate to large amount of drainage. Observation on 2/5/18 at 1:01 PM revealed the resident in bed on a low air loss mattress. The resident had a [DEVICE] in place functioning correctly with the tubing going to the posterior (back) side of the resident. Interview with the resident on 2/5/18 at 1:07 PM revealed but he/she would like the staff to pay more attention to the [DEVICE]. The resident stated he/she acquired the wound during his/her stay between 10/19/17 and 11/10/17, in the facility, but decided to return to the facility, due to the physical therapy department. On 2/7/18 at 7:59 AM the resident reported staff came and assisted him/her to change position every couple of hours, but it hurt too much on his/her left side, so he/she did not stay positioned on that side very long. An interview with direct care staff A on 2/6/18 at 10:59 AM revealed he/she helped reposition the resident every two hours and he/she believed the resident could only be up in the wheelchair for 30 minutes a day. Staff A would alert the nurse if there were any complications, for instance the device making a different noise, with the [DEVICE]. Interview with licensed nursing staff D on 2/6/18 at 11:30 AM revealed the resident had a pressure reduction mattress with a [DEVICE] in place. He/she ensured the resident was repositioned every 2 hours by watching the direct care staff and observing the resident's position in bed. He/she reported the wound nurse changed the [DEVICE] when the resident did not go to the wound clinic. Interview with administrative nursing staff B on 2/6/18 at 1:19 PM revealed the resident had a sacral flap in the past and he/she liked to sit in his/her wheelchair most of the day prior to the flap breaking down. After the flap was noted to be deteriorating, the resident agreed to not spend as much time in his/her wheelchair. The resident had always been on a bariatric air mattress and was then referred to surgery for [REDACTED]. During an interview on 2/12/18 at 10:45 AM, administrative nursing staff E revealed administrative nursing staff B did weekly wound measurements, which were to include a detailed description of the wounds. Staff B was expected to monitor the measurements of the wound and if he/she noted a worsening, then he/she would be expected to notify the physician or physician extender to provide an update and obtain treatment orders. On 2/12/18 at 5:12 PM, staff E reported he/she did not know what occurred to delay the formal assessment of the wounds from 10/19/17 to 11/6/17. He/she stated it was possible the addition of the resident limiting chair time was not in place until 10/31/17 as the care plans were working documents and updated and revised as indicated. He/she would have expected the staff to provide turning assistance every 2 hours upon the resident's admission as a standard of care. A phone interview with outside consultant wound nurse H on 2/13/18 at 10:43 AM revealed he/she would have expected the facility to implement more aggressive interventions sooner and he/she believed the resident had not been provided adequate repositioning assistance due to how significant the wound was. Consultant H stated the expectation for resident #8 upon his/her admission to the facility, would have been to ensure and document the repositioning of the resident, limiting the resident's time sitting up (either in bed or wheelchair), and documentation of the assessment of the wound. Review of the policy Pressure Ulcer/Injury Prevention, last revised 11/2017, revealed a skin assessment should be performed weekly by a licensed nurse. Wound assessment should be performed and recorded weekly to include a description of the pressure ulcer. When skin breakdown occurred, a change in the plan of care was required to treat the resident. The facility failed to assess a small open area to resident #8's sacral flap; to include the type of injury, a description of the wound characteristics, the progress towards healing and potential complications, if infection was present, the presence of pain, and a description of the dressings and treatment, for 17 days after first documented. A complete and accurate assessment of the wound was not completed for 17 days, and the facility failed to implement timely and effective interventions specific to the wounds and the resident experienced worsening of small open area of skin breakdown to a prior sacral graft site. Resident #8 required surgical debridement of the wound with placement of a [DEVICE] to aid in wound healing. - Resident #6's [DIAGNOSES REDACTED]. cease functioning on a permanent basis leading to the need for a regular course of long-term [MEDICAL TREATMENT] (an artificial way to filter blood to eliminate waste products from the body) or a kidney transplant to maintain life) and diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). Review of the admission minimum data set ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 13, indicating no cognitive impairment. The resident required extensive assist of 1 staff member for bed mobility and toileting. Review of the quarterly MDS dated [DATE] revealed no change in cognition. He/she required extensive 2 person assist for bed mobility and toileting. He/she had a surgical wound and the facility had implemented a pressure reduction device for the resident's bed and chair, nutrition/hydration, pressure ulcer care, surgical wound care, and applications of ointments/medications. Review of the activity of daily living (ADL) care area assessment (CAA) dated 10/16/17 revealed the resident needed extensive assist with all ADLs except for locomotion and personal hygiene which required limited assistance and eating which required supervision. Review of the pressure ulcer CAA dated 10/16/17 revealed the resident was at risk for skin breakdown. Review of nutritional CAA dated 10/16/17 revealed resident was at risk for altered nutritional status. Review of the resident's plan of care, initiated 11/10/17, revealed the resident had a surgical incision to the left foot and ankle. It had a non-removable dressing in place which needed to stay on until he/she saw the surgeon for a follow up appointment. Staff were to inspect the skin during bathing, especially over boney prominences and report any changes in the skin status to the physician. Wound care was to be provided as ordered, with the current orders located on the treatment administration record, and observe the effectiveness and/or response to treatment. Ensure pressure reduction devices, a pressure reduction mattress and cushion for chair, were provided. Review of the inter-agency transfer form, dated 10/31/17, revealed treatment orders for the facility staff to clean the incision and apply dressings on Mondays, Thursdays, and as needed (PRN). The resident readmitted to the facility on [DATE], per a nursing note, after having his/her left subtalar fused (a surgical procedure to fuse together the heel bone and the ankle into a fixed position). He/she had a clean, dry, and intact dressing and ACE wrap to the left lower leg. Review of an appointment communication form, dated 11/6/17, revealed resident #6 had followed up with the surgeon who removed the sutures, left the staples in place, and placed a posterior (back) splint on the resident. A signed order dated 11/7/17 revealed the facility staff were to leave the splint to the left foot in place until seen by the surgeon in 2 weeks. A nursing note dated 11/20/17 revealed the resident had a follow up appointment with the surgeon and returned with orders for daily dressing changes and follow up in 1 week. Review of the resident clinical record failed to yield any description of the wounds, measurements, or potential etiology of the wounds from 11/20/17 to 12/6/17 (16 days) until the resident was assessed at a wound center. Review of wound clinic documentation dated 12/6/17 revealed the resident had 4 separate skin ulcers: left lateral (pertaining to the side, away from the middle) lower leg - 10.2 centimeters (cm) x 3 cm x 0.2 cm left medial (the middle) malleolus (part of the ankle) - 3.4 cm x 5.1 cm x 0.1 cm left heel plantar (the bottom) - 1.3 cm x 1.4 cm x 0.6 cm left heel posterior (back) - 0.7 cm x 3.3 cm x 0.3 cm Per the wound physician, the wounds had been protected and insulated from trauma such as pressure, shearing, maceration, and friction. There was significant [MEDICAL CONDITION] and his/her [DIAGNOSES REDACTED]. The resident followed up with the surgeon on 12/11/17 per a nursing note. Review of a nursing note dated 12/20/17 revealed the resident attended an appointment at the wound clinic. The resident was seen at the wound clinic on 1/3/18 per a nursing note with changes to the treatment orders. Review of physician progress notes [REDACTED]. Further review of the resident's clinical record failed to yield any documentation from the facility regarding the etiology, description, or effectiveness of treatments between 10/31/17 and 2/6/18. Observation on 2/6/18 at 5:27 PM revealed the resident lying in bed, with his/her legs elevated on a cushion. Any wounds were not able to be seen due to the dry and intact dressing located on the resident's left ankle. Interview with the resident on 2/5/18 at 4:12 PM revealed the wounds were getting better and he/she had no concerns about how the facility staff provided wound care. Interview with direct care staff C on 2/6/18 at 5:52 PM revealed he/she ensured the dressings stayed clean and dry and would alert the licensed nursing staff if they were not. Interview with licensed nursing staff F on 2/6/18 at 5:38 PM revealed the resident had daily dressing changes to his/her left leg. He/she reported the interventions to prevent the wounds from worsening were an air mattress and not keeping the resident up in a wheelchair for long periods. He/she reported the resident left the facility so often for treatments, that was hard to control the time he/she sat up in the chair. Interview with administrative nursing staff E on 2/7/18 at 8:03 AM confirmed the facility could not locate any wound monitoring for the resident. On 2/12/18 at 10:45 AM he/she stated the facility had a different form for non-pressure related skin issues and the wound nurse was expected to document on the wounds weekly. Review of the policy entitled Pressure Ulcer/Injury Prevention, revised 11/2017, revealed wound assessments were to be performed and recorded on the pressure ulcer status record form or electronic assessment in the resident's medical record. The facility failed to properly assess and monitor for effective treatment on multiple non-pressure skin ulcers on resident #6.

