Every finding on record at Lutheran Community Home

Based on observation, record review, and interview, the facility failed to protect residents' personal health information for 2 of 4 observations conducted. Findings included 1. The 200 Hall was observed on 12/04/2025 at 10:23 A.M. Two Medication Carts were sitting in the hallway across from the nurse's station both. Both medication carts were unattended. One Medication Cart had an empty medication card laying on the top labeled with Resident 32's name. The medication was Losartan Potassium 100 milligrams (mg). A second Medication Cart had an empty medication card laying on the top labeled with Resident 40's name. The medication was Losartan HCTZ (Hydrochlorothiazide). No staff members were in the immediate area or near the medication carts. Two unidentified people walked past the cart. At 10:27 A.M., a staff member took the medication card for Resident 40 from the top of the medication cart, tore the top half of the card off, and disposed of the rest of the card. 2. The 200 Hall was observed on 12/05/2025 at 9:04 A.M. The medication cart was unattended at the time of the observation. A paper laying face up on the top of a medication cart had a list of resident names and personal information. The unattended nurses station was observed. A paper laying face up on the nurse's station desk, had a list of resident names and personal health information. Several unidentified people walked past the nurse's station and the medication cart. During an interview, on 12/05/2025 at 9:06 A.M., RN 6 indicated paperwork with residents' information should not be left out in the open and proceeded to turn the papers face down. The current Safeguarding of Resident Identifiable Information policy, with a copyright date of 2024, was provided by the Director of Nursing on 12/05/2025 at 1:24 P.M. The policy indicated, .Medical records shall not be left in open areas where unauthorized persons could access identifiable resident information.Paper notes or reminders with resident's personal or medical information shall not be left unattended or viewable by unauthorized persons. 3.1-3(o)

Based on record review and interview, the facility failed to notify the physician and document physician's ongoing guidance for 1 of 19 resident records reviewed for notification of change. (Resident 4) Findings include:The clinical record for Resident 4 was reviewed on 12/03/2025 at 2:33 P.M. An admission Minimum Data Set (MDS) assessment, dated 10/23/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, fractures of the tibia, hypertension, renal failure, seizure disorder, anxiety, and depression. The resident's Electronic Medication Administration Record (EMAR) indicated the resident had the following physician orders:-Daily weight for chronic kidney disease, with a start date of 10/18/2025, and a discontinued date of 10/27/2025, and-Furosemide tablet 40 milligrams (mg), administer 1 tablet, once a day as needed for weight gain of two pounds or more in 24 hours and/or bilateral lower extremity swelling, with a start date of 10/18/2025. The resident did not receive the prescribed, as needed, Furosemide medication on the following dates when the resident gained two pounds or more:10/18/2025 - weight 219.0 10/19/2025 - weight 228.0, a weight gain of 9 pounds, 10/22/2025 - weight 223.010/23/2025 - weight 228.2, a weight gain of 5.2 pounds, and 10/24/2025 - weight 224.610/25/2024 - weight 230.0, a weight gain 5.4 pounds. The EMAR indicated the resident had a physician's order for the following:Offer chocolate high protein drink, twice a day, with a start date of 10/24/2025, and a discontinued dated of 11/21/2025.The record indicated the resident either drank none of the drink or refused the drink 29 times out of the 40 times the drink was offered in the month of November 2025. The Progress Notes lacked documentation the physician had been notified of the changes in the resident's weight or the refusals of the prescribed nutritional drink supplements. During an interview on 12/04/2025 at 12:10 P.M., Resident 4 indicated she did not like the chocolate drink supplement because it gave her diarrhea. She had refused it repeatedly. The facility had offered other flavors, but she just didn't want it. She had problems with her colon ever since she was young. During an interview on 12/04/2025 at 9:13 A.M., the Administrator indicated physician notifications were documented in the Progress Notes. During an interview on 12/05/2025 at 12:13 P.M., the DON indicated when a physician was notified, facility staff were to document in a Progress Note, on the Electronic Healthcare Record, the nature of the notification. When the staff received a response from the physician, they should document the response in a Progress Note as well. If staff did not give the prescribed, as needed, Furosemide for the weight gain, they should have documented in a Progress Note as to why. In regard to the chocolate dietary supplement drink, the nursing staff should have notified the NP to change the supplement to something agreeable with the resident. The resident recently had surgery prior to admission to the facility. During an interview on 12/05/2025, the DON indicated the resident had not been sent out to the emergency room for treatment since admission to the facility. The current Change in a Resident's Condition or Status policy, dated February 2018, was provided by the Administrator on 12/05/2025 at 1:50 P.M. The policy indicated, .The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician.when there has been.A need to alter the resident's medical treatment significantly.Refusal of treatment or medications.two.or more consecutive times.The nurse supervisor/charge nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. 3.1-5(a)(3)

Based on record review and interview, the facility failed to document residents' meal consumption for 3 of 4 residents reviewed for nutrition. (Residents 84, 4, and 72) Findings include: 1.The clinical record for Resident 84 was reviewed on 12/04/2025 at 11:57 A.M. An admission Minimum Data Set (MDS) assessment, dated 11/02/2025, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, expressive language disorder, aphasia (a partial or total loss of language skills due to brain damage), diabetes, and dementia. The resident had complaints of pain or difficulty with swallowing or eating and was on a mechanically altered diet. The resident's current Nutritional Status Care Plan indicated she was at risk for impaired nutritional status and listed an Approach to monitor and record meal intakes, with a start date of 10/29/2025. The resident's Meal Consumption Record lacked documentation of meals for the following dates and times: -On 11/03/2025 at breakfast and lunch, -On 11/05/2025 at dinner, -On 11/06/2025 at breakfast and lunch, -On 11/14/2025 at lunch, -On 11/15/2025 at lunch, -On 11/18/2025 at lunch and dinner, -On 11/25/2025 at lunch, -On 11/26/2025 at lunch, -On 11/29/2025 at lunch, -On 11/30/2025 at dinner, and -On 12/01/2025 at dinner. 2. The clinical record for Resident 4 was reviewed on 12/03/2025 at 2:33 P.M. An admission MDS assessment, dated 10/23/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, fractures of the tibia, hypertension, renal failure, seizure disorder, anxiety, and depression. The resident's current Nutritional Status Care Plan indicated she was at risk for impaired nutritional status and listed an Approach to monitor and record meal intakes, with a start date of 10/22/2025. The resident's Meal Consumption Record lacked documentation of meals for the following dates and times: -On 11/01/2025 at breakfast and lunch, -On 11/03/2025 at breakfast and lunch, -On 11/05/2025 at breakfast, -On 11/08/2025 at dinner, -On 11/09/2025 at breakfast and lunch, -On 11/10/2025 at breakfast and lunch, -On 11/11/2025 at dinner, -On 11/08/2025 at dinner, -On 11/09/2025 at lunch and dinner, -On 11/10/2025 at breakfast and dinner, -On 11/11/2025 at dinner, -On 11/12/2025 at breakfast and lunch, -On 11/13/2025 at breakfast and lunch, -On 11/17/2025 at breakfast and lunch, -On 11/19/2025 at dinner, -On 11/20/2025 at breakfast, lunch, and dinner, -On 11/22/2025 at lunch, -On 11/23/2025 at dinner, -On 11/24/2025 at breakfast and lunch, -On 11/27/2025 at breakfast and lunch, -On 11/28/2025 at dinner, -On 12/01/2025 at breakfast and lunch, and -On 12/03/2025 at dinner. 3. The clinical record for Resident 72 was reviewed on 12/03/2025 at 2:41 P.M. A Quarterly MDS assessment, dated 11/18/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, peripheral vascular disease and hypertension. The resident's Meal Consumption Record lacked documentation of meals for the following dates and times: -On 11/01/2025 at breakfast, lunch, and dinner, -On 11/02/2025 at breakfast, lunch, and dinner, -On 11/03/2025 at dinner, -On 11/04/2025 at dinner, -On 11/05/2025 at breakfast and dinner, -On 11/06/2025 at breakfast, lunch, and dinner, -On 11/07/2025 at dinner, -On 11/08/2025 at dinner, -On 11/09/2025 at lunch and dinner, -On 11/10/2025 at breakfast and dinner, -On 11/11/2025 at dinner, -On 11/12/2025 at dinner, -On 11/13/2025 at breakfast, lunch, and dinner, -On 11/14/2025 at breakfast and dinner, -On 11/15/2025 at breakfast, lunch, and dinner, -On 11/16/2025 at breakfast, lunch, and dinner, -On 11/18/2025 at breakfast and dinner, -On 11/19/2025 at dinner, -On 11/20/2025 at breakfast, lunch, and dinner, -On 11/21/2025 at breakfast and lunch, -On 11/22/2025 at dinner, -On 11/23/2025 at dinner, -On 11/24/2025 at breakfast, lunch, and dinner, -On 11/25/2025 at breakfast, lunch, and dinner, -On 11/26/2025 at breakfast, and dinner, -On 11/27/2025 at breakfast and lunch, -On 11/28/2025 at breakfast, lunch, and dinner, -On 11/29/2025 at breakfast, lunch, and dinner, -On 11/30/2025 at breakfast, lunch, and dinner, -On 12/01/2025 at dinner, and -On 12/02/2025 at breakfast, lunch, and dinner. During an interview, on 12/04/2025 at 11:27 A.M. Certified Nurse Aide (CNA) 3 indicated resident meal consumptions were document on the computer charting system. Every meal should be documented. They were able to document if the resident refused or if they were out of the facility. The current facility policy titled, Point of Care Documentation, updated January 2018, was provided by the DON on 12/04/2025 at 1:37 P.M. The policy indicated, .Resident documentation will occur accurately and timely.The Dietician will review weights and meal consumption records.Resident Food intake will be monitored and recorded by direct care staff. 3.1-46(a)(1)

Based on record review and interview, the facility failed to provided physician prescribed medications and appropriate dosage for 2 of 19 residents reviewed for pharmacy services. (Residents 4 and 3) Findings include:1.The clinical record for Resident 4 was reviewed on 12/03/2025 at 2:33 P.M. An admission Minimum Data Set (MDS) assessment, dated 10/23/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, fractures of the tibia, hypertension, renal failure, seizure disorder, anxiety, and depression. The Progress Notes indicated the resident was admitted to the facility on [DATE] at 5:20 P.M. The resident's Electronic Medication Administration Record (EMAR) indicated they did not receive the following prescribed medication; Lacosamide 100 milligrams (mg) for seizures, with a start date of 10/17/2025:s on the following dates and times: -On 10/17/2025 at 7:00 P.M. to 10:00 P.M., due to medication being unavailable. -On 10/18/2025 at 7:00 A.M. to 10:00 A.M., due to medication being unavailable. The resident's Electronic Medication Administration Record (EMAR) indicated they did not receive the following prescribed medication; Sitagliptin 50 mg for diabetes with chronic kidney disease, with a start date of 10/17/2025 on the following date: -On 10/18/2025 at 7:00 A.M. to 10:00 A.M., due to medication being unavailable. The resident's Electronic Medication Administration Record (EMAR) indicated they did not receive the following prescribed medication, Enoxaparin (a blood thinner) syringe, 30mg/0.3 milliliters (ml), subcutaneous, for fracture, with a start date of 10/17/2025: -on 10/23/2025 at 7:00 P.M. to 10:00 P.M., due to medication being unavailable. The resident's Electronic Medication Administration Record (EMAR) indicated they did not receive the following prescribed medication; Amitriptyline 10 mg, give 3 tabs, 30 mg, for depression, with a start date of 10/17/2025: -On 11/18/2025 at 7:00 P.M. to 10:00 P.M., due to medication being unavailable. The resident's Electronic Medication Administration Record (EMAR) indicated they did not receive the following prescribed medication; Desvenlafaxine extended-release tab for depression, with a start date of 10/17/2025: -On 11/18/2025 at 7:00 A.M. to 10:00 A.M., due to medication being unavailable. The resident's Electronic Medication Administration Record (EMAR) indicated they did not receive the following prescribed medication; Esomeprazole magnesium 40 mg, for Gastro-esophageal disease, with a start date of 10/17/2025: -On 11/18/2025 at 7:00 P.M. to 10:00 P.M., due to medication being unavailable. The resident's Electronic Medication Administration Record (EMAR) indicated they did not receive the following prescribed medication; Glimepiride 2 mg, for diabetes, with a start date of 10/17/2025: -On 11/18/2025 at 7:00 A.M. to 10:00 A.M., due to medication being unavailable. The resident's Electronic Medication Administration Record (EMAR) indicated they did not receive the following prescribed medication; Tizanidine 4 mg, for muscle spasms, with a start date of 10/17/2025: -On 11/17/2025 at 7:00 P.M. to 10:00 P.M., due to medication being unavailable. -On 11/18/2025 at 7:00 P.M. to 10:00 P.M., due to medication being unavailable. During an interview, on 12/05/2025 at 10:53 A.M., Nurse Practitioner (NP) 5 indicated they communicated with the facility daily. If a resident needed a medication, they could order it and get it that same day. If the facility had a newly admitted resident, they would get medications the day they came to the facility. They have the discharge order set for medications from the hospital. The nurses upload medication orders in the computer and the prescriptions get filled by their contracted pharmacy. They also had alternative places to get medications if they needed them. During an interview, on 12/05/2025 at 12:13 P.M., the Director of Nursing (DON) indicated residents' prescribed medications should be available to them. The facility had local pharmacies they could use if they needed too. Medications should be available. Medications ordered during the day were usually delivered that same night. Staff had an Emergency Drug Kit (EDK) onsite they could get medications from if they were available. Staff should notify the NP if they do not have medications available to get approval for waiting for the pharmacy delivery. The NP notification should be in the Progress Notes. The resident recently had surgery. The Progress Notes lacked documentation the NP had been notified of the delay in the medications or any process for monitoring or obtaining alternative treatment orders. A Progress Note, dated 11/18/2025, indicated medications had not been ordered until 11/17/2025. The pharmacy indicated there had been a glitch in their system and medications would not be delivered until the night of 11/18/2025. The current Unavailable Medications policy, with a copyright date of 2025, was provided by the DON on 12/05/2025 at 1:24 P.M. The policy indicated, .Staff shall take immediate action when it is known that the medication is unavailable.Notify physician of inability to obtain medication upon notification of awareness that medication is not available. Obtain alternative treatment orders and/or specific orders for monitoring resident while medication is on hold. The current Pharmacy Services policy, with a copyright date of 2025, was provided by the DON on 12/05/2025 at 1:24 P.M. The policy indicated, .It is the policy of this facility to ensure that pharmaceutical services.are provided to meet the needs of each resident.The pharmacist is responsible for helping the facility obtain and maintain timely and appropriate pharmaceutical services that support residents' healthcare needs. 2. The clinical record for Resident 3 was reviewed on 12/03/2025 at 10:19 A.M. A Quarterly MDS assessment, dated 11/14/2025, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, fractures, anemia, hypertension, depression, and dementia. A physician's order, dated 03/21/2025 through 07/17/2025, indicated the resident was to receive Depakote 125 mg, three times a day for dementia. A Progress Note, dated 06/11/2025 at 8:15 A.M., indicated the resident had a current order for Depakote 125 mg, three times a day. The writer found a medication card of Depakote 250 mg for the resident. The resident received 250 mg (double the ordered dose) of the medication three times a day for 4 and a half days. The medication card was pulled from the medication cart as it was a medication error. A Progress Note, dated 06/11/2025 at 10:30 A.M., indicated the DON and SSD were made aware of the medication error. The resident's family and the pharmacy were made aware of the medication error. A Progress Note, dated 06/11/2025 at 11:41 A.M., indicated the Nurse Practitioner was notified of the resident's Depakote medication error. There was a new order to obtain the Depakote level the next morning. The residents Depakote lab was reviewed by the Nurse Practitioner on 06/12/2025 with no new orders. During an interview, on 12/04/2025 at 10:40 A.M., RN 4 indicated when administering medications, she would make sure the physician's order matched the medication card. If the two didn't match, then she would look at the resident's progress note and find out if the order changed. During an interview, on 12/04/2025 at 1:43 P.M., the DON indicated in June the pharmacy sent the wrong medication card for the resident. They sent 250 mg tablets, but the resident was supposed to get 125 mg tablets. Nursing staff administered the 250 mg tablets. When administering medications the nurse should verify the right dose of medication was being given. The current, undated, facility policy titled, Medication Error was provided by the DON on 12/04/2025 at 2:52 P.M. The policy indicated, .Medications shall be administered.According to physician's order. The current, undated, facility policy titled, Medication Administration was provided by the DON on 12/04/2025 at 2:52 P.M. The policy indicated, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice.Ensure that the six rights of medication administration are followed:.Right dosage.Compare medication source (bubble pack, vial, etc.) with MAR [Medication Administration Record] to verify resident name, medication name, form, dose, route, and time. 3.1-25(b)(1)

Based on observation and interview, the facility failed to maintain medication storage areas appropriately related to undated medication and a staff member's personal items for 1 of 4 medication carts reviewed (300 Hall Medication Cart), and a resident's personal items for 1 of 3 medication rooms reviewed (300 Hall Medication Room). Findings included:1.Medication storage areas on the 300 Hall were observed on 12/04/2025 at 10:46 A.M., With RN 2, and included, but were not limited to, the following: a. The 300 Hall Medication Cart contained a Lispro insulin pen for Resident 92 that was not labeled with an open date. The RN indicated the pen had not been opened yet, it had been out of the refrigerator since Friday, 11/28/2025, and she would date the pen when she opened it. The pen was good for 28 days. Usually, it was the same day, when a pen was removed from the refrigerator and when it was opened. An insulated coffee cup with a lid was in a drawer of the medication cart sitting next to clean health care supplies. The RN identified the coffee cup as being their own. b. In the 300 Hall Medication Room, in a cabinet labeled Wound Supplies, a pack of cigarettes, along with two loose cigarettes, and a lighter, were laying on a shelf next to a box of insulin safety syringes. RN 2 indicated she thought the cigarettes had been confiscated from a resident. The Lispro insulin package insert indicated unused insulin pens should be stored in the refrigerator at 36 degrees farenheit to 46 degrees farenheit, insulin pens, unopened, not in use, at room temperature, were good for 28 days. Therefore, the pen should have been labeled with a date the day it was taken out of the refrigerator.During an interview, on 12/05/2025 at 12:34 P.M., the Director of Nursing (DON) indicated staff's personal items should not be stored in the medication carts. The resident's cigarettes should have been discarded or sent home with the family. The current Medication Storage policy, with a copyright date of 2025, was provided by the DON on 12/05/2025 at 1:24 P.M. The policy indicated, .It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature .segregation, and security .3.1-25(o)