The facility census totaled 113 residents with 3 residents sampled for medication review. Based on observation, interview and record review the facility failed to ensure staff transcribed orders correctly, clarified new orders when there was a drastic change and failed to ensure staff administered medications as ordered to ensure residents were free of any significant medication errors for 1 of 3 residents (#3). Resident #3 required hospitalization with a low calcium level after receiving triple his/her regular dose of [MEDICATION NAME] (a medication used to treat secondary elevated [MEDICAL CONDITION] (a gland that makes the hormone which plays a key role in regulating calcium in the blood and bones). Findings included: - Review of resident #3's POS (physician's orders [REDACTED]. Review of the admission MDS (minimum data set) dated 4/7/16 revealed a BIMS (brief interview for mental status) score of 15, indicating intact cognition with no behaviors. The resident required limited assistance for bed mobility and transfers. The resident received an anticoagulant 6 out of the 7 days of the observation period. Review of the ADL (activities of daily living) CAA (care area assessment) dated 4/13/16 revealed the resident admitted following a hospital stay for a new arteriovenous fistula (a surgically created connection between an artery and vein) to receive [MEDICAL TREATMENT] (is a life-support treatment that uses a special machine to filter harmful wastes, salt, and excess fluid from the blood) treatments. The resident required staff assistance with all ADLs except eating due to weakness related to [MEDICAL CONDITION] (too much calcium in the blood) and both legs had [MEDICAL CONDITION]. Review of the ADL care plan dated 4/21/16 revealed the resident had a self-care deficit related to bilateral (both sides) lower extremity amputations. The care plan directed staff to: provide task segmentation, set-up help with ADLs but to let the resident perform what he/she could, allow extra time for resident self-performance due to weakness and fatigue, and administer medications, labs and treatments as ordered. Review of the physician orders [REDACTED]. The orders included [MEDICATION NAME], a medication used to treat secondary elevated [MEDICAL CONDITION] (a gland that makes the hormone which plays a key role in regulating calcium in the blood and bones) and for [MEDICAL CONDITION] with [MEDICAL TREATMENT]. The order read [MEDICATION NAME] 30 mg (milligrams) tablets, give 3 tablets by mouth every day (total daily dose of 90 mg). Facility staff entered the order into the electronic system and a summary of all orders were printed out and signed by physician extender H on 3/16/16. Review of the March 2016 MAR (medication administration record) revealed the resident received the medication as planned on 3/19/16 at 7:00 am with the 17th and 18th not initialed as given. Physician orders [REDACTED]. Review of the interdisciplinary notes dated 3/19/16 revealed the resident admitted to the hospital. Review of the hospital discharge directions signed 3/25/16 revealed the resident received a pacemaker during the hospital stay and treatment of [REDACTED]. The hospital discharge directions included physician progress notes [REDACTED]. The physician progress notes [REDACTED]. One of the medications listed was [MEDICATION NAME] 30 mg tablet give 3 tablets by mouth three times a day, rather than once daily as ordered prior to hospitalization . Review of the resident's electronic medications orders revealed the orders were entered by a licensed nurse into the nursing home's electronic system from the hospital discharge directions. The orders were reviewed by a second licensed nurse and both signed the document to indicate both had checked for accuracy of the transcription of the orders. Neither nurse called the physician to clarify and confirm the [MEDICATION NAME] previously ordered 1 time a day should now be given 3 times a day with meals (a total daily dose increase of 180 mg which was triple what he/she received prior to hospitalization ). Review of the March 2016 MAR (medication administration record) revealed staff circled their initials for administration times of 3/25/16 at 7:00pm, 3/26/16 at 7:00 am and 12:00 pm without indications of why the medication was not given. The record indicated the resident received 1 dose on 3/26/16 at 7:00 pm, on 3/27/16 all 3 dose times were initialed as given and on 3/28/16 staff initialed the 7:00 am and 12:00 pm doses as given. An interview with the resident on 4/28/16 at 8:00 am revealed he/she questioned the nurse about the dosage on 3/28/16 and the nurse called the physician to clarify the order. Review of the orders revealed a telephone order on 3/28/16 to change the [MEDICATION NAME] to 90 mg one time a day. Review of the March 2016 MAR revealed a handwritten transcribed order dated 3/28/16 which directed staff to start [MEDICATION NAME] 90 mg once daily and planned the first dose for 3/29/16 at 7:00 am. Review of a nurse note revealed on 3/28/16 a nurse received a call from the facility front desk about supper time stating the resident was at the front desk and stated he/she felt like he/she was passing out. The nurse went to the resident and performed an assessment noting his/her blood sugar to be 92 (within normal range of 70-100). The resident started vomiting large amounts of fluid. The resident was oriented to person but stated he/she could not see and did not know where to go. The nurse called the physician on call and received orders to transport the resident to the emergency room and the resident left the facility by emergency medical services at 5:50 pm. Later notes reflected the resident admitted to the hospital. Review of the hospital lab report dated 3/28/16 revealed the resident's Creatinine level measured critically high at 6.18 mg/dl (milligrams per deciliter) with a range of 0.72-1.25 mg/dl as normal and his/her calcium level measured low at 7.3 mg/dl with a range of 9.9-10.5 mg/dl as normal. Review of the physician progress notes [REDACTED]. The note indicated the physician's nurse practitioner called the physician who managed the resident's kidney function to clarify the orders and discuss the resident's condition. The note identified the resident's calcium level as low and [MEDICATION NAME] needed to be decreased to 90 mg daily per renal orders. Review of hospital directions and inter-agency transfer record signed by a physician on 3/31/16 revealed re-admission orders [REDACTED]. The orders included [MEDICATION NAME] 30 mg tablets give 3 tablets by mouth every day (a total dose of 90 mg daily). Review of the printed summary of the physician's orders [REDACTED]., even though the hospital directions had the ordered dose listed as 90 mg daily. Review of the March 2016 MAR revealed the resident received [MEDICATION NAME] 90 mg tablet at 7:00 pm on 3/31/16. The April 2016 MAR included the same order and staff circled their initials for all 3 doses on 4/1/16, on 4/2/16 circled 7:00 am and 12:00 pm dose with initials for the 7:00 pm dose. The April 2016 MAR reflected the resident received 3 doses of 90 mg on 4/3/16 and 1 dose the morning of 4/4/16 before staff contacted the physician. The standard of practice regarding medication administration included the person administering the medication should initial the resident ' s record to indicate the medication was administered. If the medication was not administered the initials should be circled and a reason recorded. Review of a nurse note dated 4/4/16 at 4:18 pm revealed the off-going nurse informed him/her in report of the resident's concerns about his/her dosage of [MEDICATION NAME] as being too much. The nurse indicated he/she reviewed the orders and MAR to find an entry for [MEDICATION NAME] as 90 mg 3 times a day. The nurse called the physician to clarify and received orders for the [MEDICATION NAME] to be 90 mg daily. The nurse indicated he/she corrected the order, updated the MAR and notified the director of nursing of the medication error. On 4/27/16 at 5:30 pm observation revealed the resident sat in an electric wheelchair at the table in the dining room eating independently. On 4/28/16 at 8:00 am observation revealed the resident sat in his/her room in the electric wheelchair packing up some items. The resident said he/she was getting ready to leave for [MEDICAL TREATMENT]. Interview with the resident on 4/28/16 at 8:00 am revealed he/she had concerns about his/her medications. The resident reported when he/she first came to the facility he/she took [MEDICATION NAME] 90 mg once a day. He/she went to the hospital and had a pacemaker put in and when he/she came back the nurses started giving him/her the medication 3 times a day. The resident said he/she took a few doses of it then his/her family member called the kidney doctor and then called the facility and got it fixed. Later that day he/she did not feel well and went to the hospital by ambulance and stayed there for 3 days. The resident said his/her mind wasn't right, he/she had difficulty with movement, had trouble seeing, and could only detect light. Then he/she went back in the hospital and when he/she came back to the facility the nurses got his/her medicine messed up again. The resident said he/she planned to discharge soon to another facility because of the medication errors. Interview with administrative nurse D on 4/28/16 at 10:00 am confirmed he/she had entered the orders into the facility's electronic system on 3/25/16 as written on the re-admission orders [REDACTED]. Interview with licensed nurse A on 4/28/16 at 1:30 pm revealed he/she had entered the re-admission orders [REDACTED]. Nurse A did not know why he/she entered the [MEDICATION NAME] order as 3 times day when the admitting orders clearly said once a day. Nurse A reported he/she received retraining on order transcription and putting orders into the electronic system after the medication error occurred. Interview with licensed nurse B on 5/10/16 at 2:41 pm confirmed he/she reviewed/compared the orders entered into the facility's system to the admitting orders for the resident. Nurse B said he/she just missed the difference of 3 times a day versus daily on the [MEDICATION NAME]. Nurse B reported he/she followed standard procedures for verifying the orders and received verbal education/re-training on the procedures for order entry after the medication error occurred to prevent a mistake from happening again. Interview with administrative nurse staff C on 4/28/16 at 10:00 am revealed he/she was aware of the 2 medication errors regarding the [MEDICATION NAME] for this resident and had not investigated it. Interview with physician extender H on 5/10/16 at 11:20 am revealed the discharge instructions from the hospital included typed medication orders, laboratory results, prior medical record summaries and all were reviewed by the physician and signed electronically. These documents were to be considered as orders. Physician extender H confirmed staff discovered the medication error on 3/28/16 and orders were given by phone at that time to decrease the [MEDICATION NAME] to once daily. Review of the physician desk reference (PDR) revealed the medication [MEDICATION NAME] came in 30 mg, 60 mg and 90 mg tablets and should only be increased gradually every 2-4 weeks through sequential doses. If serum calcium (a test for calcium in the blood and not stored in the bones) fell below 7.5 mg/dl, or if [DIAGNOSES REDACTED] symptoms (muscle weakness/cramps, fatigue, sensations of pins and needles) persisted hold administrations until calcium levels reached 8.0 mg/dl or [DIAGNOSES REDACTED] symptoms resolved. Patient counseling included to report to a physician if nausea/vomiting and potential symptoms of [DIAGNOSES REDACTED] occur. A request was made to the facility on [DATE] for policies regarding processing physician orders [REDACTED]. The facility provided 5 different policies (Physician orders [REDACTED]. The facility failed to ensure staff transcribed orders correctly, clarified new orders when there was a drastic change and failed to ensure staff administered medications as ordered to ensure resident #3 was free of significant medication errors.