Based on observation, interview, and record review, the facility failed to update Care Plans related to behaviors and monitoring alert systems for 2 of 3 residents' Care Plans reviewed. (Residents C and D)Findings include:1.The clinical record for Resident C was reviewed on 10/23/2025 at 10:39 A.M. An Annual Minimum Data Set (MDS) assessment, dated 10/03/2025, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, unspecified dementia, anemia, and hypertension. The resident had physical and verbal behavior symptoms for 4 to 6 days of the assessment period. A Progress Note, dated 08/28/2025 at 5:56 P.M., indicated Resident B had wandered into Resident C's bedroom. Resident C had asked the resident to leave and when the other resident did not leave, Resident C smacked at the resident's face. A Progress Note, dated 10/06/2025 at 10:57 A.M., indicated Resident C was stating that another female resident ambulated up to this resident to slap me across the face. Resident C was sitting with staff completing an activity at the time. The other female resident was ambulating around the unit. Resident C stated, I'll slap her across the face. She better not do something to me, I'll do it right back! Resident C was repeating statements and staff attempted to redirect her. A Progress Note, dated 10/14/2025 at 9:34 A.M., indicated Resident B was on the unit and was in front of Resident C's room and stated, That lady slapped me. Upon speaking with the resident, it was voiced that Resident B had entered Resident C's room and Resident C slapped her. The incident was not witnessed. The Care Plan lacked any indication that Resident C had any behaviors towards other residents. During an interview, on 10/23/2025 at 1:42 P.M., the Director of Nursing (DON) indicated resident Care Plans were developed by the management staff. The Care Plans could be developed and revised at any time. Residents would be Care Planned for behaviors, changes in condition, and falls to name a few. Resident C had two incidents with another resident where she slapped the other resident in the face. Resident C should have been Care Planned for having behaviors towards other residents. 2. A facility reported incident, dated 10/17/2025, indicated a Certified Nurse Aide (CNA) heard an exterior door alarm sound, she went to the door and observed Resident D exiting through the door at the end of the hall. The resident had fallen on the concrete. He had abrasions and skin tears on his face and a bruise on his left eyebrow. The clinical record was reviewed on 10/23/2025 at 10:05 A.M. An admission MDS assessment, dated 10/16/2025, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, heart disease, hypertension, and stroke. A Progress Note, dated 10/17/2025 at 6:17 P.M., indicated the resident had returned from the local emergency room. A roam alert bracelet was placed on the resident's left ankle. During an observation on 10/23/2025 at 1:14 P.M., the resident was in bed, and the roam alert bracelet was on his left ankle. The resident's Care Plans were reviewed and lacked a Care Plan for the roam alert system. The resident's orders lacked orders for the roam alert bracelet, monitoring the functionality of the device, and monitoring the skin under the device. During an interview on 10/23/2025 at 2:04 P.M., the Assistant Director of Nursing indicated if a resident was determined to be an elopement risk, a roam alert bracelet would be placed on them. The computer would be updated with their name and picture, and an order would be placed in the Electronic Medication Administration Record (EMAR) to monitor the resident and the device. A Care Plan should also be written for the use of the device. There should have been a Care Plan for the roam alert device, and an order added to his EMAR. The current facility policy, titled Resident Alarms was provided by the DON on 10/23/2025 at 2:33 P.M. The policy indicated, .When alarms are utilized, additional monitoring shall be provided, including but not limited to: Verifying alarms are working properly. Monitoring for adverse consequences associated with the use of the alarms. The current facility policy, titled Comprehensive Care Plans was provided by the Administrator on 10/23/2025 at 2:10 P.M. The policy indicated, .It is the policy of this facility to develop and implement a comprehensive person – centered care for each resident. This citation relates to Intake 2642237. 3.1-31(a)

Based on record review and interview, the facility failed to ensure medications were administered as ordered to prevent significant medication errors for 1 of 5 residents reviewed for medications. (Resident 10) Findings include: Resident 10's clinical record was reviewed on 09/13/24 at 10:38 A.M. An Annual MDS (Minimum Data Set) assessment, dated 07/12/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, Parkinson's disease, psychotic disorder, epilepsy, and dementia. The resident's February 2024 EMAR (Electronic Medication Administration Record) included, but was not limited to, the following medication orders: - A physician's order, with a start date of 09/28/22 and an end date of 04/29/24, to administer two 50 mg (milligram) chewable phenytoin (an anti-seizure medication) tablets twice a day (once between 7:00 A.M. and 10:00 A.M., and then again between 7:00 P.M. and 10:00 P.M.). - A physician's order, with a start date of 09/28/22 that was discontinued on 02/16/24, to administer one half (25 mg) of a 50 mg chewable phenytoin tablet at bedtime. The resident would have received 100 mg of the phenytoin medication in the morning and 125 mg of the medication at bedtime. A Progress Note, dated 02/16/24 at 1:30 P.M., indicated there was a new order from the Nurse Practitioner to increase the resident's bedtime dose of phenytoin to 150 mg due to low levels of the medication identified in the resident's recent bloodwork. - A new physician's order, with a start date of 02/16/24 and an end date of 03/08/24, indicated staff were to administer 1.5 (one and a half) of a 50 mg chewable phenytoin tablet at bedtime. The February and March 2024 EMAR documentation indicated the 100 mg of the phenytoin medication continued to be administered twice a day as ordered and the additional 1.5 tablet dose of the medication (75 mg) was administered every evening until the order was discontinued on 03/08/24. A pharmacy recommendation, dated 03/07/24, indicated the resident had been receiving 100 mg of the phenytoin medication in the morning and 125 mg of the medication in the evening. The medication order was changed and now the resident was receiving 100 mg in the morning and 175 mg in the evening. The order from the Nurse Practitioner was to increase the dose to 150 mg in the evening. The pharmacist indicated they thought the staff put the order in computer incorrectly and the medication dose should have only gone from 125 mg to 150 mg in the evening. Please evaluate and change the order. During an interview on 09/13/24 at 12:50 P.M., the ADON (Assistant Director of Nursing) indicated she thought the order was clarified when it was originally received. She thought the pharmacy put a sticker on the medication card that would have ensured staff administered the appropriate dose of the medication (50 mg not 75 mg) but was unable to provide any supportive documentation. There was no indication in the resident's record the medication order was clarified. Nursing staff initialed the EMAR each time the medication was administered, and the EMAR indicated the amount of the medication administered was 75 mg. The facility didn't have a policy related to ensuring physician's orders were input correctly or regarding obtaining clarification if there were questions. It was just standard nursing practice to ensure orders were implemented accurately. 3.1-48(c)(2)

Based on interview, observation, and record review, the facility failed to provide perineal care in an appropriate manner for a resident with a history of UTIs (Urinary Tract Infections) for 1 of 3 residents reviewed for UTIs. ( Resident 55) Findings include: During an interview on 09/05/24 at 12:55 P.M., Resident 55 indicated she had recently been tested for a UTI and was unsure if the facility had started them on an antibiotic. When being toileted, the resident indicated some of the staff members cleaned them well, and some did not. Morning care for the resident was observed on 09/12/24 at 9:39 A.M. CNA (Certified Nurse Aide) 2 gathered clean linens from a linen closet in a common hallway and entered the resident's room. The CNA assisted the resident from her bed to the bathroom, donned gloves, removed their brief, helped the resident to sit on the toilet, removed her gloves, and gave the resident a moment to use the toilet. The CNA used hand sanitizer then went out into the resident's room to gather clothes for the day and reentered the bathroom. The CNA donned gloves, wet a couple of washcloths and left them lying in the bathroom sink bowl. She applied soap to one cloth, handed it to the resident to wash her face, put the soapy cloth back in the sink, picked a wet cloth out of the sink, handed it to the resident to rinse her face, rinsed the cloths with water, leaving them both lying in the sink, and handed the resident a small towel to dry her face. The CNA added soap to one cloth, handed it to the resident to wash under her breasts and arms, put the soapy cloth back in the sink bowl, picked a wet cloth out of the sink, handed it to the resident to rinse the soap off, placed the cloth back in the sink, handed the resident the towel to dry with, then assisted her with her shirt. The CNA removed her gloves, wrapped a clean brief around the resident's legs, put the resident's glasses on, removed the resident's shoes, assisted her with her pants, pulling them up to her knees, used hand sanitizer, put the resident's shoes back on her feet, and donned clean gloves. The CNA assisted the resident to a standing position, rinsed the two washcloths in water, put soap on one, wiped the resident's buttocks, wiped the buttocks with the other wet cloth, left the two cloths in the sink, and dried the resident's backside. The CNA rinsed the cloths, left them lying in sink, added soap to one cloth, briefly wiped at the front of the resident's private area, wiped with the rinsing cloth, then wiped with the towel. The CNA removed her gloves, adjusted the resident's brief, then assisted the resident to wash her hands and move to her wheelchair in the resident's room. During an interview and observation, in the resident's bathroom, the CNA indicated she used two washcloths, a soapy one, one to rinse, and a small towel to dry. The washcloths used were observed on the side of the sink. The soapy washcloth was marked with a two-inch wide streak of brown feces. There were only the two washcloths and one small towel in the bathroom that had been used for the procedure. During an interview on 09/12/24 at 10:02 A.M., when toileting a resident, CNA 2 indicated you should wash the front of the peri area first, and she had not done it that way with Resident 55. During an interview on 09/12/24 at 1:55 P.M., RN 3 indicated Resident 55 had a lot of UTIs. Usually when she had a UTI she would complain of burning. The resident had received antibiotics through an IV (Intravenous) line and IM (Intramuscularly) at times due to having a lot of allergies to antibiotics. The resident currently received the antibiotic Linezolid for a UTI. Other than IV antibiotics, the Linezolid was the only one the resident was not allergic too and it came in pill form. The clinical record was reviewed on 09/12/24 at 2:10 P.M. An Annual MDS (Minimum Data Set) assessment, dated 09/03/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, peripheral vascular disease, hypertension, and glaucoma. The recent physician's orders for antibiotics for UTIs were provided by the ADON (Assistant Director of Nursing) on 09/13/24 at 11:12 A.M., and indicated the resident had received the following: - Daptomycin 700 mg (milligrams) IV, once a day, with a start date of 02/01/24, and an end date of 02/08/24, - Cephalexin 125 mg, by mouth, as a preventative due to frequent UTIs, once a day, with a start date of 04/11/23, and an end date of 09/10/24, - Ertapenem 1 gram, IM, once a day, with a start date of 08/02/24, and an end date of 08/06/24, and - Linezolid 600 mg, by mouth, twice a day, for seven days, with a start date of 09/09/24, that the resident was currently receiving. The current Perineal Care policy, dated 02/2018, was provided by the DON (Director of Nursing) on 09/12/24 at 2:33 P.M. The policy indicated, .It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible .Gather supplies needed .Basin .If perineum is grossly soiled .Cleanse buttocks and anus, front to back; vagina to anus . 3.1-41(a)(2)

Based on record review and interview, the facility failed to follow a physician's recommendation related to a urinalysis for 1 of 19 residents reviewed for laboratory services. Findings include: The clinical record for Resident 64 was reviewed on 07/20/23 at 10:25 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 06/07/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, hypertension, obstructive uropathy, Alzheimer's disease, and depression. A Psychiatry Progress Note, dated 06/06/23, indicated the resident was sitting in his room. Per the nursing staff, the resident had not displayed any sadness or tearfulness. He had decreased agitation but continued to to be restless and had multiple falls trying to get up unassisted. The resident had some nights where he was awake and not sleeping. His appetite seemed fair. He was having increased aggression and inappropriate sexual behaviors. The assessment and plan, included but was not limited to, .Recent UTI (Urinary Tract Infection): Recommend rechecking a Urinalysis [UA] to make sure it is cleared. Reviewed recent UA and was positive with Proteus mirabilis and pseudomonas aeruginosa . The resident laboratory results from May to current were provided by the DON (Director of Nursing) on 07/25/23 at 11:04 A.M. The results lacked a urinalysis. The clinical record lacked any indication that the recommendation was acknowledged. During an interview on 07/25/23 at 10:55 A.M., the DON indicated when the psychiatry physician came to the facility, she would make recommendations and the facility Nurse Practitioner would either agree or disagree with the recommendations. The Social Service Director would review the psychiatry notes that were available, see if there were any additional recommendations, and send them to the Nurse Practitioner. If the Nurse Practitioner agreed with the recommendation, she would input the orders or a nurse on the floor would input them. She believed the urinalysis wasn't put on the list for the Nurse Practitioners review. There should have been a note that the Nurse Practitioner agreed or disagreed with the recommendation. The current, undated, facility policy tilted, Physician Orders was provided by the DON on 07/25/23 at 11:49 A.M. The policy indicated, .Physician orders must be given and managed in accordance with applicable laws and regulations . 3.1-49(a)

Based on observation, interview, and record review, the facility failed to ensure the proper application of an orthotic device for a resident with a contracture (Resident 16) and failed to provide restorative nursing services for residents with limited range of motion (Residents 60 and 64) for 3 of 4 residents reviewed for limited range of motion. Findings include: 1. Resident 16 was observed on 07/18/23 at 11:31 A.M. The resident was in her wheelchair in front of the television. A neck pillow was in place. The resident's right hand was closed as though it was contracted. There was no splint or brace device in use. The resident was observed in her room in bed on 07/18/23 at 2:10 P.M. The resident was awake and moving her thumb and fingers on her left hand. The resident's right hand was closed and there was no splint device in place. The resident was observed in the common area in front of the television on 07/20/23 at 10:30 A.M. A neck pillow was in place. The resident's right hand was closed. The index and middle fingers of the resident's left hand were extended. There was no splint device in place. A nursing staff member approached the resident on 07/20/23 at 10:32 A.M. and applied a splint device to the resident's left hand. The resident was observed in the common area near the television on 07/25/23 at 10:30 A.M. The resident was wearing a splint device in their left hand. CNA (Certified Nurse Aide) 11 approached the resident and offered her a drink. The resident did not take the drink. The resident's record was reviewed on 07/20/23 at 2:59 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 06/02/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, cerebral palsy, malnutrition, and severe intellectual disabilities. The resident's range of motion was impaired in their arms and legs, and they required extensive staff assistance for all ADLs (Activities of Daily Living). The assessment indicated the resident did not participate in therapy or restorative programs, including splint or brace assistance during the assessment review period. An Occupational Therapy Plan of Treatment for the certification period of 04/24/23 through 07/22/23 was provided by the DON (Director of Nursing) on 07/25/23 at 2:41 P.M. The treatment plan indicated the resident was left handed. The resident used sign language and managed her drinking cup with her left hand. The resident's guardian reported the resident only used her left hand to do most things. The assessment summary indicated that skilled occupational therapy was indicated to reduce the risk of skin breakdown and contracture in the resident's right palm and to develop a restorative nursing program for contracture prevention. The resident's current MD orders included, but were not limited to, an open ended order, with a start date of 05/04/23, that indicated a Soft Orthosis Roylan Palm Guard with finger separators was to be worn on the resident's right hand during daytime waking hours. Instructions for wear were posted in resident's room and in the therapy book at nurses' station. Instructions for the resident's orthotic device were provided by RN 10 on 07/25/23 at 10:45 A.M. The document, dated 05/01/23, and titled [Resident 16's] Orthosis Wear and Schedule indicated the resident was to wear the palm guard during daytime waking hours. Staff were to clean and dry the resident's right hand/palm prior to application of the device then perform PROM (Passive Range of Motion) to the right digits as tolerated then place palm protector onto the resident's right hand. During an interview on 07/25/23 at 10:33 A.M., CNA 11 indicated the restorative nursing aides documented the application of orthotic devices in the residents' EHR (Electronic Health Record), regular CNAs did not. During an observation and interview on 07/25/23 at 10:41 A.M., CNA 11 indicated the resident's device was currently on the resident's left hand and it was supposed to be on the right hand. The resident used her left hand to hold her drink cup. The resident's right hand was more contracted than the left. The device should have been on the resident's right hand. During an interview on 07/25/23 at 10:45 A.M., RN 10 indicated she hadn't worked on the resident's hall for very long and was not sure which hand the orthotic device was supposed to be in. The current facility policy, titled NURSING POLICY ASSISTIVE DEVICES POLICY, updated January 2021, was provided by the DON on 07/25/23 at 11:47 A.M. The policy indicated, .The purpose of this policy is to provide a reliable process for the proper and consistent use of assistive devices .to maintain or improve function .direct care staff will be trained on the use of the devices as needed .A nurse with responsibility for the resident will monitor for the consistent use of the device . 38769 2. The clinical record for Resident 64 was reviewed on 07/20/23 at 10:25 A.M. A Quarterly MDS assessment, dated 06/07/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, hypertension, obstructive uropathy, Alzheimer's disease, depression. A suggested program, dated 06/13/23, indicated Resident 64 was to participate in a transfer and an active range of motion restorative program with staff. His goal was to pull up to a standing position using the handrail with limited assistance three to five times and to participate in active range of motion exercises to the bilateral upper and lower extremities, completing two sets for 10 to 15 repetitions The programs were added to the restorative list. The Point of Care for Transfers, dated July 2023 lacked documenting for the following dates: - 07/01/23, - 07/04/23, - 07/08/23, - 07/15/23, - 07/16/23, and - 07/20/23. The Point of Care for Active Range of Motion, dated June and July 2023 lacked documentation for the following dates: - 06/23/23, - 06/27/23, - 07/01/23, - 07/04/23, - 07/08/23, - 07/15/23, - 07/16/23, - 07/20/23, - 07/21/23, and - 07/22/23. 3. The clinical record for Resident 60 was reviewed on 07/20/23 at 10:42 A.M. A Quarterly MDS assessment, dated 05/30/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, hypertension and dementia. A suggested program, dated 04/25/23, indicated Resident 60 was to participate in an eating and a passive range of motion restorative program with staff. Her goal was to self-feed with supervision with 25% to 50% verbal cues and participate in passive range of motion to the bilateral upper extremities with extensive assistance for two sets with 10 repetitions each. The programs were added to the restorative list. The Point of Care for Eating, dated July 2023 lacked documentation the following dates: - 07/02/23, and - 07/16/23. The Point of Care for Passive Range of Motion, dated June and July 2023 lacked documentation the following dates: - 06/03/23, - 06/04/23, - 07/02/23, and - 07/16/23. During an interview on 07/25/23 at 9:57 A.M., the MDS Coordinator indicated she would receive a therapy recommendation for a restorative program and then she would add the resident to the restorative list. The residents' restorative programs were completed daily and documented in the point of care. The current facility policy titled, Restorative Nursing Programs and updated January 2021, was provided by the DON on 07/25/23 at 11:49 A.M. The policy indicated, .It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level .The Restorative Nurse is responsible for maintaining a current list of residents who require restorative nursing services, and for ensuring that all elements of each resident's program are implemented .Restorative aides will implement the plan for a designated length of time, performing the activities, and document the plan .The Restorative Nurse, or designated licensed nurse, will provide oversight of the restorative aide activities, review the documentation at least weekly, and evaluate the effectiveness of the plan monthly . 3.1-42(a)(2)

Based on record review, interview, and observation, the facility failed to follow Care Plan interventions related to falls for 2 of 5 residents reviewed for accidents. (Residents 66 and 64) Findings include: 1. The clinical record for Resident 66 was reviewed on 07/21/23 at 11:16 A.M. A Significant Change MDS (Minimum Data Set) assessment, dated 07/07/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, Neurocognitive disorder with Lewy bodies, hypertension, depression, and insomnia. The resident received scheduled and as needed pain medications. He had no falls since the last assessment. A Quarterly MDS assessment, dated 06/01/23, indicated the resident had 2 or more falls since the previous assessment, dated 03/01/23, one with an injury that was not major. The Care Plan for falls was provided by the DON (Director of Nursing) on 07/21/23 at 3:13 P.M. The record indicated the resident was at risk for falls related to a Neurocognitive disorder with Lewy Bodies. An intervention, with a start date of 04/11/2023, indicated the resident was to have non-skid strips placed in front of the resident's toilet. A Fall Event report, dated 04/08/23, indicated the resident had a fall in his bathroom, the resident had had three or more falls in the last three months and was disoriented with diminished safety awareness. The IDT (Interdisciplinary Team) note indicated the resident was to have non-skid strips placed in front of the toilet. During an interview, record review, and observation, on 07/21/23 at 1:57 P.M., LPN (Licensed Practical Nurse) 7 indicated staff knew what the Care Plan interventions were by using the paper pocket sheets that were printed off for each staff at the beginning of each shift. A copy of the current pocket sheet was provided at that time and lacked the intervention of having non-skid strips in front of the resident's toilet. The resident's bathroom was observed with LPN 7 and non-skid strips were not in place in front of the resident's toilet. 38769 2. The clinical record for Resident 64 was reviewed on 07/20/23 at 10:25 A.M. A Quarterly MDS assessment, dated 06/07/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, hypertension, obstructive uropathy, Alzheimer's disease, depression. A Fall Event, dated 06/06/23, indicated the resident had an unwitnessed fall in his room. The resident was sitting on the side of his bed with his breakfast. The resident's legs were wrapped in his blanket, and he was sitting on the floor with his back against the bed. He denied hitting his head and was able to move all extremities. No injuries were noted. An IDT Note, dated 06/06/23 at 4:55 P.M., indicated the resident had a fall on 06/06/23 at 8:30 A.M. An intervention to prevent further falls was to place non-skid strips to the floor of the right side of the bed. The Complete Care Plan was provided by the DON on 07/21/23 at 3:13 P.M. The care plan included, but was not limited to, falls with a start date of 10/24/22. The intervention, with a start date of 06/06/23, indicated the resident was to have non-skid strips on the floor of the right side of the bed. During an observation on 07/21/23 at 2:15 P.M., the resident's room was observed and there were no non-skid strips by the bed. During an observation and interview on 07/21/23 at 2:17 P.M., the resident's room did not have non-skid strips present. CNA 15 indicated the resident had frequent falls. The resident had been in the same room for a while. The resident used to have non-skid strips by his bed, but they were coming up and no longer there. She wasn't sure how long the strips had been gone. The clinical record lacked any indication the non-skid strips had been removed or discontinued. The current facility policy titled, Fall Prevention Program, with a revised date of 01/01/23 was provided by the DON on 07/21/23 at 3:13 P.M. The policy indicated, .Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls .Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. Interventions will be monitored for effectiveness. The plan of care will be revised as needed . The current, undated, facility policy titled, Care Plans- Comprehensive, was provided by the DON on 07/21/23 at 3:13 P.M. The policy indicated, .An individualized comprehensive care plan that includes measurable objectives and timetable to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident. The care plan is based on the understanding of the resident's strength, goals, life history, and preferences .The care plan is accessible to any person involved in the implementation of the care plan . 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to follow appropriate infection control guidelines related to indwelling urinary catheter care for 2 of 3 residents reviewed for urinary catheters and Urinary Tract Infections. (Residents 64 and 76) Findings include: 1. During an observation on 07/19/23 at 10:12 A.M., Resident 64 was at the end of a hallway, sitting in his wheelchair. His indwelling urinary catheter tubing was dragging the floor. During an observation on 07/19/23 at 1:38 P.M., the resident was sitting at the dining room table. The resident's indwelling urinary catheter tubing was resting on the floor. During an observation on 07/20/23 at 1:57 P.M., QMA (Qualified Medication Aide) 12 propelled the resident from the dining room to the common area in front of the TV. The indwelling urinary catheter tubing was dragging the floor. During an observation and interview on 07/24/23 at 11:36 A.M., the resident was sitting in the common area with his indwelling urinary catheter tubing resting on the floor under the resident's foot. QMA 8 indicated the resident's indwelling urinary catheter tubing should not touch the floor. The clinical record was reviewed on 07/20/23 at 10:25 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 06/07/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, hypertension, obstructive uropathy, Alzheimer's disease, and depression. A Progress Note, dated 05/04/23, indicated the resident had received a 1 gram Rocephin (an antibiotic) IM (intramuscular) injection in the buttock, for a UTI (Urinary Tract Infection). 34232 2. On 07/18/23 at 1:54 P.M., an isolation cart was observed sitting in the hallway outside of Resident 76's room. A passing staff member indicated the resident had ESBL (Extended Spectrum Beta-Lactamase, an enzyme found in some strains of bacteria) in his urine. During an observation and interview on 07/18/23 at 1:41 P.M., Resident 76 indicated he had an indwelling urinary catheter because he had an infection. He had been on an antibiotic for the infection. During an observation on 07/20/23 at 1:29 P.M., the resident was sitting in his wheelchair in his room. One to two inches of his indwelling urinary catheter tubing was touching the floor. An isolation cart was still sitting in the hall outside the resident's room door. During an observation on 07/20/23 at 2:32 P.M., the resident was sitting in his wheelchair in his room. His indwelling urinary catheter tubing was touching the floor. A facility staff member was sitting in the room reviewing the meal menus with the resident. During an observation on 07/20/23 at 2:59 P.M., the resident was sitting in his wheelchair in his room. Over an inch of his indwelling urinary catheter tubing was touching the floor. Two staff members, RN 5 and CNA (Certified Nurse Aide) 4, donned PPE (Personal Protective Equipment) before assisting the resident to bed using a mechanical lift. While the CNA pushed the wheelchair into place, the tubing was dragging on the floor making a scraping sound. The staff attached the resident's harness to the lift, moved the resident over the recliner, and lowered the resident into the seat. The nurse pulled a small trash can up next to the resident's recliner, hung the indwelling urinary catheter bag to the side of the trash can, then picked a piece of trash up off the floor and tossed it in the trash can. During an observation on 07/24/23 at 11:22 A.M., the resident was sitting in his recliner in his room. His indwelling urinary catheter bag was covered with a dignity bag with two to three inches of the bag laying on the floor at the side of his recliner. The floor was wet in the immediate area. During an observation and interview with RN 5 on 07/24/23 at 11:28 A.M., the resident was still sitting in his recliner with his indwelling urinary catheter bag laying on the floor. RN 5 indicated staff had hooked the catheter bag to the side of the resident's recliner. They normally hung it on the trash can. The facility policy did not say anything about where they should hang the catheter bags, they just needed to be off the floor. The resident was still in isolation for ESBL in his urine. During an interview on 07/24/23 at 12:33 P.M., LPN 7 indicated indwelling urinary catheters should be kept off the floor and hanging below the bladder. Urinary catheters should not be hung on a trash can. The clinical record was reviewed on 07/20/23 11:24 AM. An Admission MDS assessment, dated 07/06/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, fracture of left fibula, renal insufficiency, obstructive uropathy, and UTI in the last 30 days. The resident had an indwelling urinary catheter in place and was frequently incontinent of bowel. The Progress Notes for June and July 2023 were provided by the Administrator on 07/24/23 at 12:36 P.M., and included, but were not limited to, the following: - A note, dated 06/29/23 at 8:40 P.M., indicated the resident was on IV (Intravenous) antibiotics for a UTI with ESBL. The physician's orders were provided by the Administrator on 07/24/23 at 1:54 P.M., and included, but were not limited to, the following: - The resident received Meropenem (an antibiotic) one gram intravenous, every 12 hours with a start date of 06/29/23, and a discontinued date of 07/03/23, and - a current open-ended order to keep catheter and tubing as free of kinks as possible. Maintain catheter bag below level of the bladder but do not allow to rest on the floor, every shift, with a start date of 06/29/23. The Care Plan indicating the resident had an indwelling urinary catheter for a diagnosis of obstructive uropathy, with a start date of 06/29/23, was provided by the Administrator on 07/24/23 at 12:36 P.M. The interventions included, but were not limited to, .Keep catheter and tubing as free of kinks as possible. Maintain catheter bag below level of the bladder but do not allow to rest on the floor . The current Catheters - Catheter Care policy, updated in January 2021, was provided by the Administrator on 07/24/23 at 12:36 P.M. The policy indicated, .It is the policy of this facility to provide catheter care to all residents that have an indwelling catheter to assist in reducing bladder and kidney infections . 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to store medications appropriately related following manufacturer's guidelines, labeling medication, and having unsecured loose tablets in the medication carts for 4 of 5 medication carts reviewed. (Medication Carts One and Two on the 100 Hall, and Medication Carts One and Two on the 200 Hall) Findings include: 1. The 100 Hall Medication Carts were observed on 07/18/23 at 10:20 A.M., with RN 2. Cart One contained the following items and loose pills laying in the bottom of drawers: - an Albuterol inhaler with a spacer attached, laying on its side in the bottom drawer for Resident 11, - three small white oval tablets, - one medium white oval tablet, - one small white round tablet, and - one medium pink round tablet. Cart Two contained the following items and loose pills laying in the bottom of drawers: - a Fluticasone inhaler laying on its side in a box for Resident 65, - a box of cornstarch with the top of the box open, the powder cornstarch visible, with a plastic spoon sticking up out of the cornstarch powder that RN 2 indicated was for Resident 18 who used it under her breasts, - one small white oval tablet, - one medium white oval tablet, - two medium white round tablets, and - one large white round tablet. RN 2 indicated inhalers were normally kept upright. Flonase had to be stored upright. 2. The 200 Hall Medication carts were observed on 07/18/23 at 10:37 A.M., with QMA (Qualified Medication Aided) 3. Cart One contained the following items and loose pills laying in the bottom of drawers: - one opened tube of Nystatin ointment with no resident name or label, - one small tube of Erythromycin eye ointment for Resident 16 with no open date, - a Symbicort inhaler for Resident 21 laying on its side in the third drawer, - four small white oval tablet halves, - one small white rectangular tablet, and - one small pink oval tablet half. Cart two contained the following loose pills laying in the bottom of drawers: - one medium orange round tablet, - one small white oval tablet half, and - one large red round tablet was laying on the floor under the cart. During an interview on 07/18/23 at 11:02 A.M., QMA 3 indicated inhalers should be stored upright and at room temperature. During an interview on 07/25/23 at 10:30 A.M., the ADON (Assistant Director of Nursing) indicated they had had a staff member, QMA 13, doing the medication cart audits weekly but that staff member had gone back to working the floor. The current Medication Storage Policy, updated in January of 2021, was provided by the Administrator on 07/25/23 at 11:01 A.M. The policy indicated, .It is the policy of this facility to ensure all medications housed on our premises will be stored .according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security . 3.1-25j) 3.1-25(k)(1) 3.1-25(k)(2) 3.1-25(k)(3) 3.1-25(k)(4) 3.1-25(k)(5) 3.1-25(k)(6) 3.1-25(k)(7)

Based on observation, interview, and record review, the facility failed to provide appropriate care and services related to perineal care for incontinence and the use of a bedpan, and hand hygiene for 2 of 6 residents reviewed for bowel and bladder related to Urinary Tract Infections. (Residents J and H) Findings include: 1. During an observation and interview on 3/21/23 at 2:10 p.m., CNA (Certified Nursing Aide) 2 assisted Resident H to the bathroom. The CNA propelled the resident's wheelchair into the bathroom and used a gait belt to assist the resident to the toilet. The CNA donned gloves with no hand hygiene observed. She removed the residents' urine-soaked brief, doffed the gloves, washed her hands with soap and water, and donned clean gloves. CNA 2 moved the wheelchair twice, touching both the hand grips and arm rests with both gloved hands. When the resident indicated she was finished, the CNA had her stand with her legs apart. CNA 2 picked up a package of wipes, used one wet wipe to clean the peri area by wiping from front to back, folding the same wet wipe for a total of eight wipes. She placed a clean brief on the resident, pulled up the resident's pants, and moved the wheelchair around to the sink by holding the handles with her gloved hands so the resident could her wash hands. CNA 2 doffed her gloves, washed her hands with soap and water, used her left hand to turn off the water, and then used two paper towels to dry her hands. The CNA indicated hand hygiene should be done before and after providing care, and during if the gloves needed to be changed. She did not remove her gloves after wiping the resident's peri area and should have. She acknowledged she also touched the gait belt and wheelchair with those same dirty gloves. 2. During an observation and interview on 3/21/23 at 2:43 p.m., QMA (Qualified Medication Assistant) 3 indicated Resident J was on the bedpan and the staff were about to get her cleaned up. QMA 3 and RN (Registered Nurse) 4 entered the room and donned gloves, no hand hygiene was observed. QMA 3 went into the bathroom and with her gloved right hand, turned on the water in the bathroom sink, and wetted several wash clothes. The QMA had brought the wash clothes, a package of wet wipes, and peri wash into the resident's room. QMA 3 moved the over the bed tray table to the bedside, laid a towel on the table, laid the wet wash clothes on the towel, and readjusted the height of the table. QMA 3 and RN 4 pulled back the resident's blanket. The RN assisted the resident to roll to the right side, while the QMA removed the bedpan. The QMA then opened the wet wipes placing the package on the bed next to the resident. The QMA used a wet wipe to wipe the resident's anus, folded the wipe three additional times and continued to clean stool from the rectum area. During the cleaning of the rectal area the QMA had stool on her right glove, on the thumb pad area. She used a wet wipe to remove the stool from the glove. The QMA then started to place a clean chuck and brief under the resident. The surveyor requested the QMA to lift the resident's left buttock and stool was observed in the vaginal area. The QMA had the resident roll to her back, bend her knees, and spread her legs. QMA 3 used a wet washcloth and peri wash to clean first, the left side of the labia, she folded the cloth and wiped the right side of the labia, she did not separate the labia but wiped over the top from the pubic area down toward the vagina. The QMA bagged the dirty linens, gathered the trash, and doffed gloves. QMA 3 went to the bathroom, used her bare right hand to turn on the water, used soap and water to wash her hands. She indicated the water was way too hot. She used the wrist area of her right arm to try and turn the water to a cooler setting but was unable to. She rinsed the palm and back of her right hand, rinsed the palm of her left hand, and with soap still visible on the back of her left hand she used a paper towel to dry her hands. She indicated hand hygiene should be performed before and after care. During an interview on 3/21/23 at 1:53 p.m., the ADON (Assistant Director of Nursing) indicated a total of six residents recently had UTIs (Urinary Tract Infections). On 3/21/23 at 2:07 p.m., the ADON provided the lab reports for all six resident with recent UTI's. On review of the laboratory reports indicated 4 of the 6 residents' culture reports were positive for Escherichia coli (E-coli - a type of UTI usually caused by bacteria commonly found in the gastrointestinal tract.). Resident H's laboratory report, dated 3/13/23, indicated the resident's urine culture was positive for e-coli. The current facility policy titled Perineal Care and with a revised date of January 2021, was provided by the Director of Nursing on 33/21/23 at 2:59 p.m. The Policy indicated, .It is the practice of this facility to provide perineal care to .prevent infection .Policy Explanation and Compliance Guidelines .2. Gather supplies needed. 6. Perform hand hygiene and don gloves .9. a. Cleanse buttock and anus .vagina to anus .using a separate washcloth or wipes .b. Thoroughly dry .10. Re-position resident in supine position. Change gloves if soiled .11. Females: c. Separate the resident's labia with one hand, cleanse perineum with the other hand .e. Clean urethral meatus and vaginal orifice .f. Pat dry with towel .16. Removed gloves and discard. Perform hand hygiene . This Federal tag relates to Complaints IN00403708. 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to provide consistent urinary catheter care for 1 of 4 residents reviewed for UTIs (Urinary Tract Infections). (Resident 14) Findings include: During an interview on 07/18/22 at 2:14 P.M., RN 7 indicated Resident 14 had a urinalysis completed and had ESBL (Extended Spectrum Beta-Lactamase, an enzyme found in some strains of bacteria) in her urine. The resident had completed a series of antibiotics. The staff wore a gown and gloves when in contact with the resident's urine. The resident had an indwelling urinary catheter. During a family interview on 07/18/22 at 2:29 P.M., the family indicated the resident had a [CONDITION(S)] that was resistant to antibiotics. The resident had no signs or symptoms currently and had recently been on antibiotics for seven days. The clinical record was reviewed on 07/20/22 at 3:02 P.M. A Significant Change MDS (Minimum Data Set) assessment, dated 05/05/22, indicated the resident was rarely understood. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was totally dependent on two or more staff members for bed mobility, dressing, toilet use, and personal hygiene. The urinalysis culture results record was provided by the ADON (Assistant Director of Nursing) on 07/25/22 at 3:12 P.M. The results, dated 07/03/22, indicated the resident had ESBL in her urine and the antibiotic [MEDICATION(S)] was order for seven days. The June 2022 EMAR/ETAR (Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. The record contained the following orders: - An open ended order, with a start date of 04/18/22, to anchor an indwelling urinary catheter for a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . - An open ended order, with a start date of 04/19/22, to empty the urinary catheter bag and record the amount every shift, three times a day, - An open ended order, with a start date of 04/19/22, to keep the catheter and tubing as free of kinks as possible, maintain the catheter bag below the level of the bladder, but do not allow to rest on the floor, every shift, days, evenings, and nights, and - An open ended order, with start date of 05/11/22, to irrigate the urinary catheter with normal saline as needed for sediment / blockage. The record lacked an order for [MEDICAL RECORD OR PHYSICIAN ORDER] The progress notes for June 2022 were provided by the ADON on 07/25/22 at 10:00 A.M., and contained the following: - A note, dated 06/04/22 at 10:12 P.M., indicated good peri care had been provided by the staff. - A note, dated 06/29/22 at 3:36 P.M., indicated a CNA (Certified Nurse Aide) had reported to LPN (Licensed Practical Nurse) 5 the resident's urinary catheter was not intact and urine had leaked out all over the bed. The LPN replaced the catheter and the urine was thick, yellow, mucousy, and had a strong odor. No other notes indicated urinary catheter care had been provided. The July EMAR/ETAR was provided by the ADON on 07/22/22 at 10:25 A.M. The record contained the following orders: - An order, with a start date of 07/03/22 and an end date of 07/10/22, for [MEDICATION(S)] (antibiotic) twice a day for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] - An open ended order, with a start date of 04/19/22, to empty the urinary catheter bag and record the amount every shift, three times a day, - An open ended order, with a start date of 04/19/22, to keep the catheter and tubing as free of kinks as possible, maintain the catheter bag below the level of the bladder, but do not allow to rest on the floor, every shift, days, evenings, and nights, and - An open ended order, with start date of 05/11/22, to irrigate the urinary catheter with normal saline as needed for sediment / blockage. The record lacked an order for [MEDICAL RECORD OR PHYSICIAN ORDER] The July 2022 progress notes were provided by the Admissions Nurse on 07/22/22 at 12:05 P.M. and contained the following: - A note, dated 07/01/22 at 11:00 A.M., indicated the hospice CNA (Certified Nurse Aide) had provided am care and shampooed the resident's hair. The hospice nurse had obtained urine from the catheter for a urinalysis, culture, and sensitivity, - A note, dated 07/03/22 at 2:51 P.M., indicated the resident's urine culture results confirmed ESBL in the resident's urine, the resident was placed in contact isolation, staff were to wear PPE (Personal Protective Equipment) when in direct contact with the resident's urine, and there was a new order for the antibiotic [MEDICATION(S)], twice a day, for seven days, - A note, dated 07/08/22 at 11:27 A.M., indicated a hospice CNA had been in to complete ADLs (Activities of Daily Living) for the resident, and - A note, dated 07/18/22 at 2:10 P.M., indicated a CNA alerted RN 7 to the residents pad on her bed being wet with urine. The RN changed the resident's indwelling urinary catheter and had thick, amber urine with sediment returned. The CNA indicated the resident had vomited during her afternoon meal. No other notes indicated urinary catheter care had been provided. The Care Plan was provided by the ADON on 0725/22 at 10:00 A.M. A bowel and bladder care plan, with a start date of 04/20/22, indicated the resident had an indwelling urinary catheter to promote healing of a sacral ulcer. An approach, with a start date of 04/20/22, indicated to provide catheter care daily. During an interview on 07/21/22 at 2:07 P.M., on the 400 Hall, LPN 3 and QMA (Qualified Medication Aide) 2 indicated the CNAs completed catheter care for the residents. They checked it through out the shift and emptied the drainage bag once a shift. The staff on the 400 hall worked eight hour shifts. The CNAs documented the output in the EHR (Electronic Health Record). The QMA offered to demonstrate urinary catheter care. Urinary catheter care was observed on 07/21/22 at 2:25 P.M. QMA 2 used hand sanitizer and donned a gown and face shield. She was already wearing a surgical mask. She entered the resident's room, washed her hands with soap and water, donned gloves, got paper towels, placed the paper towels on the floor next to the resident's urinary catheter bag, placed a graduated cylinder on the paper towels, then placed a package of aloe wipes directly on the floor next to the paper towels, not on the paper towels. She removed her gloves, washed her hands, donned clean gloves, took the spout out of the receptacle on the catheter bag, unclamped the spout, drained the urine into the graduated cylinder, reclamped the spout, cleaned the end of the spout with an aloe wipe, and replaced it in the receptacle on the urinary catheter bag. She put the package of aloe wipes back on the lid of the soiled linen receptacle, picked up the cylinder of urine and paper towels, and emptied the cylinder in the toilet. She threw the paper towels away and rinsed out the cylinder and placed it back in a plastic bag. She removed her gloves and gown and exited the resident's room. She used hand sanitizer and cleaned her face shield. She charted the amount emptied on the catheter order that indicated to empty and document the amount. The results of her documentation of the amount was visible under the vitals records. The QMA failed to clean around the insertion site of the catheter and she did not document that she had provided that type of care. During an interview on 07/22/22 at 11:43 A.M., CNA 6 indicated the CNAs emptied the catheters and cleaned around the insertion site, one time per shift, three times a day, and documented on the resident's record. During an interview on 07/22/22 at 11:47 A.M., the ADON indicated each resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order for catheter care daily was under the nursing orders. The nurses should have been signing off on it on the EMAR/ETAR. It was a nursing order to provide catheter care daily. Catheter care consists of washing around the catheter insertion site. The nurses did not have to be the ones to complete the care. They put catheter care in the residents' orders to ensure it was completed daily. The nurse would have to observe the catheter care being done by another staff member or complete the care themselves in order to sign off that it had been completed. All residents who had an indwelling catheter should have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The staff should have clicked on the order when they were putting in the other catheter orders for monitoring. They had urinary catheter orders that included several different orders. There was a list of orders that the staff clicked on to include them in the EMAR/ETAR and the nurses signed off on them indicating the care was provided. The current Catheters - Catheter Care policy, with an updated date of January 2021, was provided by the Administrator on 07/22/22 at 10:51 A.M. The policy indicated, .Catheter care is to be performed every shift and as needed .Provide privacy .Assist resident to a lying position .Drape resident to expose only the perineal area. Expose insertion site .starting at the urinary meatus moving out, wipe the catheter making sure to hold the catheter in place as to not pull on the catheter . 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to store medications appropriately related to labeling medications and having unsecured, loose capsules and tablets in the medication carts for 2 of 4 medication carts reviewed. (200 Hall Medication Cart and 100 Hall Medication Cart) Findings include: 1. A medication cart on the 200 hall was observed on 07/18/22 at 11:03 A.M., with QMA (Qualified Medication Aide) 4, and contained the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] ear drops with no open date for Resident 54, the bottle was not transparent, - [MEDICATION(S)] eye drops with no open date for Resident 70, - [MEDICATION(S)] inhaler with no open date for Resident 48, and - [MEDICATION(S)] tube of ointment, 1/4 full, with no open date for Resident 44. The cart contained the following loose pills laying in the bottom of the drawers: - four pills in small single bubble packs, the QMA indicated they were [MEDICATION(S)] tablets, - eight whole white tablets of various shapes and sizes, - one oval lavender tablet, - one oval green tablet, - one round red tablet, and - one red capsule. The QMA indicated the medication carts were to be cleaned daily on night shift. She disposed of the loose pills in the sharps container. 2. A medication cart on the 100 hall was observed on 07/18/22 at 11:23 A.M., with LPN (Licensed Practical Nurse) 5, and contained the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] - Sustane eye drops with no open date for Resident 25, - [MEDICATION(S)] spray, 3/4 full, with no open date, for Resident 73, - [MEDICATION(S)] inhaler with no open date for Resident 73, - A bottle of chewable [MEDICATION(S)] vitamins, less than half full, with no open date for Resident 67, and - A [MEDICATION(S)] insulin pen, over 3/4 full, with no open date, resident name, or pharmacy label. The cart contained the following loose pills laying in the bottom of the drawers: - three small round white tablets, - one large round white tablet, - one small oval white tablet, - one small peach 1/2 tablet, and - an open roll of Rolaids, 3/4 full, with no resident name or label. The LPN indicated the staff generally dated all items when they were opened. She did not know how long insulin pens were good for once they were removed from the refrigerator. The [MEDICATION(S)] insulin pen package insert was provided by the DON (Director of Nursing) on 07/22/22 at 3:17 P.M. The insert indicated, .Recommended Storage .After initial use of the [MEDICATION(S)] pen, the pen can be stored for 30 days at controlled room temperature .This will reduce the potential for contamination, infection and leakage while also ensuring dosing accuracy . The current Medication Storage Policy, updated in January of 2021, was provided by the DON on 07/22/22 at 3:53 P.M. The policy indicated, .It is the policy of this facility to ensure all medications housed on our premises will be stored .according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security . 3.1-25j) 3.1-25(k)(1) 3.1-25(k)(2) 3.1-25(k)(3) 3.1-25(k)(4) 3.1-25(k)(5) 3.1-25(k)(6) 3.1-25(k)(7)