The facility census totaled 113 residents with 3 residents sampled for medication review. Based on observation, interview and record review the facility failed to ensure staff transcribed orders correctly, clarified new orders when there was a drastic change and failed to ensure staff administered medications as ordered to ensure residents were free of any significant medication errors for 1 of 3 residents (#3). Resident #3 required hospitalization with a low calcium level after receiving triple his/her regular dose of [MEDICATION NAME] (a medication used to treat secondary elevated [MEDICAL CONDITION] (a gland that makes the hormone which plays a key role in regulating calcium in the blood and bones). Findings included: - Review of resident #3's POS (physician's orders [REDACTED]. Review of the admission MDS (minimum data set) dated 4/7/16 revealed a BIMS (brief interview for mental status) score of 15, indicating intact cognition with no behaviors. The resident required limited assistance for bed mobility and transfers. The resident received an anticoagulant 6 out of the 7 days of the observation period. Review of the ADL (activities of daily living) CAA (care area assessment) dated 4/13/16 revealed the resident admitted following a hospital stay for a new arteriovenous fistula (a surgically created connection between an artery and vein) to receive [MEDICAL TREATMENT] (is a life-support treatment that uses a special machine to filter harmful wastes, salt, and excess fluid from the blood) treatments. The resident required staff assistance with all ADLs except eating due to weakness related to [MEDICAL CONDITION] (too much calcium in the blood) and both legs had [MEDICAL CONDITION]. Review of the ADL care plan dated 4/21/16 revealed the resident had a self-care deficit related to bilateral (both sides) lower extremity amputations. The care plan directed staff to: provide task segmentation, set-up help with ADLs but to let the resident perform what he/she could, allow extra time for resident self-performance due to weakness and fatigue, and administer medications, labs and treatments as ordered. Review of the physician orders [REDACTED]. The orders included [MEDICATION NAME], a medication used to treat secondary elevated [MEDICAL CONDITION] (a gland that makes the hormone which plays a key role in regulating calcium in the blood and bones) and for [MEDICAL CONDITION] with [MEDICAL TREATMENT]. The order read [MEDICATION NAME] 30 mg (milligrams) tablets, give 3 tablets by mouth every day (total daily dose of 90 mg). Facility staff entered the order into the electronic system and a summary of all orders were printed out and signed by physician extender H on 3/16/16. Review of the March 2016 MAR (medication administration record) revealed the resident received the medication as planned on 3/19/16 at 7:00 am with the 17th and 18th not initialed as given. Physician orders [REDACTED]. Review of the interdisciplinary notes dated 3/19/16 revealed the resident admitted to the hospital. Review of the hospital discharge directions signed 3/25/16 revealed the resident received a pacemaker during the hospital stay and treatment of [REDACTED]. The hospital discharge directions included physician progress notes [REDACTED]. The physician progress notes [REDACTED]. One of the medications listed was [MEDICATION NAME] 30 mg tablet give 3 tablets by mouth three times a day, rather than once daily as ordered prior to hospitalization . Review of the resident's electronic medications orders revealed the orders were entered by a licensed nurse into the nursing home's electronic system from the hospital discharge directions. The orders were reviewed by a second licensed nurse and both signed the document to indicate both had checked for accuracy of the transcription of the orders. Neither nurse called the physician to clarify and confirm the [MEDICATION NAME] previously ordered 1 time a day should now be given 3 times a day with meals (a total daily dose increase of 180 mg which was triple what he/she received prior to hospitalization ). Review of the March 2016 MAR (medication administration record) revealed staff circled their initials for administration times of 3/25/16 at 7:00pm, 3/26/16 at 7:00 am and 12:00 pm without indications of why the medication was not given. The record indicated the resident received 1 dose on 3/26/16 at 7:00 pm, on 3/27/16 all 3 dose times were initialed as given and on 3/28/16 staff initialed the 7:00 am and 12:00 pm doses as given. An interview with the resident on 4/28/16 at 8:00 am revealed he/she questioned the nurse about the dosage on 3/28/16 and the nurse called the physician to clarify the order. Review of the orders revealed a telephone order on 3/28/16 to change the [MEDICATION NAME] to 90 mg one time a day. Review of the March 2016 MAR revealed a handwritten transcribed order dated 3/28/16 which directed staff to start [MEDICATION NAME] 90 mg once daily and planned the first dose for 3/29/16 at 7:00 am. Review of a nurse note revealed on 3/28/16 a nurse received a call from the facility front desk about supper time stating the resident was at the front desk and stated he/she felt like he/she was passing out. The nurse went to the resident and performed an assessment noting his/her blood sugar to be 92 (within normal range of 70-100). The resident started vomiting large amounts of fluid. The resident was oriented to person but stated he/she could not see and did not know where to go. The nurse called the physician on call and received orders to transport the resident to the emergency room and the resident left the facility by emergency medical services at 5:50 pm. Later notes reflected the resident admitted to the hospital. Review of the hospital lab report dated 3/28/16 revealed the resident's Creatinine level measured critically high at 6.18 mg/dl (milligrams per deciliter) with a range of 0.72-1.25 mg/dl as normal and his/her calcium level measured low at 7.3 mg/dl with a range of 9.9-10.5 mg/dl as normal. Review of the physician progress notes [REDACTED]. The note indicated the physician's nurse practitioner called the physician who managed the resident's kidney function to clarify the orders and discuss the resident's condition. The note identified the resident's calcium level as low and [MEDICATION NAME] needed to be decreased to 90 mg daily per renal orders. Review of hospital directions and inter-agency transfer record signed by a physician on 3/31/16 revealed re-admission orders [REDACTED]. The orders included [MEDICATION NAME] 30 mg tablets give 3 tablets by mouth every day (a total dose of 90 mg daily). Review of the printed summary of the physician's orders [REDACTED]., even though the hospital directions had the ordered dose listed as 90 mg daily. Review of the March 2016 MAR revealed the resident received [MEDICATION NAME] 90 mg tablet at 7:00 pm on 3/31/16. The April 2016 MAR included the same order and staff circled their initials for all 3 doses on 4/1/16, on 4/2/16 circled 7:00 am and 12:00 pm dose with initials for the 7:00 pm dose. The April 2016 MAR reflected the resident received 3 doses of 90 mg on 4/3/16 and 1 dose the morning of 4/4/16 before staff contacted the physician. The standard of practice regarding medication administration included the person administering the medication should initial the resident ' s record to indicate the medication was administered. If the medication was not administered the initials should be circled and a reason recorded. Review of a nurse note dated 4/4/16 at 4:18 pm revealed the off-going nurse informed him/her in report of the resident's concerns about his/her dosage of [MEDICATION NAME] as being too much. The nurse indicated he/she reviewed the orders and MAR to find an entry for [MEDICATION NAME] as 90 mg 3 times a day. The nurse called the physician to clarify and received orders for the [MEDICATION NAME] to be 90 mg daily. The nurse indicated he/she corrected the order, updated the MAR and notified the director of nursing of the medication error. On 4/27/16 at 5:30 pm observation revealed the resident sat in an electric wheelchair at the table in the dining room eating independently. On 4/28/16 at 8:00 am observation revealed the resident sat in his/her room in the electric wheelchair packing up some items. The resident said he/she was getting ready to leave for [MEDICAL TREATMENT]. Interview with the resident on 4/28/16 at 8:00 am revealed he/she had concerns about his/her medications. The resident reported when he/she first came to the facility he/she took [MEDICATION NAME] 90 mg once a day. He/she went to the hospital and had a pacemaker put in and when he/she came back the nurses started giving him/her the medication 3 times a day. The resident said he/she took a few doses of it then his/her family member called the kidney doctor and then called the facility and got it fixed. Later that day he/she did not feel well and went to the hospital by ambulance and stayed there for 3 days. The resident said his/her mind wasn't right, he/she had difficulty with movement, had trouble seeing, and could only detect light. Then he/she went back in the hospital and when he/she came back to the facility the nurses got his/her medicine messed up again. The resident said he/she planned to discharge soon to another facility because of the medication errors. Interview with administrative nurse D on 4/28/16 at 10:00 am confirmed he/she had entered the orders into the facility's electronic system on 3/25/16 as written on the re-admission orders [REDACTED]. Interview with licensed nurse A on 4/28/16 at 1:30 pm revealed he/she had entered the re-admission orders [REDACTED]. Nurse A did not know why he/she entered the [MEDICATION NAME] order as 3 times day when the admitting orders clearly said once a day. Nurse A reported he/she received retraining on order transcription and putting orders into the electronic system after the medication error occurred. Interview with licensed nurse B on 5/10/16 at 2:41 pm confirmed he/she reviewed/compared the orders entered into the facility's system to the admitting orders for the resident. Nurse B said he/she just missed the difference of 3 times a day versus daily on the [MEDICATION NAME]. Nurse B reported he/she followed standard procedures for verifying the orders and received verbal education/re-training on the procedures for order entry after the medication error occurred to prevent a mistake from happening again. Interview with administrative nurse staff C on 4/28/16 at 10:00 am revealed he/she was aware of the 2 medication errors regarding the [MEDICATION NAME] for this resident and had not investigated it. Interview with physician extender H on 5/10/16 at 11:20 am revealed the discharge instructions from the hospital included typed medication orders, laboratory results, prior medical record summaries and all were reviewed by the physician and signed electronically. These documents were to be considered as orders. Physician extender H confirmed staff discovered the medication error on 3/28/16 and orders were given by phone at that time to decrease the [MEDICATION NAME] to once daily. Review of the physician desk reference (PDR) revealed the medication [MEDICATION NAME] came in 30 mg, 60 mg and 90 mg tablets and should only be increased gradually every 2-4 weeks through sequential doses. If serum calcium (a test for calcium in the blood and not stored in the bones) fell below 7.5 mg/dl, or if [DIAGNOSES REDACTED] symptoms (muscle weakness/cramps, fatigue, sensations of pins and needles) persisted hold administrations until calcium levels reached 8.0 mg/dl or [DIAGNOSES REDACTED] symptoms resolved. Patient counseling included to report to a physician if nausea/vomiting and potential symptoms of [DIAGNOSES REDACTED] occur. A request was made to the facility on [DATE] for policies regarding processing physician orders [REDACTED]. The facility provided 5 different policies (Physician orders [REDACTED]. The facility failed to ensure staff transcribed orders correctly, clarified new orders when there was a drastic change and failed to ensure staff administered medications as ordered to ensure resident #3 was free of significant medication errors.

The facility census totaled 117 residents with 26 included in the sample. The sample included the review of 4 residents with pressure ulcers. Based on observation, interview, and record review, the facility failed to provide the services to heal existing pressure ulcers and prevent new ones in developing for 4 of 4 sampled residents. (#21, #58, #235,#293 ) Resident #21 developed blisters on both heels and resident #58 developed additional open area on the left toe. Resident #235 developed an open area to the coccyx and resident #293 developed a recurring open area to the coccyx. Findings included: - Review of the physician's orders [REDACTED].#21 had the following Diagnoses: [REDACTED]. Review of the facility's Initial Data Collection Tool, completed when the resident moved into the facility and dated 5/10/13, identified both of the resident's heels as reddened, wore heel protectors, and with Stage 2 open areas on the resident's buttocks due to a yeast infection. Review of the admission MDS (Minimum Data Set-a required assessment) dated 5/17/13 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15 (indicated the resident had little to no cognitive impairment), required extensive assist of one staff member for bed mobility, transfers, toilet use, personal hygiene, with occasional urinary incontinence, incontinence of bowel, at risk for developing pressure ulcers and had unhealed pressure ulcers. The assessment identified the resident had 1 stage 1 (red, but not open) pressure ulcer, and 1 stage 2 (open) pressure ulcer that was present on admission, the assessment identified the most severe pressure ulcer had granulation tissue, and the staff provided a pressure relieving mattress device for the chair and bed and pressure ulcer care. Review of the comprehensive care plan for impaired skin integrity; with an onset date of 5/10/13 identified the resident had an open area to a heel. The care plan directed staff to complete Braden scale risk assessment quarterly and PRN (as needed), complete skin assessment, educate resident/responsible party about skin condition, inspect skin during bathing, especially over bony prominences, observe for pain and medicate PRN per physician orders, observe for signs/symptoms of infections or delayed healing and report to physician PRN regarding any redness ([DIAGNOSES REDACTED]), drainage-purulent (producing or containing pus) or bloody, provide diet as ordered and observe nutritional status and dietary needs consult dietitian, provide incontinent care PRN apply barrier cream PRN, refer to therapy as needed, report changes in skin status to physician. Wound care as ordered by licensed nurse, cream to buttocks and off load heels, observe effectiveness of and response to treatment as ordered. The care plan failed to identify the causal factors of the development of the open area on the heel, which heel had the open area or specific intervention(s) to offload the heels. Review of the telephone order dated 5/10/13 revealed an order for [REDACTED]. The order also directed staff to turn the resident every 2 hours and PRN. Review of a physician note, dated 5/13/13 identified the red area on the resident right heel was now a blister. A telephone order by the physician dated 5/13/13 instructed staff to keep the right heel off the bed with pillows and do no place a boot to the right foot. Staff failed to identify on the care plan the blister on the right heel or develop interventions to prevent it from becoming worse and promote healing. Review of the physician's progress note, dated 5/20/13, identified the blister to the right heel "now dry" and "appears to be healing". Review of the physician's progress note, dated 5/22/13 identified blister to right heel dry. Review of the physician's progress note, dated 5/24/13 identified the resident had a blister to the right heel and denied pain. The note also identified left heel with dry blister not boggy. Blister to right heel not dry, appears to be healing, Keep up off bed, hold boot to right leg (the care plan and record lacked indication that staff used boots to keep the heels off the bed) and keep up off bed. Staff failed to update the care plan to identify the blister to the left heel, or develop new interventions to prevent it from becoming worse and promote healing. Review of the physician's progress note, dated 5/29/13 revealed left heel with dry blister, not boggy, no induration noted. Blister to right heel dry, appears to be healing, no signs of infections. Keep up off bed, hold boot to right leg and keep off bed. Review of a physician's progress note, dated 5/31/13 revealed the resident's skin was assessed with [REDACTED]. The left heel with dry blister, not boggy- no changes no indurations noted. Blister to right heel blister dry, appears to be healing no signs of infections keep up off bed, hold boot to right leg and keep up off bed. Review of the physician progress notes [REDACTED]." The notes failed to address the resident's heels. Review of the review of the May 2013 Treatment Administration Record (TAR) revealed the following: air mattress due to [DIAGNOSES REDACTED]. There were no specific interventions to address the resident's heels to promote healing. Review of the weekly Skin Integrity Data Collection sheet dated 5/18/13 revealed staff identified the resident's inner aspect of the right heel had a blister. The assessment lacked measurements. Review of the next weekly Skin Integrity Data Collection sheet, dated 6/1/13 and conducted by staff, lacked any information or measurements for the blisters on the resident's heels. On 7/23/13 at 4:08 p.m., Administrative nurses A and N identified the resident only had Stage 2 pressure areas on his/her buttocks. Nurse A stated the charge nurse that identified the open areas on the resident's buttocks was wrong, the physician identified the open areas were due to a yeast infection. Nurse A confirmed the record lacked any measurements of the resident's heels. On 7/30/13 at 1:04 p.m., Licensed nurse BB identified the resident had a pressure relieving mattress and medicated cream to the buttocks, but did not remember the resident having any areas to the heels. Staff BB identified that on the initial skin assessment impairments are identified and then assessments of those areas were to be done weekly. Staff BB stated that the unit manager was responsible for measuring the skin impairments. On 7/30/13 at 1:28 p.m., Administrative Nurse N identified the facility monitored and measured all wounds, including blisters, on a weekly basis. Administrative nurse N identified the resident's record lacked measurements for the resident's blisters because the resident's heels never had blisters on them when he/she looked at the resident's skin. On 7/30/13 at 1:42 p.m., Advanced Practice Registered Nurse RR revealed that he/she could not remember an issue to the resident's heels. Staff RR remembered the resident had a yeast infection to the buttocks but did not remember blisters to the heels. If the resident did develop blisters to the heels, he/she expected to be notified by the staff and expected the staff to measure the areas so he/she could monitor for changes in the wound including the wounds getting larger or showing improvement. Review of the facility's policy on Post-admission Weekly Skin Assessments revealed the following: A complete assessment is essential to an effective pressure ulcer prevention and treatment program. A comprehensive individual evaluation helps the facility to identify the resident at risk of developing pressure ulcers, the level and nature of risks, and the presence of pressure ulcers. 1) On a weekly basis, a licensed professional completes a skin assessment of the resident. 2) The skin is observed for pressure damage caused by medical devices (e.g., catheters, oxygen tubing, cervical collars, etc.). 3) The results of the skin assessment are documented on the Weekly Skin Integrity Data Collection form. The facility failed to provide the necessary services to ensure a resident with impaired skin integrity did not develop pressure ulcers unless unavoidable. The resident developed blisters on both heels. - Review of resident #58's face sheet located in the resident's closed record, revealed an admission date of [DATE]. Review of the physician's orders [REDACTED]. Review of the resident's admission MDS (Minimum Data Set-a required assessment) dated 5/15/13 identified the resident had a BIMS (Brief Interview for Mental Status) score of 15/15 (indicating the resident had little to no cognitive impairment), required extensive assist of two staff for bed mobility, toilet use, required extensive assist of one staff member for locomotion, dressing, personal hygiene, set up help and supervision with eating, and dependent on two staff for transfers. The resident was continent of bowel and bladder, at risk for pressure ulcers, coded as having 1 unstageable pressure ulcer that was present upon admission, with a measurement of 6.0 cm (centimeters) in length, 7.0 cm in width and with necrotic (dead) tissue, as well as a surgical wound. The staff provided a pressure reducing device to the chair and bed, pressure ulcer care, surgical wound care and applications of dressings to feet. Review of the resident's ADL (Activities of Daily Living) CAA (Care Area Assessment) dated 5/21/13 revealed the resident was non-complaint with care, alert and oriented, able to make needs known. The CAA identified the resident had appropriate insight, mood, affect, memory and judgment, the resident decided what he/she wants to do and when. His/her participation in therapy was limited by his/her choice, attended [MEDICAL TREATMENT] three times weekly and chose to stay in his/her room often. Review of the Urinary Incontinence CAA dated 5/21/13 revealed the resident's mobility was restricted related to NWB (Non-Weight Bearing) status to right lower extremity and amputation, the resident used a urinal independently and requested bed pan for bowels. Review of the Pressure Ulcer CAA, dated 5/21/13, revealed the staff altered resident's diet to promote wound healing to include prostat (a dietary protein supplement) 30 ml (milliliters) three times a day, nepro (a dietary protein supplement) 240 ml daily, large meal portions with all meals, and double egg portions at breakfast. Staff identified the resident as non-compliant, did not attempt to self-transfer, and was alert and oriented and able to make his /her needs known. The resident decided what to do and when. Review of the resident's care plan dated 5/8/13 revealed the resident had a non-healing wound to the right lower extremity resulting in [MEDICAL CONDITION]. The care plan identified the resident had a lower extremity wound due to [MEDICAL CONDITIONS] on the left foot. The care plan directed the staff to complete Braden scale risk assessment quarterly and PRN (as needed), complete weekly skin assessments, education resident/responsible party about skin condition and treatment, inspect skin during bathing especially over bony prominences, observe for pain and medicate PRN per physician orders, observe for signs and symptoms of infections or delayed healing and report to physician PRN including redness/[DIAGNOSES REDACTED], drainage-purulent or bloody, separation of incision on the right extremity, provide diet as ordered and supplements as ordered and observe nutritional status and dietary needs. Consult dietician PRN, refer to therapy as needed, report changes in skin status to physician. Wound care as ordered coordinate with wound clinic as indicated, physician orders [REDACTED]. Review of the resident's Weekly Skin Integrity Data Collection sheet, started when the resident admitted to the facility and dated 5/8/13 revealed the staff documented the resident's skin as dry, with bruises, an open area with notation of a surgical site on the right leg [MEDICAL CONDITION] and right hand abrasion. Staff made a notation on a body graph of the resident's left leg that identified an ace wrap dressing was on the resident's left leg from knee to toes. Staff removed the dressing to view the left leg and documented the resident's leg had dry skin, with bruises, an open area with a notation of black escar (scab-like material). The notation also identified the resident's left heel and bottom of the foot as black. Staff documented the resident had an open area "approximately 3 cm (centimeters) in diameter on bottom of foot and amputation surgical site Right bka ([MEDICAL CONDITION])." Review of the resident's Weekly Skin Integrity Data Collection sheet, dated 5/18/13 revealed the staff documented the resident's left foot as dry, dark skin tone, with an open area on foot, black with drainage. The graph that staff documented on revealed staff identified an area to the outer aspect of the left foot including the small toe as black and the heel and side of foot black and open. The assessment lacked measurements of the size of the open areas or black areas to monitor for increases in size. The care plan lacked specifics to what the staff were doing to protect and heal the resident's skin. Review of the resident's Weekly Skin Integrity Data Collection sheet, dated 5/24/13 revealed staff identified the resident's skin as dry, with dark skin tone, an open area on foot and heel. Staff documented on the graph the small toe and outer aspect of the foot as black and open, and the heel black and open. The assessment lacked measurements. Review of the resident's Weekly Skin Integrity Data Collection sheet, dated 5/31/13 identified the resident's skin as dry, dark skin tone with an area of old, black hard sore to left heel. Staff documented on the graph the resident's left heel had a black hard sore and outer area of left foot with a black, open area with bloody red drainage. The assessment lacked measurements or if they notified the physician. Review of the resident's Weekly Skin Integrity Data Collection sheet, dated 6/8/13 identified the