Based on record review and interview, the facility failed to ensure wound healing medications/supplements were available for 1 of 6 residents reviewed for pharmacy services. (Resident 56) Findings include: The clinical record for Resident 56 was reviewed on 07/20/22 at 2:00 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 06/22/22, indicated the resident was rarely/never understood. The diagnoses included, but were not limited to, traumatic [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], and [CONDITION(S)]. The resident had an unhealed pressure ulcer. A current physician's order, with a start date of 07/01/22, indicated Pro-Stat Sugar Free, 30 ml (milliliters) twice a day, for wound healing. The July 2022 EMAR (Electronic Medication Administration Record) indicated the resident had not received the Pro-Stat for the following dates and times due to the medication being unavailable: - 07/06/22 7:00 A.M. to 10:00 A.M., and 7:00 P.M. to 10:00 P.M., - 07/07/22 7:00 A.M. to 10:00 A.M., and 7:00 P.M. to 10:00 P.M., - 07/08/22 7:00 A.M. to 10:00 A.M., and 7:00 P.M. to 10:00 P.M., - 07/09/22 7:00 P.M. to 10:00 P.M., - 07/10/22 7:00 P.M. to 10:00 P.M., and - 07/11/22 7:00 A.M. to 10:00 A.M., and 7:00 P.M. to 10:00 P.M. The clinical record lacked documentation the pharmacy or physician had been notified of the medication/supplement not being available. During an interview on 07/22/22 at 3:04 P.M., LPN 10 indicated the Pro-Stat for residents was supplied by the dietary department. If it was unavailable from dietary and there was a physician's order the pharmacy would be contacted, and it would be ordered through them. If the medication/supplement was unavailable to administer the pharmacy should have been contacted and a progress note documented in the clinical record. During an interview on 07/22/22 at 3:08 P.M., the ADON (Assistant Director of Nursing) indicated the Pro-Stat was provided by dietary and if they could not get it in a timely manner then it would be ordered from the pharmacy. The current facility policy titled, Medication Reordering updated January 2021, was provided by the DON (Director of Nursing) on 07/25/22 at 11:53 A.M. The policy indicated, .It is the policy of the facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biologicals in a timely manner to meet the needs of each resident . 3.1-25(a)

Based on record review and interview, the facility failed to accurately monitor a resident's meal intake for 1 of 3 residents reviewed for nutrition. (Resident 10) Findings include: The clinical record for Resident 10 was reviewed on 07/20/22 at 10:29 A.M. A Significant Change MDS (Minimum Data Set) assessment, dated 04/29/22, indicated the resident was moderately cognitively impaired. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The current Care Plan titled, Nutritional Status, with a start date of 07/19/19, included, but was not limited to, an intervention with a start date of 07/19/19 that indicated staff were to observe and record the resident's intake of food. The July 2022 Vitals Report for breakfast, lunch, dinner, and supplements was provided by the DON (Director of Nursing) on 07/22/22 at 1:37 P.M. The report lacked documentation of the dinner meal for the following dates: - 07/01/22, - 07/02/22, - 07/03/22, - 07/08/22, - 07/13/22, - 07/15/22, - 07/16/22, - 07/17/22, and - 07/21/22. During an interview on 07/21/22 at 10:19 A.M., QMA (Qualified Medication Aide) 12 indicated staff were to monitor resident's fluid and food intake and document in the resident's clinical record. During an interview on 07/22/22 at 11:43 A.M., CNA (Certified Nurse Aide) 6 indicated the resident's meal consumption was documented in the resident's clinical record. The current facility policy titled, Assist Nutrition and Hydration, updated January 2021 was provided by the DON (Director of Nursing) on 07/22/22 at 3:54 P.M. The policy indicated, .Residents within the facility will maintain adequate parameters of nutritional and hydration status, to the extent possible, to ensure each resident is able to maintain the highest practicable level of well-being . 3.1-46(a)(1)

Based on observation, record review, and interview, the facility failed to implement interventions to prevent pressure ulcers for 2 of 6 residents reviewed for pressure ulcers. (Residents 56 and 28) Findings include: 1. During an observation and interview on 07/22/22 at 10:30 A.M., Resident 58 was lying in bed on his left side. His left foot was lying on the bed and resting on the mattress. RN 11 had indicated the resident had a healed pressure ulcer to the left foot close to the pinky toe where the foot was currently pink/red in color. The clinical record for Resident 56 was reviewed on 07/20/22 at 2:00 P.M. An Annual MDS (Minimum Data Set) assessment, dated 02/07/22, indicated the resident was rarely/never understood. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was at risk for pressure ulcers and required two or more total staff assistance with bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. The complete Care Plans was provided by the DON (Director of Nursing) on 07/22/22 at 3:17 P.M. The Care Plan included, but were not limited to, A Care Plan for skin related to the resident's high risk for pressure injury/ulcer with a start date of 06/23/20 that included the following interventions: - Apply pressure relieving mattress to the bed, check for bottoming out to ensure appropriateness of the mattress choice, - consult provider for appropriateness of using topical medication and gently apply to promote absorption, - encourage and assist with routine changes in position, - inspect skin over bony prominences and dependent areas with position changes, - keep linens free of wrinkles and foreign matter, - keep skin clean and dry. Use a skin lubricant/lotion on all areas, blot the skin dry, and never rub, - notify dietary of risks, - observe fluid intake daily, - protect skin from mechanical injury via slide board, turn sheet, trapeze, and/or lubricant use, - reposition at least every 2 hours or more frequently depending on resident's condition and tolerance of pressure. Reduce pressure over bony prominences and avoid positioning directly on the greater trochanter, and A Care Plan for skin related to the resident's risk for pressure ulcers and risk for development of non-pressure skin conditions due to intracranial injury, [CONDITION(S)], contractures, [CONDITION(S)], convulsions, chronic pain, dysphagia, [CONDITION(S)], gastroesophageal reflux, [CONDITION(S)], and history of pressure ulcers with a start date of 04/05/16, included the following interventions: - geri sleeves to the bilateral upper extremities at all times, - use caution when removing/placing clothing to avoid skin tears, - assist resident to turn and reposition every two hours and as needed, - assure proper application of any splints/braces, - avoid friction of the skin with bed linens, bed, or chair, - keep bed linens as wrinkle free as possible and free of foreign matter, - leave carelift sling under resident. Limit creasing and tucking as much as possible, - observe for and report any signs of skin breakdown to the MD, - pressure reducing cushion in the wheelchair, - pressure reducing mattress to the bed, - provide heel and elbow protectors if applicable. Keep padding under resident's elbow on wheelchair table. Pad foot pedal pegs on wheelchair if foot pedals are not attached, - provide incontinence care after each incontinent episode, - provide showering per schedule. Place bath blanket between resident and shower gurney for protection of skin, - refer to dietician as necessary to evaluate nutritional needs, - resident to wear socks at night, - siderails to aid in improved mobility and transfers, and - use lotion to maintain skin hydration. Thoroughly was and rinse resident's skin and blot dry rather than rubbing. The Point of Care bathing documentation indicated the resident had received either a bed bath or partial bed bath the following dates: - 02/05/22 a partial bed bath, - 02/07/22 a partial bed bath, - 02/08/22 a partial bed bath, - 02/09/22 a shower and partial bed bath, and - 02/12/22 a partial bed bath. A Wound Management Detail Report, dated 02/13/22 at 9:59 A.M., indicated there was a fluid filled purple blister to the left foot found during the A.M., care. There was redness surrounding the area that measured 5.7 cm (centimeters). There was 2+ [CONDITION(S)] on the whole top half of the foot and it was warm to touch. A Wound Management Detail Report, dated 02/13/22 at 7:18 P.M., indicated the resident had an unstageable- deep tissue injury (Persistent non-blanchable deep red, maroon or purple discoloration) to the left foot that measured 5.5 cm (centimeters) X (by) 3.5 cm. The wound was a dark, fluid filled blister and skin prep was applied. A Wound Management Detail Report, dated 02/23/22 at 1:10 P.M., indicated the resident had an unstageable wound with slough (yellow or white) /eschar (dry, adherent, intact without [CONDITION(S)] or fluctuance) to the left foot. The blood filled blister had reabsorbed and was an intact area of eschar/scabbing. A Wound Management Detail report, dated 03/11/22 at 11:37 P.M., indicated the resident had gone to a wound care center and had the eschar removed from the left foot. The skin was pink/red and healed. A Weekly Skin Sweep, dated 02/05/22, indicated the resident had no new skin areas. The February 2022 EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) indicated the following: - An open ended physician order, dated 02/14/22, to keep the left foot propped up to keep pressure off of it as much as possible, every shift, - An open ended physician order, dated 02/14/22, for nursing to apply skin prep to the left foot pressure area by the 5th metatarsal, every shift - An open ended physician order, dated 05/29/20, to assure the resident's shoes were on in the A.M., once a day The EMAR/ETAR orders were signed out per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The clinical record lacked any indication the resident's feet had been elevated or that there was any redness or skin impairment to the left foot prior to the finding on 02/13/22 of a purple fluid filled blister. During an interview on 07/21/22 at 10:19 A.M., QMA (Qualified Medication Aide) 12 indicated she would alert the nurse of any new skin conditions. The residents were offered showers twice a week and the nurse assessed the skin once a week. During an interview on 07/21/22 at 2:21 P.M., RN 11 indicated the resident had a feeding tube and took nothing by mouth. The resident was unable to move around in the bed on his own, so the staff had to reposition him. He had pressure ulcer to his left foot that had since healed, and she was unsure how it developed. During an interview on 07/22/22 at 2:18 P.M., the DON indicated the resident had a blister that was a deep tissue pressure injury. The resident had contractures and with the resident having fragile skin the deep tissue injury could have developed quickly and the resident had some [CONDITION(S)] as well. The resident's left foot should be propped up to keep pressure off of it, and skin prep should continue to be applied to the left foot as a preventative. 2. The clinical record for Resident 28 was reviewed on 07/20/22 at 1:23 P.M. A Quarterly MDS assessment, dated 02/25/22, indicated the resident was cognitively intact. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was at risk for pressure ulcers and required two or more staff assistance with bed mobility, dressing, toilet use, personal hygiene, and bathing. The complete Care Plan was provided but the ADON on 07/22/22 at 3:20 P.M., the Care Plans included but were not limited to, A Care Plan for skin related to the resident's moderate risk for pressure injury/ulcer with a start date of 06/23/21, included the following interventions: - check bony prominences for redness, - encourage ambulation as much as the resident is able, - encourage changes in position at least every two hours and assist as required, - keep bed linens free of wrinkles and foreign matter, - keep skin clean and dry. Thoroughly wash and rinse all soap, blot dry and never rub, - report/record skin condition each week or more frequently if problem exists, - use skin lubricant/lotion during A.M. and evening care, - when lifting the resident, avoid friction the skin with linens, bed, or chair, and - when moisture is found, change the linens, gown, and pads, as soon as possible. If moisture is from urine or feces, the area should be washed and dried, and A Care Plan for skin related to the resident's risk for pressure ulcers and risk for development of non-pressure skin conditions due to decreased mobility related to [CONDITION(S)], and personal history of pressure ulcers and incontinence with a start date of 05/27/21, included the following interventions: - air mattress, - apply skin prep to bilateral heels every three days for thirty days after admission/re-admission, then discontinue, - assist resident to turn and reposition every 2 hours, - avoid friction of the skin with bed linens, bed, or chair, - encourage adequate food and fluid intake to maintain optimal nutrition, - encourage resident to get out of bed daily as tolerated and encourage to ambulate if able, - encourage resident to turn and reposition every two hours and as needed, - keep linens as wrinkle free as possible and free of foreign matter, - monitor lab values as ordered, - observe for and report any signs of skin breakdown to MD, - pressure reducing cushion in wheelchair, - provide medications as ordered, - provide showering per schedule, - refer to dietician as necessary to evaluate nutritional needs, - siderails to aid in improved mobility and transfers, - use lotion to maintain skin hydration. Thoroughly wash and rinse resident's skin and blot dry rather than rubbing, and - weekly skin sweeps. A Weekly Skin Sweep, dated 03/30/22, indicated the resident had no new skin concerns. A Wound Management Detail Report, dated 04/01/22 at 2:45 P.M., indicated the resident had a darkened area to the tip on the right great toe that measured 0.9 cm X 0.7 cm. A Wound Management Detail Report, dated 05/04/22 at 2:35 P.M. indicated the resident had an unstageable-deep tissue injury to the right great toe that measured 0.5 cm X 0.7 cm. The wound was closed. The treatment was for skin prep, three times a day and a bed cradle to the end of the bed to relieve pressure from the blankets, and offloading boots. A Wound Management Detail Report, dated 06/01/22 at 6:49 A.M., indicated the resident had an unstageable-deep tissue injury to the right great toe that measured 0.8 cm X 0.7 cm. The wound was improving. A Wound Management Detail Report, dated 07/20/22 at 7:46 A.M., indicated the wound to the right great toe had healed. A Wound Management Detail Report, dated 05/04/22 at 2:32 P.M., indicated the resident had an unstageable-deep tissue injury to the left great toe that measured 0.1 cm X 0.2 cm. A Wound Management Detail Report, dated 06/16/22 at 1:27 P.M., indicated the wound to the left great toe had healed. The March, April, and May 2022 EMAR/ETAR included the following: - an open ended physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] - an open ended physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The EMAR/ETAR orders were signed out per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A Progress Note, dated 03/16/22 at 2:15 P.M., indicated the resident was refusing to use a pillow to keep her heels floated off the bed. A fax was sent to the NP (Nurse Practitioner) to ask for waffle boots to apply to the resident's feet to avoid pressure areas, with the resident choosing to stay in bed frequently. A Progress Note, dated 03/16/22 at 2:55 P.M., indicated waffle boots could be used. A Progress Note, dated 03/24/22 at 12:04 P.M., indicated the resident had been compliant with all orders including the recent order for offloading boots while in bed. A Progress Note, dated 03/30/22 at 12:57 P.M., indicated the resident had no behaviors that shift and had stayed in bed. A Progress Note, dated 04/01/22 at 2:43 P.M., indicated the resident had 2+ [CONDITION(S)] noted to her left calf. The NP was notified and ordered to prop the left leg up and change position. An area had been found on the resident's right great toe that measured 0.7 cm X 0.9 cm, blanchable and skin prep was applied. A Progress Note, dated 04/06/22 at 10:56 A.M., indicated the facility wound nurse was contacted to look at the resident's pressure areas and buttocks. She had stated she would come look at them that day and awaiting new orders from the facility wound nurse. A Progress Note, dated 04/08/22 at 10:31 A.M., indicated the facility wound nurse was contacted to update regarding the redness on the resident's right great toe worsening. The wound nurse was to look at the area and would look for a bed cradle to help keep the blankets off the resident's toes. A Progress Note, dated 05/04/22 at 3:04 P.M., indicated a new area was noted to the resident's left great toe. There were no Progress Notes in the clinical record from 04/30/22 through 05/04/22. The clinical record lacked a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record lacked any indication the resident's toes had redness or impairment prior to the deep tissue injuries on 04/01/22 and 05/04/22. During an interview on 07/21/22 at 2:18 P.M., RN 11 indicated the resident didn't get out of bed often. She had an air mattress, a bed cradle, and protective boots for her heels. They would turn and reposition the resident as she would allow. The resident had pressure injuries to the tops of her toes that she believed started from the blankets resting on her feet. The resident was tiny and fragile. During an interview on 07/22/22 at 2:13 P.M., the DON indicated the resident had been refusing a lot of care and turning and repositioning. She believed the pressure wounds on her toes had started from the bed covers because she was refusing to wear her boots. They had started using a bed cradle since then, They had started the skin prep on 04/01/22. The resident had no redness prior to the pinpoint areas starting on the top of her toes. During an observation on 07/21/22 at 10:49 A.M., the resident's toes were observed with no areas noted. Offloading boots and a bed cradle were in place. The current facility policy, titled Pressure Injury Prevention and Management updated January 2021 was provided by the DON on 07/22/22 at 3:17 P.M. The policy indicated, .This facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries .The facility shall established and utilize a systemic approach for pressure injury prevention and management, including assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate . 3.1-40(a)(1)