resident's skin as dry, with dark skin tone, open area to the skin. The assessment lacked measurements. Review of the resident's Weekly Skin Integrity Data Collection sheet, dated 6/14/13 identified the resident's skin as dry, with dark skin tone, an open area to the left inner foot, as well as a newly developed open area by the resident's big toe. The assessment lacked measurements, or if the physician was notified of the resident's new open area. Review of the resident's Weekly Skin Integrity Data Collection sheet, dated 6/21/13 identified the resident's skin as dry, with dark skin tone, open areas were "old", left inner aspect of area by big toe open, heel black. Review of the resident's Weekly Skin Integrity Data Collection sheet, dated 6/30/13 identified the resident's skin as dry, dark skin tone, left foot marked with heel black and left outer aspect of foot by big toe as open. On 7/7/13 on the resident's Weekly Skin Integrity Data Collection sheet, staff marked on the graph the open area to the resident's left heel and the outer aspect of the left big toe area. On 7/14/13 on the resident's Weekly Skin Integrity Data Collection sheet, staff assessed the resident's skin as dry, dark skin tone, an open area on the left heel and outer aspect of the big toe. Review of the resident's physician order [REDACTED]. Review of a Wound Center progress note, dated 6/12/13 revealed measurements of the resident's left heel 5.5cm (length) x 5.0cm (width) in size, identified the area as dry with eschar (dead skin). The assessment was marked not debrided (dead skin removed), delayed healing (pressure). The progress note identified the area as wound #2. The staff coded the left lateral foot as wound #3 and assessed the area as 3cm x 2.6cm x 0.8cm (depth) and described the area as soft and mushy. The wound clinic referred to the area as a "possible deep tissue injury." The progress note had hand written notations next to wound #2 as "pressure." The facility provided assessments by the Wound Center on progress notes dated 6/19, 6/21, 7/12, and 7/26. While the assessments documented the resident resisted care, the facility failed to update the care plan to reflect what interventions were attempted and refused, as well as what education the facility provided to the resident regarding the impaired skin issues and how best to heal the open areas. Review of the physician's progress note dated 7/8/13 revealed the pressure sore on the lateral side of the left foot with exposed bone, but had good granulation (healing tissue). On 7/30/13 at 12:23 p.m., direct care staff F remembered the resident needed assistance with toileting, would call for assistance with transfers to bed side commode, the resident would call when he/she had questions about his/her dressing, and that he/she directed the nurses on how to change the dressing instead of following the doctors ' orders. On 7/30/13 at 1:29 p.m. Administrative Nurse C revealed the facility's expectation included for staff were to measure an open wound during wound rounds that are done weekly by the unit managers. On 7/30/13 at 5:15 p.m. Administrative Nurse A revealed nurses were to do a complete head to toe body assessment on all residents upon admission or readmission. Nurse A expected the staff to notify the physician of any changes in the wound such as redness that opened up or any area that increased in size. Nurse A stated that he/she would expect the nurses to measure an area that is open weekly during wound rounds to monitor for healing or to monitor the wound for need for change in treatment or increase in size. On 7/30/13 at 1:42 p.m., Advanced Practice Registered Nurse RR revealed staff RR had taken care of the resident several times. Staff RR described the black areas on the resident's left foot were related to skin grafts and that it remained unchanged from admission to admission. The resident was very difficult to work with and did not allow the staff to assess the open areas. Staff RR was unaware of any breakdown to the lateral aspect of the left foot that opened and exposed a tendon or bone and revealed the resident was seen by the wound clinic. Staff RR was unable to recall the resident having any wounds like that, and that he/she expected that the staff should have measured any area that opened to monitor for worsening or improvement in the wounds and they would have expected to be notified of any changes in the wound. Review of the facility's policy on Assessment and Monitoring of Healing (Wounds) dated 10/7/10 revealed the following: Pressure ulcers are assessed and monitored once a week to determine if the treatment plan is working or should be re-evaluated. Frequency of monitoring may be indicated for residents who area at risk for complications (such as infection) secondary to impaired skin or tissue integrity (e.g., residents who are immunosuppressed or who have a poor nutritional status, diabetes mellitus, or coagulation disorders). In addition, if bone or tendon is exposed, if a resident has an infected wound, or if a wound cannot be assess (i.e., it is covered with necrotic tissue), the wounds are monitored and assessed with [REDACTED]. With each dressing change the pressure ulcer is observed for developments that may indicate the need for change in treatments such as: Wound deterioration or improvement, more or less exudate, signs of infection. The facility failed to adequately monitor a resident with an open pressure ulcer on the left foot by including measurements of the open areas and developing new interventions as well as educating a resident that was non-compliant with care. The resident developed new open areas by the big toe. - Review of resident # 293's signed physician orders [REDACTED]. Findings included: - Review of the admission MDS (minimum data set) dated 7/1/13 revealed a BIMS (brief interview for mental status) score of 11 indicating moderate cognitive impairment. The resident required extensive assistance of two with bed mobility, and extensive assistance of one staff for transfers, ambulation, locomotion, dressing, toilet use and personal hygiene. The resident was occasionally incontinent of urine. The resident was at risk for breakdown though no pressure ulcers identified on the assessment. The resident received skilled rehabilitation (physical and occupational therapy) 5x weekly with plans to return home when able. Review of the CAA (care area assessment) dated 7/1/13 failed to trigger for pressure ulcers. Review of the interim care plan with a date of 6/24/13 revealed the resident was at risk for skin breakdown with a reddened area on the coccyx. Approaches included monitor the red area on coccyx and follow/up treatment as needed. Review of the comprehensive care plan dated 7/15/13 revealed the resident was at risk for skin breakdown. Approaches included monitoring skin with pericare and bathing for redness, complete weekly skin assessment by licensed nurse. The care plan failed to identify a pressure ulcer or treatment for [REDACTED]. Review of the Initial Data Collection Tool identified the resident as having a stage I pressure area to the coccyx. Review of the treatment record revealed the resident received a [MEDICATION NAME] (a wound dressing)dressing to the coccyx every 3 days and monitor placement of the dressing daily and an order for [REDACTED]. Review of the pressure ulcer prevention check list revealed the resident had a pressure reducing mattress. No chair cushion listed. Review of the admission nurses notes dated 6/25/13 revealed coccyx is red, blanches poorly with a 0.2cm (centimeters) center that does not blanche. Review of the Pressure ulcer status record provided on 7/30/13 by administrative nurse N included the following stages and measurements: On 6/24/13 the pressure ulcer was a stage 3 (full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed) with the measurements of 0.7cm x 0.6 cm on the coccyx. An entry on 6/27/13 staff staged the pressure ulcer on coccyx as a stage 3 measuring 0.7 cm x 0.6 cm with no depth, drainage or odor. Dietary and physician notified by administrative nurse N. An entry on 7/3/13 staged the pressure ulcer on coccyx as a stage 3 measuring 0.7cm x 0.1cm and had no depth, drainage or odor. Measurements on 7/8/13 showed the area as closed with no measurements. On 7/15/13 the area closed with no measurements. On 7/22/13 the pressure ulcer had reopened and now staged a stage 2 with measurements 0.7 cmx 0.4 cm with no depth with dietary and physician notified by nurse N. The staff failed to revise the care plan to reflect this change. Review of the progress notes dated 6/27/13 and 7/22/13 failed to document that dietary or the physician notified regarding the pressure ulcer. Review of the physician orders [REDACTED]. Review of the Nutrition Data Collection/assessment done on admission revealed the resident was to receive a regular diet and Ensure (high protein supplement drink) twice daily and a history of taking 50-75% of meals since admission. The resident complained of poor fitting dentures though declined relining or dental exam stating he/she would just wait till he/she went home. The resident had meat ground or chopped. Observation on 7/24/13 at 8:30 a.m. revealed the resident sat at a dining table in a regular dining chair. The resident ate from a plate of scrambled eggs, biscuit and sausage patty sandwich. Fluids included orange juice water and a cup of coffee. The chair had no cushion in place. Observation on 7/24/13 at 4:04 p.m. revealed the resident sat in a wheelchair in her room visiting with visitors and no cushion noted in the chair. During an interview on 7/29/13 at 4:15 p.m. direct care staff I reported the resident did a lot for him/herself and took him/herself to the toilet and dressed him/herself most of the time. The resident had some kind of sore on his/her bottom but wasn't sure what. If the resident needed the area treated he/she would just call the nurse to come down. If the resident sat in his/her wheelchair there was some sort of cushion in it but did not use the wheelchair that often he/she sat in his/her chair in the room. During an interview on 7/30/13 at 9:20 a.m. direct care staff L reported the resident would walk to the dining room and then back to his/her room and sit in the chair. Staff would remind the resident to shift positions when the resident sat in the chair. No cushions used in the resident ' s chair. During an interview on 7/24/13 at 11:00 a.m. licensed nurse N reported the resident had an area on his/her coccyx that opened and closed. The resident was thin and nurses kept a [MEDICATION NAME] (wound dressing)pad over the area. No other treatment done that nurse N knew of. On 7/29/30 at 1:30 p.m. licensed nurse J reported the resident had a small spot on the coccyx when he/she came in. The nurse thought the staff put some kind of lotion on the resident but not on the pressure area. That area had a dressing on it. Review of the undated facility policy named Post-admission Weekly Skin Assessments revealed: On a weekly basis, a licensed professional completes a skin assessment of the resident. The results of the skin assessment were documented on the Weekly Skin Integrity Data Collection form. Review of the policy named Treatment Orders- revised on 10/7/10 revealed: Procedure 1. After observation/evaluation of the affected skin area, the physician is notified. 3. The physician orders [REDACTED]. 5. The treatment is documented on the Treatment Administration Record. Review of the policy named Assessment and Monitoring of Healing with a revision date of 10/7/10 revealed: Purpose; To gather data for the purpose of planning and implementing wound care treatment procedures (nursing care plan). To evaluate outcomes, rational, frequency. Policy: Pressure ulcers are assessed and monitored once a week to determine if the treatment plan is working or needed re-evaluated...With each dressing change, the pressure ulcer is observed for developments that may indicate the need for change in treatment such as: Wound deterioration or improvement, more or less exudate and signs of infection. The physician, resident, and family/caregiver are kept informed of the progress (or lack of progress) towards healing. The facility failed to provide a treatment to the resident to prevent an area of pressure for resident #293 after the area reopened on 7/22/13. - Review of resident #235's signed physician orders [REDACTED].(cancer of the cervix), right groin pseudoaneurysm (a leakage of arterial blood into the surrounding tissues), and [MEDICAL CONDITION] (poor nutrition). Review of the resident's admission MDS (minimum data set) dated 4/18/13 revealed a BIMS (brief interview for mental status) score of 00, indicating severe cognitive impairment. Staff did not complete a Staff Assessment for Mental Status. The resident had total dependence on two or more staff for bed mobility, transfers, toilet use, and bathing and total dependence on one staff for locomotion on and off the unit, dressing, eating, and personal hygiene. Walking did not occur during the lookback period. The resident had a risk of developing pressure ulcers determined by a formal assessment instrument/tool and clinical assessment. It indicated the resident did not have any pressure ulcers. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 10, indicating moderate impairment. The resident needed extensive assistance of one person for bed mobility, transfers, walking, locomotion on or off the unit, dressing, toilet use, and personal hygiene. The resident had a risk of developing pressure ulcers determined by a formal assessment instrument/tool and clinical assessment. It indicated the resident did not have any pressure ulcers. Review of the Pressure Ulcer CAA dated 4/24/13 revealed the resident had an increased risk for pressure ulcers and had an air mattress with bolsters in place to minimize falls with injuries and had been incontinent without urgency. Review of the resident's care plan for Pressure Ulcers dated 4/11/13 revealed the resident had an increased risk for pressure ulcers and directed staff to assist position/shift weight to relieve pressure, avoid prolonged periods of skin to skin contact, complete Braden Scale Risk Assessment quarterly PRN (as needed), complete weekly skin assessment, minimize pressure over bony prominence, notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration noted during bathing or daily care, observe lab results as ordered and report abnormal results to physician, position with pillows to maintain proper body alignment PRN, provide diet as ordered and observe nutritional status and dietary needs, consult dietary PRN, provide incontinence care after incontinence episodes. Apply barrier cream PRN, provide pressure relieving or reduction devices of specialty low air loss mattress and chair cushion, tilt in space chair, refer to therapy for positioning as needed, report skin changes to physician, turning and repositioning program every 2 hours, and use lifting device, draw sheet to reduce friction. The care plan failed to identify the open area to the coccyx identified on 4/23/13 and lacked any additional interventions to promote healing and prevent the worsening of the open area to the coccyx. Review of the resident's care plan reviewed and revised on 6/24/13 revealed "I am totally dependent on staff to provide my cares." The previous interventions remained and staff added "report skin condition changes to the physician" under the pressure ulcer section of the care plan. Review of the Initial Data Collection Tool/Nursing Service dated 4/11/13 revealed the resident had "redness of perianal area". Review of the Braden Scale for Predicting Pressure Sore Risk on 4/11/13 revealed a score of 16 indicating the resident had increased risk. Review of a physician progress notes [REDACTED]. No induration noted." Review of the resident's W

The facility census totaled 120 residents with 5 included in the sample. The sample included the review of 3 residents for issues with impaired skin integrity. Based on observation, interview, and record review, the facility failed to ensure 1 of 3 sampled residents without pressure sores did not develop pressure sores unless unavoidable (#3). The resident developed 2 pressure ulcers on the buttocks. Findings included: - Review of the annual MDS (Minimum Data Set-a required assessment) dated 11/27/12 revealed resident #3 had a BIMS (Brief Interview for Mental Status) score of 11 (indicated moderately impaired cognition), did not exhibit behaviors or refuse care, dependent on two staff for bed mobility, transfers and toileting. The assessment described the resident at risk for developing pressure ulcers and that the resident used a pressure relieving device for the chair and bed, and the staff had placed the resident on a turning and repositioning program. The assessment identified staff had placed the resident on nutritional or hydration interventions to manage the skin problems. Review of the ADL (Activities of Daily Living) CAA (Care Area Assessment-a further assessment) dated 12/12/12 identified the resident as alert and forgetful, but able to make his/her needs known. The CAA also identified the resident required assistance with ADLs. Review of the Urinary Incontinence CAA dated 12/12/12 identified the resident required assistance with ADLs, including toileting. Review of the Pressure Ulcer CAA dated 12/12/12 identified the resident required assistance with mobility and transfer, had a [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed the resident's BIMS score at a 9 (indicated moderately impaired cognition), did not exhibit behaviors or refuse care, dependent on two staff for bed mobility, transfers, toileting, and at risk for the development of pressure ulcers. The assessment revealed the resident had a healed pressure ulcer, used a pressure relieving device to the bed and chair and staff applied medications and ointments to the resident. Review of the care plan dated 3/12/12 revealed the resident had a history of [REDACTED]. The care plan also identified the resident as incontinent of bowel and bladder due to not wanting to use the mechanical lift and could be noncompliant with pressure reduction needs for the resident's skin protection. The care plan also identified that staff were to monitor the resident for signs of rash, irritation, excoriation, [MEDICAL CONDITIONS] or UTI, then treat the issue by following the physician's orders [REDACTED]. relief and comfort as the resident allowed. The care plan identified the resident would refuse at times. The guidance to staff also included for staff to use an air mattress on the resident's bed, a wheelchair cushion, to off load heels while in bed or chair for skin to skin protection (place a pillow under legs so heels do not rest on the bed and to place a pillow between legs to prevent skin to skin contact between legs). The care plan also directed staff to use moisturizing lotion to the resident's skin as needed for dry skin and moisture barrier cream with pericare as needed for skin protection. On 10/18/12, staff revised the care plan that identified the resident had a Stage II (open) pressure area on the right buttock. The revision lacked any new interventions. On 3/21/13, staff revised the care plan and identified the resident had a Stage I (reddened) area to the left buttocks and a Stage II (open) area to the right buttocks. The staff identified the treatment of [REDACTED]. The staff included a goal that the resident's "pressure areas will remain free from signs or symptoms of infection and will shows of healing by next review." Review of the resident's care plan on 3/26/13 revealed staff had revised the care plan and added the following undated interventions that were not present on 3/25/13: Administer treatment as ordered, consult therapy, Physical Therapy to treat Monday through Friday and Nursing on weekends, positioning device implemented to reduce pressure and shearing, and skin assessment weekly and 2 times weekly with bathing. Review of the facility's weekly skin assessments revealed the following: 01/19/13---reddened buttocks and perineal area, open right buttock. The staff identified the open areas as "old". 01/26/13--reddened buttocks and perineal area. Open areas on right buttock and heel. The staff identified the open areas as "old". 02/01/13--reddened areas on buttocks and perineal area, with open area on right heel. The open area is "old." 02/08/13--pink area on buttocks, skin intact. 02/16/13--redness to perineal areas and buttocks, skin intact. 02/23/13--redness to the perineal area, skin intact. 03/02/13--redness on the resident's "bottom". Skin intact 03/09/13--redness to the resident's perineal area and buttocks, skin intact. 03/20/13--Stage I (redness) to the right buttock, Stage II to the left buttock. Staff identified the open areas as "new". 03/23/13--Stage I (redness to the right buttock, Stage II to the left buttock, staff identified the open area as "old" and identified a "treatment in progress". Review of a nurse's note, dated 3/18/13 revealed an entry timed at 4:14 p.m. where staff documented the resident's buttocks were fragile with a small open area 0.2 cm x 0.1 cm on the left buttock. Staff documented they planned to lay the resident down after breakfast and lunch to take pressure off of buttocks (this was the same intervention documented in a nurse ' s note dated 1/24/13) and apply cream. Staff also planned to obtain a therapy screen to look at the resident's wheelchair cushion. Staff notified the family. The documentation lacked new interventions to immediately relieve pressure to the resident ' s buttocks. Review of a nurse's note, dated 3/21/13, revealed the staff identified wounds on the resident's buttocks. Staff documented the measurements of the wound on the left buttock as 5 cm in length x 2.3 cm in width and without depth. The wound on the right buttock measured 5 cm in length x 2.3 cm in width . Review of the verbal physician orders [REDACTED]. On 3/22/13, staff discontinued the Allevyn sacral dressing due to unable to maintain the dressing on the resident's sacrum and started a new order of [MEDICATION NAME] twice a day to the area and PRN until healed. [MEDICATION NAME] is a moisture barrier cream that provides long-[MEDICATION NAME] protection, According to the manufacturer's directions; staff were to cleanse the skin gently with mild skin cleanser, then pat or air dry. Staff were then to apply a thin layer of [MEDICATION NAME] ointment to reddened or irritated skin 2-4 times a day, or after each incontinent episode to promote comfort and long [MEDICATION NAME] protection. (If a [MEDICATION NAME] residue remained on irritated skin after gentle cleansing, it is recommended to leave the resident on the skin and apply an additional layer as needed until the skin is healed. [MEDICATION NAME] ointment is easily removed with baby oil or mineral oil when necessary) Review of a nurse's note dated 3/22/13 at 10:56 a.m. revealed staff identified a new order to discontinue the previous treatment order from 3/21/13 and to apply [MEDICATION NAME] to coccyx twice a day. The order included instructions to not clean off area between applications. On 3/26/13 at 1:50 p.m. Administrative Nursing Staff B stated APRN A had been out the previous week to look at the resident's buttocks. A request was made at that time for progress note of APRN's visit. Staff B was not sure if a progress note had been made on the visit, or if Staff A had seen the resident at the request of Administrative Nurse C. Observation on 3/26/13 at 11:36 a.m. revealed Licensed Nurse D and Administrative Nursing Staff C removed the resident ' s incontinent product and cleaned the resident's buttocks as the resident lay in bed. Observation of the incontinent product revealed a blue line which indicated the resident had experienced urinary incontinence. Observation of the resident's buttocks revealed thick layers of [MEDICATION NAME] ointment over the buttocks. Staff D used pre-moistened wipes to cleanse the areas. Bleeding was noted from the left buttock, with blood noted on the wipes after cleansing. The left buttock was bright red and had a large shallow open area. The right buttock also had an open area with white scar tissue surrounding the area. Once completed with cleansing, Staff D then applied thick layers of [MEDICATION NAME] cream to the resident's buttocks and applied a clean incontinent product. The resident did not exhibit any behaviors regarding lying in bed. Observation on 3/26 ' /13 at 1:10 p.m. revealed Direct Care Staff G and H assisted the resident into bed. As the staff checked the resident ' s incontinent product, staff G and H had the resident lying on his/her back. The resident began to repeat, " I want to lay on my side. I don ' t want to be on my back. " Staff G reassured the resident that staff G and H planned on assisting the resident onto his/her side just as soon as they could. As soon as the staff checked the resident ' s wet incontinent product, they positioned the resident onto his/her right side, cleansed the resident ' s buttocks, applied more [MEDICATION NAME] and applied a clean brief. The staff then left the resident on his/her right side and left the room. The resident did not exhibit any behaviors to indicate he/she did not want to go to bed. Observation on 3/26/13 at 2:30 p.m. revealed the resident lay in bed with the air mattress. Between the air mattress and the resident, was a folded draw sheet (to ease with turning), a green comforter, a cloth incontinent bed pad, and the resident wore slacks. On 3/26/13 at 11:45 a.m., the resident stated that he/she was told that he/she had a sore on his/her bottom and he/she said there was no pain experienced with the area. The resident also revealed that he/she is pretty set in his/her ways does what he/she wants to do. On 3/26/13 at 1:06 p.m., Direct Care Staff G stated that the facility had educated the staff on the use of the air mattress. Staff G stated that staff were to place a top sheet on top of the mattress and a paper chuck (absorbent paper placed under resident to protect against incontinent spills). They only use those two things to make sure there is air flow and to prevent extra pressure. Staff G said that the education identified the facility's education had said that the air mattresses were not effective when the resident lay on top of a blanket or a cloth incontinent pad. On 3/26/12 at 1:10 p.m., Direct Care Staff H revealed the facility's expectations included staff were to use a top sheet on the air mattress, to remove the resident's clothing and only use a paper pad for incontinence. Staff H stated that the resident would cry if staff removed the green comforter from the bed or placed the resident on his/her right side, so staff reported it to the charge nurses, who had directed the staff that it was the resident's choice to lay on top of the covers of the air mattress on his/her right side. On 3/26/13 at 11:13 a.m., Administrative Staff F stated the facility had applied an air mattress to the bed as a pressure reducing device as well as a pressure relieving cushion to the wheelchair. Staff F stated that the resident's electric wheelchair had a fixed seat so the cushion used was not as effective as the staff needed it to be so he/she was having a supplier come out and talk with the family later today to modify the chair for a more effective wheelchair cushion to relieve pressure. On 3/26/13 at 11:14 a.m., Administrative Nurse C identified the staff were applying [MEDICATION NAME] ointment to the resident's entire buttocks twice a day and that the direct care staff had been education to clean the resident but not scrub it off. Staff C described the resident as non-compliant with lying down between meals and turning every 2 hours and letting the staff change her every 2 hours and PRN in the night. The family