Based on observation, record review, and interview, the facility failed to provide meals to residents needing assistance in a dignified manner for 2 of 5 residents dining observations. (Residents 36 and 34) Findings include: 1. The dining room on the locked dementia unit was observed on 07/18/22 at 1:04 P.M. Resident 36 was sitting in a wheelchair at a table. Her meal was on the table on a plate with a plastic dome covering the plate. The resident's silverware was still wrapped in a napkin and laying on top of the cover over her plate. The resident's pop can was unopened. No staff were helping the resident to eat. Some of the residents in the locked unit's dining room were already finished with their meals. Two staff members were assisting other resident's with their meals. At 1:09 P.M., RN 7 asked the resident if she wanted to eat, took the cover off of her plate, and poured her pop into a cup of ice. The staff member stood on her feet and fed the resident her meal using a spoon. The staff member remained standing. There was a chair available for the staff member to sit down on. At 1:22 P.M., the two residents on either side of Resident 36 were finished with their meals and one had been taken to his room. RN 7 continued to stand over the resident and assist them with their meal until 1:37 P.M. The clinical record was reviewed on 07/20/22 at 10:08 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 07/08/22, indicated the resident was severely cognitively impaired. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required extensive assistance of two staff members for bed mobility, dressing, toilet use, and personal hygiene. The resident required extensive assistance of one staff member for eating. 2. The dining room on the locked dementia unit was observed on 07/20/22 at 9:16 A.M. RN 8 was standing and assisting Resident 34 with their breakfast meal. The dining room on the locked dementia unit was observed on 07/22/22 at 9:13 A.M. RN 7 was standing over the resident as she assisted her with her meal. At 9:16 A.M., RN 7 asked the resident if she wanted to eat, covered the resident's plate, and returned it to the kitchen cart. Little of the pureed meal had been eaten. During an interview at 9:18 A.M., RN 7 indicated she had offered the resident food and drinks a few times and the resident had shaken her head no and clenched her mouth shut. A second staff member attempted to assist the resident with her meal, sitting down to assist the resident in an available chair. At 9:26 A.M., the resident continued to eat while being assisted by the new staff member, CNA (Certified Nurse Aide) 9, who was speaking softly to the resident. The resident finished eating at 9:29 A.M., having consumed 25% of her meal. The clinical record was reviewed on 07/25/22 at 11:16 A.M. A Quarterly MDS assessment, dated 05/26/22, indicated the resident was severely cognitively impaired. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required extensive assistance of one staff member for eating and was on a mechanically altered diet. During an interview on 07/22/22 at 2:33 P.M., CNA 9 indicated when assisting residents with their meals she talked to the resident as she was working with them. Sometimes she would set the residents' food to the side if they had refused to eat and came back a little later and tried again. She explained to the residents the importance of eating. She helped new hires in training to assist residents with their meals. Staff should sit down at eye level with a resident and ensure they are sitting up straight when assisting them with their meals. It was a choking hazard if they were laying back. The current Meal Supervision and Assistance Policy was provided by the DON (Director of Nursing) on 07/22/22 at 3:53 P.M. The policy indicated, .The resident will be prepared for a well-balanced meal in a calm environment .with adequate supervision and assistance to .provide adequate nutrition, and ensure an enjoyable event .This includes .Monitoring for effectiveness and modifying interventions when necessary .Provide a relaxing, enjoyable environment during the mealtime . 3.1-3(v)(1)

Based on observation, record review, and interview, the facility failed to ensure infection control practices for COVID-19 were implemented during the pandemic, when the facility failed to place newly admitted residents in transmission-based precautions on the facility's yellow unit, for 5 of 10 residents reviewed for infection control (Residents B, C, D, E, F). Four residents on this unit exhibited symptoms of COVID-19 and did not have isolation precautions implemented until they tested positive for COVID-19. This created the increased likelihood of [MEDICAL CONDITION] spreading throughout the unit while staff were caring for residents without wearing all recommended PPE (personal protective equipment). The Immediate Jeopardy began on 10/08/20, when the facility failed to implement transmission based precautions when newly admitted residents began having symptoms of COVID-19 and to ensure infection control practices for COVID-19 were followed. The Administrator was notified of the Immediate Jeopardy on 10/14/20 at 3:51 P.M. The Immediate Jeopardy was removed on 10/16/20 but noncompliance remained at lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. During an observation and interview on 10/14/20 at 10:13 A.M., the yellow unit (residents, if potentially exposed to COVID-19, should be cared for in a COVID-potentially exposed zone until 14 days) was observed. There were no indications the residents were on transmission based precautions. CNA 3 entered Resident F's room to assist the resident with filling out a menu. She walked into the resident's room towards the resident's bed. The CNA was not wearing a gown. The DON (Director of Nursing) indicated the residents on the unit were all new admissions/re-admissions. The residents were quarantined to their room but were never on any droplet precautions. The facility had been looking to implement droplet precaution, but they were going through too many gowns. There were 6 residents on the yellow unit. The nurse on duty was working the yellow and red (area for resident's with COVID-19 positive) zone. The following residents were recently admitted , had resided on the yellow unit, and tested positive for COVID-19 during their 14 day quarantine: 2. The clinical record for Resident B was reviewed on 10/14/20 at 10:20 A.M. An Admission MDS assessment, dated 10/02/20, indicated the resident was cognitively intact. [DIAGNOSES REDACTED]. A Progress Note, dated 10/08/20 at 5:57 A.M., indicated the resident had been awake most of the night and had 2 cups of tea, complaining of a sore throat. The writer had messaged the NP (Nurse Practitioner) to request as needed cough drops. A Progress Note, dated 10/08/20 at 6:50 P.M., indicated the resident had complaints of a sore throat and not being able to clear mucus from her throat. A fax was sent to the NP and a new order was obtained for cough drops. A Progress Note, dated 10/10/20 at 3:36 P.M., indicated the resident was noted to have a cough, sore throat, and runny nose. The resident was afebrile. The writer notified the weekend supervisor. The resident was tested for COVID-19 and the resident was placed on isolation precautions. The LTC (Long Term Care) Respiratory Surveillance Line List, indicated Resident B's symptom onset date was 10/08/20 that included cough, sore throat and runny nose. The collection date was 10/10/20 and the resident's results were acquired on 10/10/20. The resident tested positive for COVID-19. The clinical record lacked any documentation that the resident was placed in transmission based precautions prior to testing positive for COVID-19 on 10/10/20. 3. The clinical record for Resident C was reviewed on 10/14/20 at 10:20 A.M. An Admission MDS assessment, dated 10/05/20, indicated the resident was cognitively intact. [DIAGNOSES REDACTED]. A Progress Note, dated 10/10/20 at 2:47 A.M., indicated at 0000 (midnight) the resident complained of feeling like she couldn't breath. She stated that it feels like an elephant is sitting on my chest when I try to take a breath. Vital signs taken and recorded. The resident did not want to go to the ER (emergency room ). The NP was notified and new orders were obtained to give [MEDICATION NAME] (diuretic medication), obtain a CBC (Complete Blood Count) with differential, BMP (Basic Metabolic Panel), BNP (Brain Natriuretic Peptide), and a chest X-ray. A Progress Note, dated 10/11/20 at 10:42 P.M., indicated the resident complained of Elephant on my chest again. The vital signs were taken and recorded. The NP was notified and new orders were obtained for [MEDICATION NAME] and another NP would see the resident in the morning. A Physician Assessment, dated 10/12/20, indicated .Intake .COVID symptoms: Reports Shortness of Breath . A Progress Note, dated 10/13/20 at 9:52 A.M., indicated the resident was placed in isolation due to COVID-19 diagnosis. The LTC Respiratory Surveillance Line List, indicated Resident C's symptom onset date was 10/10/20 that included shortness of breath. The collection date was 10/13/20 and the resident's results were acquired on 10/13/20. The resident tested positive for COVID-19. The clinical record lacked documentation that the resident had been placed on transmission based precautions prior to the positive COVID-19 results on 10/13/20. 4. The clinical record for Resident D was reviewed on 10/14/20 at 10:20 A.M. An Admission MDS assessment, dated 10/06/20, indicated the resident was moderately cognitively impaired. [DIAGNOSES REDACTED]. A COVID-19 Rapid [MEDICATION NAME] Test was performed on 10/10/20 at 4:30 P.M., for the resident due to a possible exposure. A Progress Note, dated 10/13/20 at 9:53 A.M., indicated the resident was on isolation precautions due to COVID-19 diagnosis. The only symptoms document for the resident were located on the respiratory line list. The resident had a cough. The LTC Respiratory Surveillance Line List, indicated Resident D's symptom onset date was 10/10/20 that included a cough. The collection date was 10/13/20 and the resident's results were acquired on 10/13/20. The resident tested positive for COVID-19. The clinical record lacked documentation that the resident had been placed on transmission based precautions prior to the positive COVID-19 test result on 10/13/20. 5. The clinical record for Resident E was reviewed on 10/14/20 at 10:20 A.M. The admission MDS assessment was in progress. The resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The resident was asymptomatic and tested for COVID-19 on 10/10/20 with routine testing. The resident's test results were acquired on 10/10/20. The resident tested positive for COVID-19 and was placed on isolation at that time. The resident was on the yellow unit upon the 10/03/20 admission. The resident was not on droplet isolation until seven days later when a positive COVID-19 test result was acquired on 10/10/20. During an interview on 10/14/20 at 12:22 P.M., RN 2 indicated that when nursing staff were assigned to a unit then they would stay on that unit for the entire shift. When a resident was placed on droplet precautions the staff should wear goggles/face shield, gloves, gown, and a mask. The residents on the yellow unit have been placed on quarantine to their rooms for 14 days and staff only wore goggles/face shield and a mask when providing care for them. They have discussed requiring full PPE when caring for the residents, but full PPE had not been implemented. During an interview on 10/15/20 at 11:57 A.M., CNA (Certified Nurse Aide) 3 indicated staff had not been wearing gowns with any residents on the yellow unit. She was always assigned to the yellow unit and would work the yellow unit her entire shift. The current facility policy titled INFECTION CONTROL POLICY NOVEL CORONOVIRUS PREVENTION AND RESPONSE, with a revised date of September 4, 2020, and provided by the Administrator on 10/14/20 at 2:00 P.M. The policy indicated .Interventions to prevent the spread of respiratory germs within the facility: .This facility will respond promptly upon suspicion of illness associated with novel coronavirus in efforts to identify, treat, and prevent the spread of [MEDICAL CONDITION] .ii. In general, for car of residents with undiagnosed respiratory infection use Standard, Contact, and Droplet precautions . The CDC guidance - Preparing for COVID-19 in Nursing Homes, dated as updated 6/25/20, indicated the following: Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown. -Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. Testing at the end of this period can be considered to increase certainty that the resident is not infected. The CDC guidance, Responding to Coronavirus (COVID-19) in Nursing Homes, dated as updated 4/30/20, indicated the following: Resident with new-onset suspected or confirmed COVID-19 - Ensure the resident is isolated and cared for using all recommended COVID-19 PPE. Place the resident in a single room if possible pending results of [DIAGNOSES REDACTED]-CoV-2 testing. The Immediate Jeopardy that began on 10/08/20 was removed on 10/16/20, when the facility intiated staff to wear gowns when entering a room on the yellow hall and all staff were inserviced on appropriate PPE and signs and symptoms of COVID-19. The Immediate Jeopardy was removed but noncompliance remained at the lower scope and severity of pattern, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, because the IP will need to review and log daily all residents with symptoms, conduct surveillance for potential infection outbreaks, and determine trends of all infections, and report any noted trends to the ED, DON, and Medical Director. 3.1-18(a)

Based on observation, interview, and record review, the facility failed to transfer a resident using the required number of staff which resulted in a resident acquiring a fractured ankle. This deficient practice effected 1 of 3 residents reviewed for accident hazards. (Resident B) Findings include: The Clinical Record for Resident B was reviewed on 07/25/19 at 12:34 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 04/23/19, indicated the resident had memory problems. The resident required the assistance of two staff members for bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident's [DIAGNOSES REDACTED]. The Progress Notes for Resident B were provided by the Administrator on 07/25/19 at 2:15 P.M. A note, dated 06/08/18 at 4:00 P.M., indicated the resident was being assisted into bed with one assist. The resident's foot became caught underneath the side of the bed. The resident voiced some discomfort at that time. The resident's right ankle was assessed and noted to have Moderate swelling on the top and around the entire diameter of the ankle. The ankle was very tender to the touch. A note, dated 06/08/19 at 4:20 P.M., indicated the NP (Nurse Practitioner) gave an order for [REDACTED]. A note, dated 06/08/19 at 5:50 P.M., indicated the emergency room nurse had called and reported the resident had a fracture to the right ankle. A note, dated 07/17/19 at 1:40 P.M., indicated the resident required the physical assistance of two staff members with the sit to stand lift prior to the ankle injury. The Emergency Department Physician Documentation, dated 06/08/19, was provided by the Administrator on 07/25/19 at 2:29 P.M. The document indicated Resident B's Chief Complaint was a right ankle injury. The X-ray findings revealed an acute fracture. The Occupational Therapy Plan of Care for Resident B was provided by the Therapy Manager on 07/25/19 at 1:23 P.M. The Plan indicated, prior to the start of care on 06/13/19, the resident performed transfers with the maximum assistance of 2 staff members. The Care Plans for Resident B were provided by the Administrator on 07/25/19 at 3:09 P.M. A Care Plan, with a discontinued date of 06/08/19, indicated a stand up lift was to be used for transferring the resident. During an interview on 07/25/19 at 10:48 A.M., CNA 3 indicated all CNA staff had a Pocket Paper (CNA Assignment Sheet) that gave specific information about each resident. The information included, but was not limited to, how each resident was to be transferred and how many staff members were required to transfer the resident. During an interview on 07/25/19 at 11:55 A.M., LPN 2 indicated all resident lifting equipment required two staff members for use. During an interview on 07/25/19 at 12:48 P.M., LPN 2 indicated Resident B required the use of the sit to stand lift with the assistance of two staff members prior to the incident involving her ankle injury. The CNAs were provided a worksheet (CNA Assignment Sheet) prior to their shift that contained information on each resident. The sheet included how each resident was transferred and how many staff were needed to provide assistance to each resident. During an interview on 07/25/19 at 12:59 P.M., the Therapy Manager indicated resident B had a lot of knee pain. On 03/06/18, the resident was discharged from therapy and required two staff physical assistance with transfers. The resident was unable to walk from a wheelchair to the bed. The resident had not shown signs of improvement with her strength or mobility. The resident had [MEDICAL CONDITION]. She had a lack of participation in therapy and they were unable to get her to a higher level of mobility. During an observation on 07/25/19 at 10:54 A.M., the sit to stand lift, on the locked unit, had a large orange sign with the number 2 on it. CNA 4 indicated the sign told staff how many staff members were required to use the lift. During an observation on 07/25/19 at 11:55 A.M., Resident C was transferred, using the sit to stand lift, with the assistance of two staff members. The procedure was explained to the resident throughout the process. No issues were observed. The CERTIFIED NURSE AIDE JOB SPECIFIC ORIENTATION checklist was provided by the Administrator on 07/25/19 at 3:09 P.M. The checklist included, but was not limited to, .Proper use of mechanical lifts, including sit to stand . This Federal tag relates to Complaint IN 678. 3.1-45(a)(2)