requested the staff to continue to encourage the resident as much as possible to change and provide perineal care, to lie down between meals and allow the staff to reposition the resident while in bed, but the resident would lie down for 15-20 minutes and then the resident wants right back up in the wheelchair. Staff C stated a local pharmacy and the family were working together to get a cushion for the chair that would provide more effective pressure relief. Nurse C also identified the resident's skin issues as ongoing and "come and go." When asked what the last measures were for the areas on the buttocks, Nurse C identified them as 4 cm x 3 cm on the left side, and 1.5 and 1 cm on the right side. Nurse C identified that APRN A had been in the previous week and that staff had continued the treatment. When asked about having Dietary Staff E look at residents with pressure ulcers, Nurse C confirmed that Dietary Staff E had not been in to see the resident since January 2013 and that Dietary Staff E should be seeing residents with wounds at least monthly. Interview with Administrative Nurse B on 3/27/13 at 10:32 a.m. revealed the resident had a history of [REDACTED]. Staff B confirmed the resident had open areas that had healed before and that had developed scar tissue after healing, so the resident had scar tissue on the buttocks. Staff B stated that the facility's policy included Dietary Staff E to see all the residents with skin breakdown weekly for evaluation and for possible intervention to improve skin integrity. Staff B stated the Dietary Staff E had seen the resident on 3/26/13. On 3/27/13 at 1:58 p.m., Dietary Staff I stated that he/she was responsible for notifying the Dietary Staff E of the residents with wounds and weight loss that are discussed at daily meetings. Staff I described the facility's policy was for Dietary E to see the residents with significant weight loss and with wounds on a weekly basis. Once the resident's wounds had healed or the weight became stable, then Dietary Staff E went back to reviewing their records quarterly. On 3/27/13 at 1:30 p.m., Administrative Staff J confirmed that APRN A had not documented the visit he/she made during the week of 3/18-22/13 onto a progress note. On 3/27/13 at 2:38 p.m., Dietary Staff E stated that he/she was not aware that the resident had a wound. Staff E stated that when he/she had been in the facility on 3/26/13, Administrative Nurse C had told him/her that the resident's wound was a rash. Staff E stated that he/she did not review records for residents with rashes. Review of the resident ' s medical record revealed that it lacked a documented On 3/28/13 at 11:13 a.m., the facility provided a progress note from APRN A dated 3/28/13. In the progress note, Staff A identified the resident's wounds on the buttocks as incontinent [MEDICAL CONDITION]. Staff A identified that he/she was asked to look at the resident due to the occurrence of open areas on both buttocks. Staff A described the open areas as superficial open area in the buttock crease, with the left side being larger than the right. Staff A identified the wounds as associated with the patients incontinence which is of the stress incontinence type. Staff A felt that both the [MEDICAL CONDITION] and the incontinence were unavoidable due to the patient ' s co-morbidities. Staff A identified that the open areas on the buttocks would heal with [MEDICATION NAME] or other treatment agents that keep the area dry. An attempt to call and visit with APRN A on 3/29/13 at 10:30 a.m. was unsuccessful, as APRN A was out of the office for several days. Review of the facility's policy on Pressure Ulcer Care Guide, dated 10/7/10, revealed that when a resident had a pressure ulcer, staff were to conduct an in-depth assessment and record it on the Pressure Ulcer Status Record in the resident's medical record on a weekly basis. The facility's procedures are such that all disciplines were alerted immediately if the resident either had skin breakdown or was identified at risk for the development of skin breakdown. The Nursing department was to coordinate the respond to resident needs (in the area of skin integrity) by the following means: With medically directed treatment for [REDACTED]. With an array of preventative measures practiced on the resident's behalf when the resident had been identified as risk. With a medically directed restorative and therapeutic program for residents who develop a skin problem after admission. Review of the manufacturer's directions on the air mattress revealed the following: "BED LINENS: Seven-inch deep fitted sheets are recommended. Multiple layering of linens or underpads beneath the patient should be avoided for the prevention and treatment of [REDACTED]. The facility failed to determine causal factors for a resident with re-occurring open areas to ensure the areas were unavoidable. Once the resident developed open areas, the facility failed to provide the necessary services to ensure the healing of the pressure sores, including the prompt identification of the issues with pressure and relieve the pressure on a resident's buttocks, including a wheelchair cushion that was not adequate to relieve pressure, failed to use an air mattress to obtain the maximum benefit for pressure relief, and failed to follow the directions for use of a moisture barrier cream. The resident developed two pressure sores, one on each buttock.

The facility census totaled 108 residents with 6 included in the sample. The sample included the review of the closed records for 3 residents with accidents. Based on interview and record review, the facility failed to provide adequate supervision and assistive devices to prevent accidents for 2 of 3 sampled residents. (#2 and #5). Both residents fell and experienced fractures of the hip, which required hospitalization s for surgical repairs. Findings included: - Review of the interim care plan for resident #2 identified the resident at risk for falls and directed staff to provide a low bed for the resident, one staff to assist the resident with transfers, and monitor and encourage the use of proper foot wear. Review of the nurse's notes revealed on 6/6/11 at 11:10 p.m. staff assisted the resident to his/her room to assist the resident to bed, and while the staff went to close the window blinds, he/she stood up and started to fall. The direct care staff that took care of the resident reached for him/her and lowered the resident to the floor without injury. On 6/7/11, the staff added to the interim care plan the intervention to apply alarms to the resident's bed and chair, and a "landing strip (mat)" beside the bed. Review of the admission MDS (Minimum Data Set-a required assessment) with an ARD (Assessment Reference Date) of 6/7/11 identified resident #2 with severely impaired cognition, required extensive assistance from one staff with transfers, walking in the room/corridor, and locomotion on the unit. The assessment also identified the resident experienced falls in the month prior to the admission to the nursing facility and experienced a fracture related to a fall, plus had one non-injury fall since the admission to the facility. Review of a history and physical form, completed by the physician and dated 6/10/11, identified the resident as an [AGE] year-old (gender) with several admissions to the hospital for "falling at home." It further identified the resident with [DIAGNOSES REDACTED]." The nurse's notes, dated 6/11/11 at 8:30 p.m. revealed the staff documented the resident as "exit seeking and tearful. Refuses to sit down or assistance with walking. Gait unsteady." Review of the Physical Therapy progress notes dated 6/13/11 at 3:49 p.m. revealed the therapist documented that "upon entering the unit patient was ambulated without assistive device. Staff question appropriate for patient, did report they tried a walker however patient did not use it. Notified nursing that in therapy we were not using a walker secondary safety concerns and the increase in shuffling gait pattern. Educated staff that therapy would allow patient to ambulation on unit with supervision without devices, however if patient is experiencing any changes of pain in his/her side he/she would require at least SBA (stand by assistance) and to not allow patient to be in his/her room alone." On 6/17/11 at 9:15 p.m., nursing staff documented the resident as alert with confusion, noncompliant with care plan, refused to sit in the wheelchair, kept walking and resisted care had both bed and chair alarms on and denied any pain or discomfort. On 6/19/11 at 9:55 p.m., staff documented they found the resident seated on the floor in front of the closet. His/her slacks were half way on and the slacks he/she had been wearing were on the bed. The resident complained of severe pain to the left lower extremity. Staff encouraged the resident to stay on the floor and wait for the ambulance." The note failed to identify if the functioning status of the alarm, or why the staff had the resident in the room alone. The staff notified the doctor, who ordered staff to send the resident to the emergency room for further evaluation. At the emergency room , the physician determined the resident experienced a fractured left hip. On 9/28/11 at 2:30 p.m., Administrative Nurse B provided the facility's investigations into resident #2's falls. The facility failed to provide the investigation into the resident's fall on 6/19/11. On 9/28/11 at 7:15 p.m., when told that there was a concern that staff failed to provide the alarms to the resident as expected and allowed the resident in the room alone, Nurse B nodded understanding of the concern. Nurse B stated he/she could not remember the fall in particular to determine if staff had followed the care plan and on 9/29/11 at 3:15 p.m., had not provided any further evidence. The facility failed to ensure staff provided sufficient supervision to maintain the safety of a resident with multiple falls, including allowing the resident to be in his/her room alone, without a working alarm, and to ambulate independently. The resident fell and experienced a fractured hip which required a hospitalization with surgical repair. - Review of the admission MDS (Minimum Data Set-a required assessment) with an ARD (Assessment Reference Date) of 10/3/10, identified resident #5 with severe cognitive impairment, required extensive assistance from two staff with bed mobility and transfers, and with a history of falls in the month prior to admitting to the facility. Review of the recapitulation of physician's orders [REDACTED]. The care plan, dated 5/19/11, identified the resident required extensive assistance from one staff, and at times "may need 2 people," used a wheelchair for mobility which the resident "can propel self at times, staff propels most of the time," for staff to encourage the resident to do as much for himself/herself as able, the resident used a low bed with mat at bedside, bed and chair alarms at all times to alert staff of attempt to self-transfers, and "I should not be left alone in my room when I am up in my wheelchair as I will attempt to transfer myself at times." On 9/28/11 at 3:30 p.m., Administrative Nurse B provided facility investigations into the resident's falls for the year. The investigations identified the resident experienced falls on 1/2/11, 3/8/11, 3/18/11 and 6/28/11. The investigation for the fall on 1/2/11 identified the staff ambulated with the resident, the resident's legs gave out and the staff lowered the resident to the floor. The action taken after that fall included educating staff not to ambulate the resident. The fall on 3/8/11 revealed the resident alone in their room and attempted to transfer independently from the wheelchair into the bed; however the staff left the bed in high position. The action taken included education of staff, including housekeeping, to lower the bed. The investigation into the fall on 3/18/11 identified the resident again attempted to independently transfer self from the wheelchair into bed. The documentation in the investigation identified the resident "continues with sporadic participation in physical therapy. Therapist discussed with (him/her) the importance of calling for assistance prior to attempting transfers. Non-compliance has resulted in the identified intervention." The action taken (intervention) included "To be in bed while in room - or out in line of sight while in wheelchair due to non-compliance. The final investigation into another fall on 6/28/11 identified staff found the resident on the floor in his/her room. The resident stated "I tried to transfer myself." The action taken included an X-ray of the hip, which identified an impacted fracture of the resident's hip, and "educating associates (nursing staff) on alarms, use care guide." Staff failed to follow the care plan and provide the identified need for supervision to maintain the safety of this resident with multiple falls. On 9/28/11 at 7:15 p.m., interview with Administrative Nurse B revealed that the resident "was very non-compliant" and "knew when the staff were busy and would purposefully go back to (his/her) room at that time so he/she could be in his/her room alone. In fact, he/she had been seen in his/her room alone several times, but he/she had been compliant for a while with not trying to transfer by himself/herself." When asked why, if the staff knew the resident wanted to be in his/her room alone after meals, didn't staff adjust the care to help him/her in bed at that time, Administrative Nurse C stated that the staff were not done helping other residents with eating, and not available. The facility failed to provide adequate supervision for a resident with multiple falls by not following the care plan and allowing the resident alone in his/her room, without an alarm, to transfer independently. The resident experienced a fall that resulted in an impacted fractured hip that required surgical repair.