Based on observation, interview, and record review the facility failed to ensure nursing staff promptly notified the physician of Resident #34's pressure ulcer worsening from a stage 1 pressure sore on 5/22/12, which progressed to a stage 2 on 5/31/12 and to a stage 3 on 6/20/12, for 1 of 21 residents reviewed for notification in the sample of 21. Findings Include: On 06/18/12 at 10:00 a.m. Resident #34 was observed to have an open are on her coccyx. Review of Resident #34's clinical record on 06/18/12 at 4:15 p.m. indicated the following: A physician's re-write, signed 5/26/12, included an order which was started 5/25/2012, for "Facility Barrier Cream - apply to coccyx, buttocks, & peri area three times a day for maintenance." A nurse's note dated 05/22/12 at 9:00 p.m. indicated, "Assessed pressure 1 area to coccyx. Area is chronic condition & will monitor weekly for area to be continue improvement (sic). Area is opened this week. Measuring 0.4 x 0.4 x (less than sign) 0.1. Continue A&D ointment q shift....This nurse's note was signed by LPN #2. A weekly pressure ulcer healing record dated 05/22/12 indicated Resident #34 had a 0.4 cm x 0.4 cm stage 1 pressure area on her coccyx.... "Area opened up. Cont (Continue) A&D ointment (preventative ointment frequently used for diaper rash)." A nurse's note, dated 05/24/12 at 8:30 p.m., indicated a physician's response to Resident #34's blood sugars. The nurse's note lacked documentation supporting the physician was notified of Resident #34 having a new open area. A Weekly Pressure Ulcer Healing Record, dated 05/31/12, indicated, "Area open - wound 1 x 1 cm (centimeter) 0.2 cm deep, stage 2...covered wound with moist collagen & Allevyn dsy (dressing)." A nurse's note dated 05/31/12 at 10:30 p.m. indicated, "When checking Res (Resident #34's) coccyx, found that area has re-opened approx (approximately) 1.0 x 1.0 cm, round in appearance, pink/dusky in color. 0 (No) drainage. Approx 0.2 cm deep. Cleansed area c N.S. (normal saline). Applied moistened collagen (wound treatment) to area, then applied Allevyn (wound treatment) Thin to area. Left msg in care track for wound care nurse (LPN #2)." During interview, on 6/21/12 at 8:30 A.M., with LPN #3, she indicated she had applied the collagen and dressing because the area was open and had left a note in caretracker for the wound nurse. She indicated she thought the area needed a dressing as it was open. LPN #3 indicated she had not notified a physician. The next entry on the Weekly Pressure Ulcer Healing Record, dated 06/05/12, indicated the area was "improved" and A&D ointment was used. Wound measurements for this date were 0.8 cm x 0.7 cm, a stage 2 pressure ulcer. A Weekly Pressure Ulcer Healing Record, dated 06/12/12 indicated Resident #34's coccyx area wound measured 0.2 x 0.6 cm. and A&D ointment was the treatment at this time, a stage 2 pressure ulcer. A nurses notes entry, dated 6/14/12 8 p.m., indicated " assessed pressure I area to coccyx. Measures .2 by .2 by less than .1. A & D continues every shift...routinely dependant on staff for all care..." A physician's telephone order, dated 06/18/12, indicated, "Pressure Area to coccyx: Cleanse c NS (Normal Saline) apply Collagen piece, foam & cover q day & prn x 7 days & re-eval." The facility lacked evidence of the physician having been notified of the area opening from a stage 1 pressure area on 5/22, to a stage 2 pressure area on 5/31/12, and remaining a stage 2 pressure area, until 6/18/12. On 06/20/12 at 1:35 p.m. LPN #2 was observed to measure the area on Resident #34's coccyx. The area measured 1.5 length x 1.1 width x 1.5 depth. The area was observed to have yellow slough in center with pink surrounding the slough. LPN #2 indicated the area was a stage III area. The clinical record was reviewed on 6/21/12 at 9:00 A.M. and documentation was lacking of the facility having made the physician aware of the area worsening to a stage 3 pressure ulcer. The policy and procedure, obtained from the Director of Nursing, on 6/21/12 at 9:30 A.M., no date, indicated, "The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On call Physician when there has been: ...a significant change in the residents physical/emotional/mental condition...a need to alter the residents medical treatment significantly...except in medical emergencies notification will be made within twenty four hours of a change occurring in the residents...status. 3.1-40(a)(2)

Based on observation, interview, and record review the facility failed to ensure a resident did not develop a stage 3 pressure sore while residing within the facility, in that Resident #34 was observed to have a stage 1 pressure sore on 5/22/12 which progressed to a stage 2 on 5/31/12 and to a stage 3 on 6/20/12 without physician notification of the area worsening, for 1 of 5 residents reviewed for pressure ulcers in the sample of 21. Findings Include: On 06/18/12 at 10:00 a.m. CNA #1 and CNA #2 were observed to provide incontinence care for Resident #34. The resident was observed to have been incontinent of both stool and bladder. While CNA #1 was cleansing Resident #34's bottom of stool and wiping front to back, an open area was observed in Resident #34's inner mid buttocks. Neither of the CNA's commented on the open area. On 06/19/12 at 10:45 a.m. LPN #1 and RN #1 were observed to provide incontinence care for Resident #34. The resident was observed to have been incontinent of stool and urine. While providing incontinence care, an open area was observed in the resident's mid inner buttocks. LPN #1 indicated she thought a dressing had been placed on the area last evening shift and it had probably fallen off during care and the CNA's had forgotten to tell the nurse. LPN #1 was observed to cleanse the open area with normal saline and applied a piece of collagen which had been moistened with normal saline over the resident's open area, covered the area with a foam dressing, and secured the dressing with cover-roll. Interview of LPN #1 on 06/19/12 at 10:45 a.m. indicated she needed to instruct the CNA's via the Kiosk (computer charting mechanism) to notify nursing when Resident #34's dressing came off. Review of Resident #34's clinical record on 06/18/12 at 4:15 p.m. indicated the following: Resident #34 had [DIAGNOSES REDACTED]. An annual MDS (minimum data set) assessment, dated 03/10/12, indicated Resident #34's cognitive status was severely impaired, the resident required extensive assistance of staff for transfers, bathing and hygiene, and bed mobility. The MDS assessment indicated Resident #34 required extensive assistance of staff for bed mobility, was at risk for skin breakdown and had a stage 1 pressure ulcer during the time of the MDS assessment. A physician's fax order, dated 03/08/12, indicated, "...New open area on bony prominence 1.6 x (by) 0.5 x (less than emblem) 0.1...." The fax order indicated the open area was to have a daily and as needed wound treatment of [REDACTED]. A physician's re-write, signed 5/26/12, included an order which was started 5/25/2012, for "Facility Barrier Cream - apply to coccyx, buttocks, & peri area three times a day for maintenance." Copies of Treatment Sheets were provided by LPN #1 on 06/19/12 at 11:35 a.m. The Treatment Sheets included the months of May and June 2012. Both the May and June treatment sheets had an order which was dated, 05/25/10, for "Facility Barrier Cream - apply to coccyx, buttocks, & peri area three times a day for maintenance. A "Daily Monitoring For Pressure Ulcers" sheet, dated April, 2012, indicated a coccyx area pressure sore was healed on 04/11/12. A nurses's note dated 04/25/12 at 2:00 p.m. indicated, "MD responded back to area reported on coccyx. N.O. may have wound care nurse eval (evaluate) and tx (treat) area on coccyx." A nurse's note dated 04/25/12 at 8:00 p.m. indicated, "Looked at area on coccyx. Area continues to have opened up & caused reddened area. Area Pressure I measures 0.3 x 0.3 x (less than sign) 0.1. Cont A&D ointment q shift. Relies on staff for care. Incont of B&B....Will continue to monitor...." This nurse's note was signed by LPN #2. Interview of LPN #2 on 06/19/12 at 2:00 p.m. indicated LPN #2 was the wound nurse and LPN #2 indicated the doctor usually just wanted him (LPN #2) to use his (LPN #2's) own judgement for assessing and treatment of [REDACTED]. Interview of LPN #2 on 06/20/12 at 1:55 p.m. indicated Pressure I meant the area was a stage 1 area. Review of "Pressure Ulcers in the Long Term Care Setting- copyright 2008" a stage 1 ulcer was identified as, "intact skin with non blanchable redness of a localized area." The documentation identified a stage 2 pressure ulcer as being "partial thickness loss of dermis presenting as a shallow open ulcer with a red pink ulcer bed, without slough*. May also present as an intact or open/ruptured serum-filled blister." A nurse's note dated 05/01/12 at 7:45 p.m. indicated, "Assessed pressure 1 area to coccyx area now pink. Cont A&D ointment q (every) shift....Depends on staff for care...Will cont to observe wkly (weekly)." This nurse's note was signed by LPN #2. A "Weekly Pressure Ulcer Healing Record," dated 05/01/12 indicated, Resident #34 had a pink closed area - "continue to monitor wkly (weekly)." A nurse's note dated 05/14/12 at 5:00 a.m. indicated, "Observed Res (Resident #34) to have an open area 2 cm x cm (sic) on coccyx area. Area is pale/pink, no odor, no drainage...MD notified. (Name of wound nurse) (LPN #2) notified. Requested order from MD to have WCN(wound care nurse) (LPN #2) eval & treat." A nurse's note dated 05/14/12 at 9:10 p.m. indicated, "N.O. (new order) received to have wound care nurse evaluate et treat area on coccyx. Wound care nurse notified of area. A nurse's note dated 05/15/12 at 9:00 p.m. indicated, "Assessed area on coccyx. Stg (Stage) 1. Area cont to be pink. Cont A&D ointment q shift & prn (as needed)....Incont of B & B...." This nurse's note was signed by LPN #2. A "Weekly Pressure Ulcer Healing Record," dated 05/15/12 indicated Resident #34 had a pink stage 1 area on her coccyx. A nurse's note dated 05/22/12 at 9:00 p.m. indicated, "Assessed pressure 1 area to coccyx. Area is chronic condition & will monitor weekly for area to be continue improvement (sic). Area is opened this week. Measuring 0.4 x 0.4 x (less than sign) 0.1. Continue A&D ointment q shift....This nurse's note was signed by LPN #2. A weekly pressure ulcer healing record dated 05/22/12 indicated Resident #34 had a 0.4 cm x 0.4 cm stage 1 pressure area on her coccyx.... "Area opened up. Cont (Continue) A&D ointment (preventative ointment frequently used for diaper rash)." A nurse's note, dated 05/24/12 at 8:30 p.m., indicated a physician's response to Resident #34's blood sugars. The nurse's note lacked documentation supporting the physician was notified of Resident #34 having a new open area. A Weekly Pressure Ulcer Healing Record, dated 05/31/12, indicated, "Area open - wound 1 x 1 cm (centimeter) 0.2 cm deep, stage 2...covered wound with moist collagen & Allevyn dsy (dressing)." A nurse's note dated 05/31/12 at 10:30 p.m. indicated, "When checking Res (Resident #34's) coccyx, found that area has re-opened approx (approximately) 1.0 x 1.0 cm, round in appearance, pink/dusky in color. 0 (No) drainage. Approx 0.2 cm deep. Cleansed area c N.S. (normal saline). Applied moistened collagen (wound treatment) to area, then applied Allevyn (wound treatment) Thin to area. Left msg in care track for wound care nurse (LPN #2)." During interview, on 6/21/12 at 8:30 A.M., with LPN #3, she indicated she had applied the collagen and dressing because the area was open and had left a note in caretracker for the wound nurse. She indicated she thought the area needed a dressing as it was open. LPN #3 indicated she had not notified a physician. The next entry on the Weekly Pressure Ulcer Healing Record, dated 06/05/12, indicated the area was "improved" and A&D ointment was used. Wound measurements for this date were 0.8 cm x 0.7 cm, a stage 2 pressure ulcer. A Weekly Pressure Ulcer Healing Record, dated 06/12/12 indicated Resident #34's coccyx area wound measured 0.2 x 0.6 cm. and A&D ointment was the treatment at this time, a stage 2 pressure ulcer. A nurses notes entry, dated 6/14/12 8 p.m., indicated " assessed pressure I area to coccyx. Measures .2 by .2 by less than .1. A & D continues every shift...routinely dependant on staff for all care..." A physician's telephone order, dated 06/18/12, indicated, "Pressure Area to coccyx: Cleanse c NS (Normal Saline) apply Collagen piece, foam & cover q day & prn x 7 days & re-eval." The facility lacked evidence of the physician having been notified of the area opening from a stage 1 pressure area on 5/22, to a stage 2 pressure area on 5/31/12, and remaining a stage 2 pressure area, until 6/18/12. Interview of LPN #2 on 06/19/12 at 2:00 p.m. indicated he was the wound nurse and the physician usually wanted LPN #2 to assess the wound and do what he wanted to do (for treating wounds)." On 06/20/12 at 1:35 p.m. LPN #2 was observed to measure the area on Resident #34's coccyx. The area measured 1.5 length x 1.1 width x 1.5 depth. The area was observed to have yellow slough in center with pink surrounding the slough. LPN #2 indicated the area was a stage III area. The clinical record was reviewed on 6/21/12 at 9:00 A.M. and documentation was lacking of the facility having made the physician aware of the area worsening to a stage 3 pressure ulcer. Documentation on A&D ointment was provided by the DON on 06/19/12 at 3:35 p.m. The documentation indicated A&D ointment was a skin protectant which helped to treat and prevent diaper rash and help to seal out wetness. The documentation indicated the A&D ointment should be used with each diaper change, especially at bedtime when exposure to wet diapers may be prolonged. Interview of LPN #2 (Wound Nurse) on 06/19/12 at 2:00 p.m. indicated the ointment used for the "House Barrier Cream" was A&D ointment." A policy statement titled "Pressure Ulcer Treatment" was provided by the DON on 06/19/12 at 2:40 p.m. The policy was not dated. The policy statement indicated, "Policy Statement: treatment of [REDACTED]. Since there is marked diversity in the treatment of [REDACTED].When a pressure ulcer is identified, a licensed nurse initiates a preventative plan of care, notifies the physician regarding treatment and documents notification in the clinical record, initiates the weekly pressure ulcer report, and initiates daily documentation of the wound....If the ulcer is not healing, reassess the treatment plan. If necessary, the plan and strategies should be revised if progress is not noted within 2-4 weeks...." 3.1-40(a)(2)

Based on observation, interview and record review, the facility failed to ensure residents were provided with interventions and supervision resulting in repeat falls for 2 of 4 residents reviewed for accidents in the sample of 4. Both residents sustained hip fractures. Resident B and Resident D. Findings include: 1. Resident B was identified as having had a recent fall and fracture by the Health Facility Administrator on 7/14/11 at 10:00 A.M. Resident B was observed on 7/14/11 at 11:00 A.M. to have been in his room, sitting in a recliner with an alarm to alert staff of unassisted transfers. Resident B's room was observed at the end of a hallway, in one of the rooms farthest from the nurses' station. Resident B's clinical record was reviewed on 7/14/11 at 10:30 A.M. The record indicated the resident was admitted to the facility in March of 2011. He was placed on the rehab unit of the facility to receive therapy services. The transfer record, dated 3/11, indicated the resident had a history of [REDACTED]. A care plan problem, dated 3/29/11, of " resident at high risk of falls related to history of CVA (cerebral vascular accident), weakness and unsteady gait." Interventions included: "proper foot wear, call light in reach, side rails to assist with transfers and bed mobility, therapy, transfer and ambulate with 2 assist, gait belt and quad cane, 5/9/11 toilet resident on return to unit after mealtime, 6/12/11 offer to transfer resident to recliner after mealtime." Physical therapy notes, dated 5/24/11, indicated "Patient requires supervision to safely ambulate 150 feet," requires stand by assist for transfers," requires supervision to safely complete full functional transfers." The falls risk assessments indicated the following: 5/6/11- 9:24 p.m., resident alert and oriented with 1 to 2 falls in past 3 months 5/8/11- 8:57 p.m., resident having intermittent confusion 5/24/11- 6:31 p.m., alert and oriented, with 1 to 2 falls in past 3 months 6/12/11- 7:29 p.m., intermittent confusion 6/24/11- 11:36 p.m. intermittent confusion Nurse notes indicated: A post fall reporting form, dated 5/8/11, at 5:40 p.m., indicated Resident B had a fall in his bathroom, due to weakness, getting up from the wheelchair on his own, "resident stated that he thought he could toilet himself, transferred self from wheelchair and fell to floor, landed on bottom with legs extended out." Cause-other-Resident brought back from C wing supper and left on this side of double doors (D wing) Res propelled self to room to self toilet." Physical status-weakness, recent acute illness cerebral vascular accident with left [DIAGNOSES REDACTED]. Summary- Res brought back to D-wing from C-wing after supper. D wing staff not aware res returned to wing, suppertime going on. Res propelled self back to room in wheelchair and tried to self toilet. First fall, care plan updated, intervention added to high fall risk intervention alert sheet-yes. The fall follow- up interventions included: 15 minute checks, C wing staff to notify D wing staff when resident returns to D wing, ask spouse to encourage resident to use call light, seat in lounge after meals, toilet after each meal. 5/9/11- 10 p.m. " direct care staff reviewed fall of 5/8/11. Resident usually needs to toilet after meals...will discontinue 15 minute checks and keeping resident in lounge area after meals. Sitting in lounge on (name of unit) would not be appropriate for resident, it would upset him." 5/24/11- 6:30 p.m. "resident transferred self from his wheelchair to recliner in lounge area per self. Didn't ask for staff assist...." 5/26/11- "6 p res transferred self from his wheelchair to toilet in room... per self. No staff assistance. Res was previously in lounge area for few minutes. Res stating wanting to call police because someone stole his van stated this times 2...6:15 p.m. ...Dr notified of increased confusion...no new orders just observe..." "6/3/11- 1:15 p.m., transferred to room (number on A unit, off D unit where he was)" The next nurses note entry was 6/12/11 6:30 p.m. and included a new order for x-ray of left hip. A post fall reporting form, included as part of the nurses notes, dated 6/12/11 at 5:45 P.M., indicated the resident had a fall, in his room, probable cause-lost his balance, was transferring self from wheelchair to recliner, complaint of left hip pain, history of falls on 5/8/11. Summary-Res in room in wheelchair attempted to transfer self to recliner without using call light to ask for any assistance, history of falls and stroke, new intervention-offer to transfer to recliner after mealtime. Nurses notes indicated he was sent to the hospital the next day, 6/13/11, with a [DIAGNOSES REDACTED]. The MDS assessment, dated 6/13/11, a discharge assessment, indicated the resident had an acute mental status change, had a short term memory problem, and required assistance to make decision. During interview on 7/14/11 at 11:30 A.M., with the Director of Nursing, she indicated she felt the room change may have contributed to his increased confusion. She indicated he became more confused during the facility stay. The facility lacked evidence of having implemented increased supervision or alternate interventions when the resident started showing signs of increased confusion and attempting self transfers. 2. The clinical record for Resident D was reviewed on 7/14/11 at 10:30 A.M. The record indicated Resident D had [DIAGNOSES REDACTED]. The Admission MDS (Minimum Data Set) assessment, dated 5/30/11, indicated Resident D was unable to complete the interview for mental status. The staff assessment for mental status indicated Resident D had short and long term memory problems and severely impaired decision making. Resident D required extensive assistance of two with bed mobility, transfers and toilet use. Resident D required limited assistance of two with ambulation. The MDS indicated Resident D had fallen two or more times without injury since admission. The Resident Admission Assessment, dated 5/23/11 at 2:00 P.M., indicated "...Family stated gets up unassisted at night..." A Care plan, dated 5/23/11, indicated "Resident at high risk for falls R/T (related to) dementia, weakness and unsteady gait. Res (resident) very HOH (hard of hearing)." The interventions were "1. Call light within reach. 2. Side rails to assist with transfers and bed mobility. 3. Therapy per MD orders. 4. Transfer and ambulate with 1 assist and use of gait belt. 5. Non-skid foot wear with transfers and ambulation. Clip alarm in bed and chair. Floor mat sensor beside bed. 5/25/11- 15 minute checks. 5/25/11- When room available, move closer to nurses station. 5/25/11 wear gripper socks while in bed." The clinical record lacked any documentation of Resident D being moved closer to the nurses' station. The fall care plan, dated 5/23/11, was updated on 6/14/11 to include the intervention of "Use gait belt until res in bed." The fall care plan, dated 5/23/11, was updated on 6/15/11 to include the intervention of "Assist res to bed btwn (between) 8p-9p if will allow." The Nurses Notes, dated 5/25/11 at 4:45 A.M., indicated "Fall at 4:30 AM was on end of recliner and sat on foot rest chair went to floor and res slid out to floor. No injuries noted..." The Nurses Notes, dated 5/25/11 at 11:15 P.M., indicated "Res found sitting on floor at 7 AM...." The Post Fall Reporting Form, dated 5/25/11 at 7:00 A.M., indicated "...Restless. Trying to get out of bed. might have gotten legs tangled in catheter tubing. Catheter pulled out when staff walked in..." The Post Fall Reporting Form, dated 6/14/11 at 10:00 P.M., indicated "...Fall to floor...reach out for bed. leaned over too far and fell out of wheelchair...no injuries at this point..." The Post Fall Reporting Form indicated it was a witnessed fall. The form lacked any documentation of who had witnessed the fall or if anyone was assisting Resident D at the time of the fall. The Nurses Notes lacked any documentation of the fall on 6/14/11. The Nurses Notes, dated 6/15/11 at 6:50 P.M., indicated "Met with direct care staff c/o (complaint of) (sic) fall of 6-14-11. Staff to use gait belt on resident until in bed to allow greater control for res safety. Staff to also attempt to assist res to bed btwn (between) 8P-9p before she gets too tired." The Nurses Notes, dated 6/17/11 at 9:00 A.M., indicated "CNA noted resident on floor sitting position back against corner/edge of recliner that she usually sits in. Is probable that resident attempted to transfer self from w/c to recliner. Clip alarm not in place in w/c. CNA missed putting the clip alarm in w/c. Was an unwitnessed fall. Did not hit head...Dr (name) here et (and) checked for injury. R (right) leg shorter than L (left) leg. Dr (sic) ordered for resident to have R hip xray..." The Nurses Notes, dated 6/17/11 at 1:00 P.M., indicated "Met with direct care staff concerning interventions placed 6/14/11 to use gait belt with all transfers and to attempt to assist res to bed between 7p-8p found to be effective." The MD Progress Notes, dated 6/28/11, indicated "Fall reviewed for 6/14/11. Incident occurred in process of transferring from chair to bed. Correction plan is to use gait belt with transfer, should have nonskid socks. Resident should be closely watched for fall probability. Staff counciled (sic)." The MD Progress Notes, dated 6/28/11, indicated "Fall reviewed for 6/17/11. Fall D/T (due to) dementia. Was attempting to transfer. Sensor not on to alert staff. Fall resulted in fx (fracture) of rt (right) hip. Patient transferred immediately after examination of Medical Director. Recommend staff be counseled (sic) this did occur." In an interview with the Administrator, on 7/14/11 at 11:00 A.M., no further information was provided. This federal tag relates to Complaint IN 272. 3.1-45(a)(2)