The facility census totaled 112 residents. The sample included the review of 3 residents for the facility's provision of ordered services, including one current resident and 2 closed records. Based on interviews and record review, the facility failed to prohibit neglect when the facility staff failed to provide blood glucose monitoring as ordered by the physician for 1 of 3 sampled residents. (#3) The resident's blood glucose reading, after 3 days of not monitoring, reached a critically high level of 886 mg/dL (milligrams per deciliter), and the resident required a hospitalization . This critically high blood glucose placed the resident's health in immediate jeopardy. Findings included: - Review of resident #3's closed medical record revealed the resident moved into the facility on a Friday afternoon, 7/15/11. The resident came from a hospital, with the [DIAGNOSES REDACTED]. The resident's primary physician from the hospital, Doctor J, gave the following orders to the staff: Diet is NPO (nothing by mouth), provide [MEDICATION NAME] 1.5 calories (a type of liquid nourishment) continuously per J-tube at 50ml/hr (milliliters per hour), flush J-tube with 240ml of water TID (three times a day), accuchecks (glucose monitoring) every 6 hours, and call for any blood sugar over 250mg/dL. According to a telephone order dated 7/15/11, Doctor B planned to take over the care of the resident from Doctor J, but until Doctor B or one of the physician extenders could see the resident, staff were to continue the orders from Doctor J. Review of an initial nursing assessment, dated 7/15/11, identified the resident with a history of type II diabetes (adult onset), insulin dependent, and it described the resident as quiet, friendly and passive. The initial/interim care plan, dated 7/15/11, identified the resident as diabetic, and instructed staff to conduct "glucometer finger sticks" but failed to identify how frequently, and to "administer insulin as ordered." Review of a physical therapy evaluation dated 7/15/11 noted Physical Therapist G assessed the resident on the afternoon of 7/15/11 and determined that the resident needed physical therapy, due to general weakness secondary to the resident's recent hospitalization and illnesses. Physical Therapist G identified the resident required extensive assistance from staff with ADL's (Activities of Daily Living). According to an occupational therapy evaluation dated 7/15/11, Occupational Therapist H assessed the resident also on the afternoon of 7/15/11 and determined that the resident required occupational therapy due to general weakness, and identified the resident required extensive assistance from staff with ADL's. Review of the nurse's notes dated 7/16/11 and 7/17/11 revealed staff documented they provided the ordered feedings and water flushes through the J-tube as ordered. The notes lacked documentation on the blood sugar monitoring. Review of the vital signs for the resident revealed that on 7/16/11 on the evening shift (3-11p.m.) the resident's blood pressure measured 118/62. On 7/16/11 on the night shift (11p.m.-7a.m.), staff documented the resident's blood pressure at 132/68. On 7/17/11 on the day shift (7a.m. - 3p.m.) staff documented the resident's blood pressure as 145/72. On 7/17/11 on 2nd shift, the resident's blood pressure measured 157/65, on 3rd shift 160/58. On 7/18/11 on evening shift, right before the resident went to the hospital; staff documented the resident's blood pressure as 164/67. Staff failed to address in the nurse's notes the rise in the resident's blood pressure over the weekend. According to the physical therapy and occupational therapy notes, dated 7/18/11, both identified the resident refused to participate in therapy, behavior not documented or mentioned in the record previously. On Monday, 7/18/11, Nurse Practitioner C, a physician extender for Doctor B, documented they observed the resident seated in a wheelchair by the nurse's station. Staff C described the resident as "appears ash colored. Pt (patient) denies any pain, nausea, cough, fever, chills, - but at end of interview appears agitated." The note identified they ordered staff to obtain lab work (laboratory blood tests) immediately. At the bottom of the progress note, staff C wrote the following: "The patient's glucose is over 800 (mg/dL). Resident sent to hospital. No accuchecks obtained by facility." The laboratory that performed the tests for the facility identified a normal blood sugar (glucose) as 70-99mg/dL. It identified this reading as critically high. Review of the emergency room report for the resident, dated 7/18/11 identified the resident arrived at the emergency room by ambulance at 7:30 p.m. The report identified the resident as lethargic, non-verbal, and with a blood sugar of 1073 mg/dL. The report ended by identifying Doctor J admitted the resident into the Intensive Care Unit of the hospital from the emergency room with a [DIAGNOSES REDACTED]. On 7/27/11 at 3:44 p.m., the resident's daughter/son expressed disappointment with the care their family member received at the facility. The daughter/son said they received a call on 7/18/11 in the afternoon and a nurse asked them if their family member had ever had problems with blood sugars. The daughter/son stated the resident had, ever since the resident had been diagnosed with [REDACTED]. The nurse told the daughter/son that Nurse Practitioner C ordered the resident sent to the hospital because of a high blood sugar. The daughter/son expressed frustration that the nursing staff did not seem to know the resident had a [DIAGNOSES REDACTED]. On 7/27/11 at 4:30 p.m., Doctor B stated they had received a call from Doctor J on Tuesday, 7/19/11 and Doctor J expressed their concerns over the care the resident received over the weekend. Doctor B contacted Nurse Practitioner C, who said they saw the resident for the first time on Monday morning at 7/18/11 and the resident had not looked good. Staff C ordered laboratory tests and when the blood glucose came back so high had reviewed the chart and saw that the facility staff failed to conduct the blood glucose monitoring as ordered, so they talked to Administrative Nurse A. Doctor B then said they called and talked to Administrative Nurse A, who agreed that the facility staff failed to follow the orders. Doctor B said they planned to get together with Administrative Nurse A and Administrative Staff K soon to go over what happened and how these orders were missed. On 7/27/11 at 5:10 p.m., Administrative Nurse A agreed staff had failed to provide the blood sugar monitoring as ordered, but they had educated their staff and "tweaked the system" to ensure that it wouldn't happen again. On 7/31/11 at 10:07 a.m., Charge Nurse D stated they had worked with the resident on Friday, Saturday, and Sunday from 6a.m. to 6p.m., or the day shift. Nurse D stated the facility had 4 admissions on Friday 7/15/11 and they were very busy. Nurse D stated the facility's normal procedure included one nurse conducting the physical assessment on the new resident, which is what Nurse D performed, while a second nurse processed the admission orders obviously a mistake was made" because the order for the blood sugars was missed and so they were never done over the weekend. Nurse D stated "I didn't even know (the resident) was diabetic." On 7/31/11 at 10:04 p.m., Charge Nurse E stated they had worked with the resident on Saturday and Sunday, from 6p.m. to 6a.m. Nurse E stated they had given the resident insulin and had noticed that "there were no orders for accuchecks (blood sugar monitoring)" so they identified that on the 24-hour sheets, however, they couldn't remember which day they wrote that on, either Saturday or Sunday. When asked which staff looked at the 24 hour sheets, Nurse E said that "Administration looks at them, but they are there for all nurses to review." Review of the 24 hour sheets for 7/15/11 revealed it lacked any mention of the resident. Staff failed to develop a 24 hour sheet on 7/16/11. The 24 hour sheet dated 7/17/11 did contain an entry that accuchecks were needed for resident #3, who "is diabetic." However, no staff responded to the request by 11:30 a.m. on 7/18/11 when Nurse Practitioner C ordered laboratory testing. On 8/1/11 at 8:03 a.m., Nurse Practitioner C identified they saw the resident for the first time on Monday. Staff C said the resident sat up in a wheelchair by the nurse's station, and "just didn't look good, I mean, (the resident) was very pale-(their) coloring was just bad." Staff C talked to the resident to see how they felt, and the resident said they felt fine, but by the end of the conversation, they started to get agitated, so "I ordered stat (immediate) labs (laboratory tests)." When the test results came back and the resident had a blood sugar over 800mg/dL, Nurse C sent the resident into the emergency room by ambulance. Nurse C then they talked with Administrative Nurse A and they went over the chart and discovered staff failed to follow the order for blood sugar monitoring. On 8/1/11 at 1:29 p.m., interview with Doctor J revealed when they saw the resident on Friday 7/15/11, the resident, although weak, was able to converse with the doctor and answered questions appropriately. When Doctor J saw the resident 4 days later on the following Monday, Doctor J described the resident as lethargic and unable to speak. Doctor J also said the resident's laboratory results were all within relatively normal ranges on Friday and were "terribly off" on Monday. Doctor J identified a major change in the level of consciousness in the resident. Review of the facility's policy and procedures for "Reducing the Threat of Abuse and Neglect, " dated 2/2009, defined neglect as "the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness," but failed to include systems that described how the facility identified neglect and failed to include systems that prevented the occurences of neglect. On 8/1/11 at 4:36 p.m., Administrative Staff K provided a plan of correction to abate the immediate jeopardy. The plan included Admission audits on the day following admission, all assessments will be checked for completion, admission orders [REDACTED]. The facility abated the Immediate Jeopardy on July 19, 2011 when nurse managers received training on the new procedure for auditing all resident orders. Training on the new procedure is scheduled to be completed for all nursing staff. The deficient practice remains at a scope and severity of D until all nursing staff receive training on the new procedure.