Based on interview, observation and record review, the facility failed to ensure a resident experiencing pain and signs and symptoms of a fracture received prompt care to manage pain and receive prompt treatment for [REDACTED]. Resident #61. Findings include: 1. Resident #61 was identified on the initial tour of the locked dementia unit, on 4/11/11 at 10:15 A.M., by LPN #19, as having had recent falls and a [MEDICAL CONDITION]. Resident # 61 was observed on 4/12/11 at 9:30 A.M. in her room in bed. . Resident # 61's clinical record was reviewed on 4/11/11 at 10:30 A.M. The most recent Minimum data set assessment ((MDS) dated [DATE], indicated the resident was severely cognitively impaired, required assistance with bed mobility, transfers and ambulation, and was frequently incontinent of urine. Balance during transitions and walking was not steady, only able to stabilize with human assistance while moving from seated to standing and moving on or off the toilet. The resident had fallen since the last assessment, with no injuries. The care plan, dated 10/1/10, included a problem for "Resident at high risk for falls and pain right hip and right groin pelvic area, updated 9/21/10, start date 5/15/2008, FALL 11/16/10 at 1225 a.m." Another problem, dated 9/21/10, for "resident with onset of acute pain in right hip and right groin/pelvic area." Interventions included: "administer pain meds as ordered," "administer prn (as needed) pain meds as needed, ask res to rate pain scale 1 to 10," "monitor for effectiveness of pain meds, notify MD if pain not controlled with current pain meds...." Nurses notes, dated 3/29/11 at 10:45 p.m. indicated "Resident sitting on floor by bed of room (not her own) No bruising/skin tears. No outward signs of broken hips can abduct and adduct both legs without problem. No pop/click heard when moving legs, stood with transfers without problems with assist. Resident complains of left leg pain. [MEDICATION NAME] 7.5/500 given at this time. Updated Dr-asked if would like x-ray..." The Post Fall Reporting Form indicated: "3/29/11 7:00 P.M. resident had a history of [REDACTED]. status was weakness and unsteady gait, physician was notified 3/29/11 at 11:00 P.M. Summary of factors contributing to falls: Resident has increased confusion, thought another resident's bed was hers, tried to transfer self from wheelchair to bed by self, future interventions-redirect when needed." LPN #1, on 4/11/11 at 12:15 P.M., provided a fax, dated 3/29/11 at 10:50 P.M. which indicated "found on floor-sitting by bed. No bruising/skin tears. No outward sign of broken hips can abduct and adduct both legs without problem-No pop or cluck lick heard when moving legs. Stood with transfers from floor to wheelchair and wheelchair to bed without problem with assist. Resident complaints of left leg pain would you like x-ray?" Nurse notes, dated 3/30/11 3:30 A.M. "Resident showered with assist of CNA. Noted right elbow-purple bruise, .5 cm right lateral forearm proximal to elbow, small purple bruise .5 cm right mid thigh lateral aspect 3-4 cm 4 red scrapes, horizontal unopened, right upper leg lateral aspect above knee, small purple bruise, day nurses, ADON, MD notified. ...Resident complains of pain in left leg..." Fall follow up documentation, dated 3/30/11 at 5 a.m. indicated, injuries noted-2 bruises on left arm on and near elbow, area of scrape abrasion left upper leg, lateral aspect near knee, 1 bruise red in color .5 cm above knee, 3 reddish line, 6 cm length 1 cm width area not open, comments: "resident complains of leg pain at 2:55 a.m. complained pain being pretty bad. [MEDICATION NAME]/APAP 7.5/500 one given effective." Nurse's notes, dated 3/30/11 8:40 A.M. indicated "complaints of pain left lower extremity, given prn (as needed) [MEDICATION NAME] 7.5/500 orally at this time. CNA (certified nursing assistant) reported resident cried out in pain when attempted a.m. care, to attempt care at a later time..." Fall follow up documentation, dated 3/30/11 at 12:15 P.M. indicated "question if fracture left lower leg, to request order for x-ray from physician...comments: complains of left groin/left hip pain, screams out with slight attempt with range of motion left lower extremity, complains of pain with flexing left foot in toward had, to request order for x-ray left lower extremity from doctor...resident has stayed in bed with no weight bearing or transferring no ambulation...3/30/11 1:45 P.M. new order x-ray of left hip, femur, knee, tibia, foot." Nurses notes indicated: "3/30/11 at 12:45 p.m. called Dr...office, requested an x-ray order, to return call..." "3/30/11 1:05 p.m. ...from Dr...office called with new order may obtain x-ray of lower left extremity, left hip, femur, knee tibia, foot...called (mobile x-ray service) to do x-rays as soon as possible..." "3/30/11 1:15 p.m. received copy of fax from 3/30/11 7:35 A.M. no new order received." The Assistant Director of Nursing, on 4/12/11 at 11:00 A.M., provided a fax dated 3/30/11 at 7:30 a.m. sent to the physician which indicated: "right elbow .5 diameter purple bruise right lateral fore arm .5 diameter bruise, right mid thigh lateral aspect 3 red lines, scrape 4 cm by 1 cm no open area, right lateral thigh close to knee small .4 cm diameter purple bruise. Noted 2:45 a.m. gave shower." The physician response to the fax was dated 3/30/11 9:33 a.m. Nurses notes indicated: "3/30/11 3:30 p.m. (mobile x-ray service) here to x-ray left leg.""3/30/11 430 p.m. (mobile x-ray just left after x-raying left leg. Res screaming in pain during procedure. gave one [MEDICATION NAME] 7.5/500 mg tab for pain. will monitor." "3/30/11 6:10 p.m. received results of left hip, left tibia and fibula...acute left subcapital fracture with modest displacement....faxed results to Dr...filed results under x-ray results." "3/31/11 8:30 A.M. spoke with Dr...on phone about left [MEDICAL CONDITION]. Dr...states he will call and speak to residents (family member) and then contact and orthopedic surgeon and call us back awaiting return call..." "3/31/11 1015 a.m. ...from Dr...office called with new order to transport via ambulance to...for direct admit..." "3/31/11 11 A (hospital) supervisor called to report will need to go to radiology before being admitted to (hospital) per Dr (name of orthopedic doctor)...." The medication administration records for March 2011 indicated an order for [REDACTED].M., 3:47 P.M. and 10:55 P.M. No medication was administered on 3/31/11 prior to transport and more x-rays. The controlled drug record indicated the last dose of [MEDICATION NAME] administered prior to 3/29/11 at 10:30 A.M. was January 12, 2011. The resident also had an order for [REDACTED]. The facility lacked evidence of having contacted the physician for pain medication ordered for the left hip pain or having administer medication to effectively control the resident's pain in the left hip from the displaced fracture. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure physician's orders were followed for treatment of [REDACTED].#34 resulting in Resident #34's heel pressure area progressing from a fluid filled blister to an unstageable area. This affected 2 of 4 residents, reviewed for pressure ulcers, in a sample of 21. Findings Include: 1. During initial observation tour on 04/11/11 at 10:15 a.m. with Unit Manager (UM) #13 present, Resident #34 was identified as being reliable for interview, as requiring assistance of two staff for transfers, and as having an unstageable ulcer (According to "Pressure Ulcers in the Long-Term Care Setting Clinical Practice Guideline dated 2008, unstageable is defined as - Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the ulcer bed). On 04/12/11 at 10:30 a.m. Resident #34 was observed resting in bed with her right heel on a float. The area was observed to be black in the center with skin pulled away from the eschar (black/necrotic tissue) around the bottom with reddened edges On 04/12/11 at 12:00 p.m., 12:40 p.m., 1:00 p.m., 1:40 p.m., 4:00 p.m., and 5:00 p.m., Resident #34 was observed in her room, seated in her wheelchair. The resident was observed to be wearing fuzzy socks and to have her feet positioned with the heels of her feet flat on the foot pedals of the wheelchair. Interview of Resident #34 on 04/12/11 at 12:40 p.m. indicated she had a "place" on her right heel. The resident indicated she was not aware of how or when the area started. Interview of Resident #34 on 04/12/11 at 4:00 p.m. indicated no one had ever said anything to her about keeping her heels elevated while she was in her wheelchair. The resident indicated she had been in her wheelchair since the interview on 04/12/11 at 12:40 p.m. except to get up once to go to the bathroom. Interview of LPN #10 on 04/12/11 at 1:00 p.m. indicated Resident #34 was admitted to the facility with a blister on her right heel and the blister had popped and left a "sore." Interview of RN #11 (working on the hall Resident #34 resided on) on 04/12/11 at 5:05 p.m. indicated she was not aware that Resident #34's heels had been flat on the wheelchair pedals for 5 hours. After the interview, RN #11 went directly to the resident's room and after several attempts, was able to position the resident's right heel off of the foot pedal with a pillow. Interview of CNA #12 (working the hall Resident #34 resided on) on 04/12/11 at 5:30 p.m. indicated Resident #34 sat up in her wheelchair at least half of the evening shift. CNA #12 indicated she had educated the resident about keeping her right heel elevated, but the resident didn't like to lay down. Interview of CNA #14 on 04/14/11 at 9:45 a.m. indicated the CNA worked PRN (as needed) on the floor Resident #34 resided on, and she was aware the resident was supposed to have her legs elevated when in bed, but had never been told the resident was to have her heels elevated when up in her wheelchair. Review of Resident #34's clinical record on 04/12/11 at 2:30 p.m. indicated the following: Resident #34 had [DIAGNOSES REDACTED]. A "Resident Transfer Report" sheet, dated 12/29/10, indicated Resident #34's heels were "boggy-red." A nurse's note, dated 12/31/10 at 5:00 a.m., indicated, "Large closed blister was noted to (right) heel at (2:00 a.m.) this (night). Heel elevated off bed. (Approximate) measures 6.2 (by) 5 cm....Wound Care Nurse notified. (Medical Doctor) notified...Blister is raised. No discoloration around blister. No bruising noted. Area pink." A care plan, dated 12/31/10 with updates of 01/14/11, 01/28/11, and 02/03/11 indicated Resident #34 had a pressure area on her right heel. The "Goal" of the care plan indicated,"Area will show increased improvement and a decrease in size within 2 weeks." Hand written under the Goal section was, "Blister has popped- tx (treatment) as ordered (no date). Area continues brown slough. (Wound Nurse) (new order) visit (every) 2 weeks. Next visit 02/17/11. Care plan interventions - (Antibiotic) per MD order, Treatment as ordered, Monitor for (signs/symptoms) of infection such as increased redness, warmth, or drainage & report to MD as needed, Monitor for lack of improvement or need to change (treatment). The care plan lacked documentation supporting positioning of the resident's right heel when up in wheelchair and lacked documentation supporting positioning of the resident's right heel when she is in bed. A nurse's note, dated 12/30/10 at 1:05 p.m., indicated Resident #34 was cooperative and pleasant and compliant with being turned and repositioned. A nurse's note, dated 01/19/11 at 1:30 p.m., indicated, "...Right heel has (changed) over the week; skin under popped blister has turned yellow and measures 4 cm (by) 4 cm (with) black bruise measuring 2.5 cm (by) 1.5 cm; (physician) notified of (change) & asked if OK to consult (wound specialist); OK given;....(Bilateral) heels elevated off bed; in chair for most of shift...+1 [MEDICAL CONDITION] to (right lower extremity)...." A nurse's note, dated 02/03/11 at 12:00 p.m. indicated, "Updated (Medical Doctor) (with) wound nurse recommendations and orders received. (1) cleanse wound (right) heel (with) saline (with) each (dressing) change, apply skin prep. Allow to dry (periwound. Apply Allevyn thin. Seal edges with skin pep. Change (every) 3 days. Next wound care visit 02/17/11 at 2:00 p.m." An "MD Progress Note," dated 02/17/11, indicated, "Wound Care Note: Unstageable pressure ulcer (right) heel. Covered 100% black eschar. Eschar beginning to pull away from edges. Dimensions 3.8 x (by) 3.7 cm. Periwound intact. Area tender to palpation. Small (amount) serous drainage present on removed dressing. Will continue with Allevyn thin to assist (with) autolytic debridement of eschar. No new orders. Next (appointment) 3/3/11." This entry was signed by the wound nurse. A nurse's note, dated 03/05/11 at 7:35 a.m., indicated, "...(Resident #34) pleasant and cooperative. (Alert & oriented (times) 3. Makes needs known...Makes needs [MEDICAL CONDITION] continues to right lower extremities...." A nurse's note, dated 03/10/11 at 2:30 p.m., indicated,"(Right) heel wound assessed & measured today. Area measure 4.0 cm x (by) 4.7 cm (width). Depth is unable to determine. Area is unstageable due to the wound bed being covered (with) black eschar (necrotic tissue). (Continue) current (treatment) of cleanse (with) (Normal Saline), apply Santyl to eschar, apply collagen (wound dressing) & cover (with) foam dressing. Will measure again in (1) week. (Treatment to be done daily.)" Copies of "Daily Wound/Skin Healing Records" were provided by the DON on 04/12/11 at 11:00 a.m. The records indicated the following: On 12/31/10 Resident #34 had a stage 2 "closed blister" was found on Resident #34's right heel. According to "Pressure Ulcers in the Long-Term Care Setting," dated 2008 - a stage 2 pressure ulcer is defined as, "Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink ulcer bed, without slough. May also present as an intact or open/ruptured serum-filled blister." On 01/03/11 Resident #34 had an "intact fluid filled blister" on her right heel. On 01/06/11 the blister was open and measured 3 cm (centimeters) by 4 cm. The record indicated the "top skin was peeled off." On 01/09/11 a stage 2 area remained on Resident #34's right heel which had a "pink/beefy red" wound bed. On 01/14/11 a stage 2 area remained on Resident #34's right heel. The record indicated the wound bed was a "black/purple bruise." On 01/16/11 a stage 2 area remained on Resident #34's right heel and the wound bed was "brown and healing." On 02/21/11 the area on Resident #34's right heel was unstageable and had Alleyn (sic) (wound dressing) "thin in place." On 02/25/11 area on Resident #34's right heel was unstageable, brown and had serosanguinous drainage. (This entry was the first to indicate drainage from the wound). Wound healing records, dated 02/26/11 through 03/18/11 indicated there was no change in the wound. On 03/21/11 the unstageable area on Resident #34's right foot had purulent drainage, a "moderate" odor, an "eschar" (black) wound bed and [MEDICAL CONDITION] surrounding tissue. Wound healing records, dated 03/23/11, 03/24/11, and 03/26/11 indicated no change in the wound area. Wound healing records, dated 04/09/11, 04/10/11, and 04/11/11 indicated the only change in the wound was the odor had decreased to a "slight" odor. A MDS (minimum data set) assessment, dated 01/11/11, indicated Resident #34 was alert and oriented and understood what others said to her and was understood by others. The assessment indicated the resident had impaired range of motion with her lower extremities, required extensive assistance of staff for transfers and had (1) stage 2 pressure ulcer. A physician's re-write order for March 2011 included the following orders: An order, dated 01/03/11, indicated, "elevate bilateral heel & apply skin remedy three times a day." An order, dated 01/03/11, indicated, "Cleanse ulcer on (right) heel, apply Santyl & cover with Allevyn thick and secure with cover roll & change daily." An order, dated 03/03/11, indicated,"Cleanse ulcer on (right) heel (with) (normal saline), apply Santyl (wound treatment) to eschar only, cover (with) Allevyn thick & secure (with) cover roll - (change) daily.' A Therapy note with a start of service date of 12/31/10 indicated the resident's discharge plans were to, "Discharge home and independent with caregiver." Resident #34's clinical record lacked documentation supporting Resident #34 being non-compliant with positioning and lacked documentation on resident being educated on importance of keeping heel elevated while up in wheelchair. Interview of the DON on 04/14/11 at 10:15 a.m., indicated bed pillows wouldn't work for keeping the resident's heel elevated off of the wheelchair pedals due to sliding off. The DON indicated she would talk to Therapy about getting something to use on the wheelchair pedals so the resident's heel would be elevated off of pedals when she was up in her wheelchair. The facility failed to provide documentation supporting CNAs and nursing staff were educated on interventions to keep Resident #34's heel elevated while she was sitting up in her wheelchair. 2. On the initial tour, on 4/11/11 at 10:15 A.M., LPN # 19 indicated Resident # 70 had dementia and a pressure sore on her left heel which was acquired in the facility. LPN #19 indicated Resident # 70 utilized waffle boots and a heel elevator. On 4/11/11 at 4:40 P.M., Resident # 70 was observed to be sitting in a wheelchair in the dining room. Resident # 70 was observed to have a waffle boot on the left foot. On 4/12/11 at 8:15 A.M., Resident # 70 was observed to be sitting in a wheelchair in the dining room. Resident # 70 was observed in an activity. Resident # 70 had bilateral socks and shoes on. On 4/12/11 at 9:10 A.M., LPN # 21 was observed to remove the dressing on Resident # 70's left heel. The area to the left heel was observed to cover the entire heel. The area appeared as a loose hard callous area covering half the area and a quarter of the area was dark red/purple in color. On 4/12/11 at 9:20 A.M., Resident # 70 was observed to be sitting in a wheelchair in the therapy department. Resident # 70 was observed to have bilateral socks and shoes on. The clinical record for Resident # 70 was reviewed on 4/11/11 at 1:00 P.M. The record indicated Resident # 70 had [DIAGNOSES REDACTED]. The MDS (minimum data set) assessment, dated 2/16/11, indicated Resident # 70 had impaired cognition, and required extensive assistance of two with bed mobility and transfers. The assessment indicated Resident # 70 had no pressure areas. A Care plan, dated 11/26/09, indicated a problem of "Potential for skin breakdown R/T (related to) decreased mobility." The interventions included but were not limited to "Assist res (resident) with turning and repositioning Q (every) 2 hrs and PRN (as needed) and Keep heels up off mattress." A Care plan, dated 3/1/11, indicated a problem of "Pressure area L (left) heel." The interventions were "1. ATB (antibiotic) per MD order. 2. TX (treatment) as ordered. 3. Monitor for s/s (signs and symptoms) of infection such as increased redness, warmth, or drainage and report to MD as needed. 4. Monitor for lack of improvement or need to change TX. 5. Heel elevator in bed. 6. Waffle boots BLE (bilateral lower extremities). 7. No shoes." A Wound Care Evaluation, dated 3/3/11, indicated ' ...Pressure- Stage II 6.0 x 8.0 x 0.2...Wound bed: pink with partial skin flap in place...Pt (patient) has developed a pressure area to heel that began as a large blister. Has now ruptured leaving open wound with partial skin flap in place requiring treatment... " A physician order, dated 3/31/11, indicated " DC (discontinue) [MEDICATION NAME] and foam drg (dressing) to L heel. Apply skin prep to L heel and dry thoroughly before putting sock and waffle boot on q (every) shift indef (indefinitely). " In an interview with the Director of Nursing and Assistant Director of Nursing, on 4/12/11 at 8:30 A.M., they indicated Resident # 70 had had a decline in condition and was staying in bed or the recliner more. The Director of Nursing indicated the recliner was the issue causing the pressure to Resident # 70's heel. 3.1-40(a)(2)

Based on interview, record review and observation, the facility failed to ensure Resident #99 received supervision and interventions to prevent recurrent falls resulting in a fracture, failed to ensure Resident #61 was supervised so she did not attempt to transfer herself without assistance and did not wander into others' rooms looking for her bed, resulting in a hip fracture, failed to ensure Resident #98 was supervised in order to prevent falls while attempting to transfer himself and/or go to the bathroom, and to prevent Resident #97 from attempting to help Resident #98 and turn off alarms, for 3 of 10 residents reviewed for falls in the sample of 21. Findings include: 1. On the initial tour, on 4/11/11 at 10:15 A.M., LPN # 19 indicated Resident # 99 had dementia, and has had several falls and a recent fracture. Resident # 99 utilized a wanderguard, chair alarm and bed alarms. The clinical record for Resident # 99 was reviewed on 4/11/11 at 11:45 A.M. The record indicated Resident # 99 had [DIAGNOSES REDACTED]. The MDS (minimum data set) assessment, dated 1/20/11, indicated Resident # 99 had impaired cognition, and had no behaviors. Resident # 99 required limited assistance of one with bed mobility, transfers and ambulation. Resident # 99 had 1 fall with no injury and 2 or more falls with injury since the previous assessment dated [DATE]. A care plan, dated 10/14/10, indicated a problem of "Resident at risk of falling d/t (due to) new admit to facility and hx (history of) wandering. Dx (diagnosis) of dementia." The interventions were "1. Call light within reach with frequent reminders on how to use. 2. Side rails to assist with transfers and bed mobility. 3. Monitor for dizziness and unsteady gait. 4. Monitor B/P (blood pressure) for orthostatic hypotension. 5. Res (resident) ambulates independently. 6. Ensure res wearing proper foot wear." The fall risk assessment, dated 10/14/10, indicated a score of 6. In an interview with the Director of Nursing, on 4/12/11 at 10:00 A.M., she indicated a score of 10 or greater indicated high risk for falls. The Nurses Notes, dated 10/28/10 at 2:50 P.M., indicated "Res (resident) found on floor in dining room getting ready to sweep when she tripped on robe. Found on knees and hands on floor. In this position at threshold of Activity's office. No c/o (complaints of) pain. No injury noted...robe to be hemmed." The 10/14/10 fall care plan was updated on 10/28/10 to include the intervention of "Ensure proper length of clothing (not too long)." The Nurses Notes, dated 10/30/10 7:00 P.M., indicated "This nurse observed res sitting upright on shower room floor...Observed 3 cm x (by) 0.2 cm skin tear to chin...(3) steri strips applied small amt blood present. Res stated I was putting plates in the cabinet. Intervention: 15 min checks by staff. Clothing was of proper length along with proper footwear worn..." The 10/14/10 fall care plan was updated on 10/30/10 to include the intervention of "Begin 15 min checks." The Nurses Notes, dated 11/1/10 at 9:10 A.M., indicated "Met with direct care staff to review interventions put in place with fall of 10-28-10, interventions being utilized and effective." The Nurses Notes, dated 11/1/10 at 9:20 A.M., indicated "Met with direct care staff to review fall of 10-3-10 (sic), current intervention of 15 min checks in place, care planned and on alert sheet." The Nurses Notes, dated 11/7/10 at 2:00 A.M., indicated "Res found on floor in room (number). Res lying on R (right) side, back facing door to bedroom. Res with no clothes on and lying near urine. Bed that resident slept on needed to be stripped d/t (due to) being dirty and stained. Assessment completed...Gripper socks on at this time. Res does have glasses but not worn at this time. 5 cm x (by) 6 cm (1 cm depth) purple goose egg L (left) forehead. Bed pushed up against wall. Floor sensor mat laid to side of bed not up against floor. Call light placed to where resident could reach. Reminded resident that if needing help press call light..." The 10/14/10 fall care plan was updated on 11/8/10 to include the intervention of "Toilet at 1:00 A.M." The fall risk assessment, dated 11/15/10, indicated a score of 6. The assessment indicated Resident # 99 had no falls in the last 3 months. The Post Fall Reporting Form, dated 2/11/11 at 9:00 P.M., indicated "...Date of fall: 2/11/11. Time of fall: 9:00 P.M...Observed on the floor (unwitnessed)...Ambulating in hallway...Res worrying self- cleaning, restless going in/out of other resident rooms hitting staff tonight. Given PRN (as needed) Ativan (antianxiety medication)...Based on your evaluation, what are possible care plan interventions to prevent a future fall from occurring? Social Service notified about recent behavior..." The Nurses Notes, dated 2/11/11 at 10:30 P.M., indicated "...Res stated I lost my balance. I didn't hit my head. No bruising/bleeding/skin tears noted...Had another resident's glasses at her side. Personal glasses and shoes on/worn. Denies hitting head...Res stated I laid head down softly. Lying down on L (left) side, facing towards double doors, head close to fish tank...Called daughter (name). (Daughter name) stated she was falling at home too. It's not medication related..." The fall risk assessment, dated 2/11/11, indicated a score of 12. The Nurses Notes, dated 2/14/11 at 12:50 P.M., indicated "Met with direct care staff to review fall of 2-11-11, current intervention of therapy referral in place and care planned." The 10/14/10 fall care plan was updated on 2/14/11 to include the intervention of "Therapy referral." During an interview with the ADoN (Assistant Director of Nursing), on 4/12/11 at 10:00 A.M., she provided the therapy referral completed on 2/26/11 as the intervention for the fall on 2/11/11. The Post Fall Reporting Form, dated 2/15/11 at 8:10 A.M., indicated "...Date of fall: 2/15/11. Time of fall 8:10 A.M...Res trying to pick up napkin off of floor and lost balance...Res has been having loose stool could be weak from this...Monitor res closely due to acute illness loose stool therapy to evaluate res for need for therapy..." The Nurses Notes, dated 2/17/11 at 10:00 A.M., indicated "Met with direct care staff to review effectiveness of intervention with fall of 2-11-11. Intervention of therapy referral delayed due to acute illness." The Nurses Notes, dated 2/17/11 at 10:35 A.M., indicated "Met with direct care staff to review fall of 2-15-11 intervention of monitoring res more closely D/T (due to) acute illness being utilized care planned and on alert sheet." The Post Fall Reporting Form, dated 2/19/11 at 5:30 P.M., indicated "...Date of fall: 2/19/11. Time of fall 5:30 P.M...Observed on the floor (unwitnessed)...R (right) posterior top of hand bleeding skin tear...weakness from flu, unsteady gait...Based on your evaluation, what are possible care plan interventions to prevent a future fall from occurring? 1. Use clip alarm when in chair. 2. Monitor closely..." The 10/14/10 fall care plan was updated on 2/19/11 to include the intervention of "Apply clip alarm." The fall risk assessment, dated 2/19/11, indicated a score of 18. The 10/14/10 fall care plan was updated on 2/21/11 to include the intervention of "Chair pad sensor." The Nurses Notes, dated 2/21/11 at 2:30 P.M., indicated "Met with direct care staff to review effectiveness of interventions implemented with fall of 2-15-11, intervention of monitoring closely D/T acute illness effective." The Nurses Notes, dated 2/21/11 at 5:00 P.M., indicated "Met with direct care staff to review fall of 2-19-11, current intervention of chair pad sensor in place care planned and on alert sheet." The 10/14/10 fall care plan was updated on 2/22/11 to include the intervention of "Bed alarm." The Nurses Notes, dated 2/22/11 at 4:00 P.M., indicated "Res very weak from recent loose stool. Appetite poor. Bed alarm added to res bed due to weakness and res does not always ask for assist." The Post Fall Reporting Form, dated 2/27/11 at 8:15 P.M., indicated "...Date of fall: 2/27/11. Time of fall: 8:15 P.M...Observed on the floor (unwitnessed)...Stood up while in w/c lost balance and fell to floor...L elbow abrasion no open area to elbow no treatment requested from MD...noticed wire unclipped from box so alarm did not sound...Res sitting in w/c at (hall name) med cart. This nurse also at med cart. I turned away from res for 5 seconds heard thump turned back around and res on L side on floor. Chair alarm wire leading to box was unplugged so chair alarm didn't sound...Monitor and ensure chair pad sensor wires are plugged into clip alarm box..." The 10/14/10 fall care plan was updated on 2/27/11 to include the intervention of "Monitor and ensure chair pad sensor wires are plugged into clip alarm box at all times." The fall risk assessment, dated 2/27/11, indicated a score of 10. The Post Fall Reporting Form, dated 3/11/11 at 4:10 P.M., indicated "...Date of Fall: 03/11/11. Time of fall: 4:10 P.M....lost balance...chair alarm sounding...Had PT (physical therapy) around 3p- had visitor who left around 4p...Based on your evaluation, what are possible care plan interventions to prevent a future fall from occurring? walk 2 x (times) a shift to increase strength monitor BP (blood pressure) for 1 week..." The 10/14/10 fall care plan was updated on 3/11/11 to include the intervention of "Walk 2 x (times) a shift." The fall risk assessment, dated 3/11/11, indicated a score of 18. The Nurses Notes, dated 3/19/11 at 5:30 A.M., indicated "Res found on floor, sitting in front of recliner in lounge area. Said I was going to pee...c/o (complaint of) L (left) wrist pain, no visible redness or injuries and can move all extremities. Appeared that res slid out of rec (recliner) legs tangled in blanket while attempting to stand (foot rest was down) Res made no sounds while on floor. Weak, confused, using whispering voice. Has recently had acute illness of gastrointestinal infection...Added clip alarm and chair sensor as interventions. Floor mat added for protection next to bed...Also added to use small blankets that are light in weight." The 10/14/10 fall care plan was updated on 3/19/11 to include the intervention of "Clip alarm." The 10/14/10 fall care plan was updated on 3/20/11 to include the intervention of "Use small lap blanket in w/c or recliner." The Nurses Notes, dated 3/21/11 at 2:50 P.M., indicated "Met with direct care staff concerning fall of 3/19/11. Resident has chair sensor, clip alarm has been Dc'd (discontinued). Staff will use smaller lap blanket while she is in w/c or recliner to decrease possibility of getting tangled in blanket." The Nurses Notes, dated 3/23/11 at 12:40 P.M., indicated "Met with direct care staff to review effectiveness of interventions implemented with fall of 3-19-11, interventions being utilized and effective." The Post Fall Reporting Form, dated 4/3/11 at 5:40 P.M., indicated "...Date of fall: 04/03/11. Time of fall: 5:40 P.M...Observed on the floor (unwitnessed)...Getting up from chair...Res sitting on floor. Legs bent at the knees...Did not hit head...Chair alarm...Based on your evaluation, what are possible care plan interventions to prevent a future fall occurring? Monitor closely..." In an interview with the Assistant Director of Nursing, on 4/12/11 at 9:00 A.M., she indicated the alarm was sounding when the resident fell on [DATE]. The 10/14/10 fall care plan was updated on 4/4/11 to include the intervention of "When res becomes anxious and getting up frequently involve res in activity." The Nurses Notes, dated 4/4/11 at 10:20 A.M., indicated "CNA reported res c/o discomfort R ankle with transfers. Observed R ankle sl (slightly) edematous and res c/o sl discomfort with ROM (range of motion). Called MD office to report res c/o. Spoke with nurse (name). Awaiting return call." The Nurses Notes, dated 4/4/11 at 11:00 A.M., indicated "Met with direct care staff to review fall of 4-3-11, current intervention of when res becomes anxious and getting up freq (frequently), involve her in activity- in place and care planned." The Nurses Notes, dated 4/4/11 at 3:20 P.M., indicated "X-ray of R (right) ankle received from (name). This does show a subtle chip fx (fracture) of the R inferior tip of medial malleolus with minimal displacement..." The Nurses Notes, dated 4/6/11 at 10:00 A.M., indicated "Met with direct care staff to review intervention of when res becomes anxious and attempting to get up and down, involve res in activities, intervention utilized and effective." The Post Fall Reporting Form, dated 4/7/11 at 11:00 A.M., indicated "...Date of fall: 04/07/11. Time of fall: 11:00 A.M...was in bed sleeping. Found on floor with back against bed- one hand on siderail (top)- one hand on bedside table...(V) shaped skin tear L (left) lower outer arm. Approx (approximately) 0.5 cm x (by) 0.2 cm. Scant amt (amount) bldg (bleeding)...Summary of factors contributing to fall: weakness continues, recent fall with injury subtle chip fx involving R inferior tip of medial malleolus with minimal displacement. Removed ace wrap R foot/ankle found in bed. Attempting to get out of bed...Based on your evaluation, what are possible care plan interventions to prevent a future fall from occurring? 1. Use nonskid socks when in bed..." The 10/14/10 fall care plan was updated on 4/7/11 to include the intervention of "Nonskid socks to be worn in bed." The fall risk assessment, dated 4/7/11, indicated a score of 14. The Post Fall Reporting Form, dated 4/9/11, at 7:30 P.M., indicated "...Date of fall: 04/09/11. Time of fall: 07:30 PM...Does the Resident have a history of falls? yes. When? last 4-7-11...No apparent injury...Summary of factors contributing to fall: Res sitting in w/c next to (hall name) med (medication) cart. Scooted forward in w/c and leaned over as if to p/u (pick up) something from floor. Res fell out of w/c landing on floor on buttocks...Based on your evaluation, what are possible care plan interventions to prevent a future fall from occurring? 1. Keep res as close to nurses station as possible when up in w/c; engage res in some activity while in w/c to occupy mind..." The 10/14/10 fall care plan was updated on 4/9/11 to include the intervention of "Keep close to nurses desk when up in w/c- engage in activity to occupy mind." The fall risk assessment, dated 4/9/11, indicated a score of 16. 2. Resident #61 was identified on the initial tour of the locked dementia unit, on 4/11/11 at 9:30 A.M., by LPN # 19, as having had recent falls and a hip fracture, requiring an alarming floor mat, chair clips and preferred to stay in her room most of the time. The resident was observed on 4/12/12 at 9:00 A.M. lying in bed in her room. All alarms were in place and turned on. Resident # 61's clinical record was reviewed on 4/11/11 at 10:30 A.M. The most recent Minimum data set assessment (MDS), dated [DATE], indicated the resident was severely cognitively impaired, required assistance with bed mobility, transfers and ambulation and was frequently incontinent of urine. Balance, during transitions and walking, was not steady, the resident was only able to stabilize with human assistance while moving from seated to standing and moving on or off the toilet. The resident had fallen since the last assessment, with no injuries. The care plan, dated 10/1/10, included the problem "Resident at high risk for falls and pain, right hip and right groin, pelvic area, updated 9/21/10, start date 5/15/2008, FALL 11/16/10 at 1225 a.m." Approaches included: "side rails to assist with transfers and bed mobility, non skid foot wear with transfers and ambulation, ambulate with assist of 1-2 assist, walker and gait belt, keep room free of clutter, let res(resident) feel in control, clip alarm while up in chair, 11/3/10 bed against wall and floor mat beside bed, 11/16/10 gripper socks on at all times, check sensor connections on floor senor, make sure plugged in and all the way, 2/17/11 anti-roll back device on wheelchair, 3/30/11 staff to assist resident into bed after supper." A fall risk assessment, dated 8/24/10, indicated the resident was at a high risk of falls and was disoriented at all times, with 1 to 2 falls in the past 3 months. A fall risk assessment, dated 2/16/11, indicated the resident was at a high risk of falls. A nurse's note, dated 8/24/10 at 1:15 p.m., indicated "went to (residents room) to straight cath (catheterize)...Resident was not in bed. Wheelchair next to bed, checked room bathroom. Door was closed, found resident in sitting position with back against wall with legs spread outward. When asked if she hit her head-stated that she did... initiating bed and clip alarms for safety...." A nurse's note, dated 8/25/10 1 p.m. "Late entry for 8/22/10 at 3:00 A.M. , resident found on floor in training room, resident stated she went into the basement to take a nap, resident was assessed and no sign of injury noted, resident was assisted back to bed..." During an interview with the facility Administrator, on 4/12/11 at 11:00 A.M., she indicated the training room door should have been locked. She further indicated staff were not sure if the resident had fallen on 8/22 or laid down on the floor. A nurse's note, dated 11/16/10 5 A.M. indicated: "CNA (certified nursing assistant) called nurse to resident's room at 12:25 A.M. Res lying on floor on right side with her head next to roommate's bed. Alert and confused. stated 'I was looking for my baby...I don't know how I got here'..." A Post Fall Reporting Form indicated: "2/15/11 4:00 P.M. , previous falls on 8/24/10 and 11/16/10, observed on the floor in residents room, probable cause-lost balance, the activity during the incident was: ambulating in bedroom or to/from bathroom, footwear-slippers, non skid socks, what mechanical devices were in use-floor mat alarm, bed rails-2, wheelchair was on other side of room, status of resident at time of falls-incontinence, summary of factors contributing to fall- incontinent of bowel, vomit on bed/shirt getting up from bed unassisted- interventions added; anti-rollback device on wheelchair so will not roll backward when/if resident getting out of bed and wants to use wheelchair." Nurses notes, dated 3/29/11 at 10:45 p.m. indicated "Resident sitting on floor by bed of room (not her own) No bruising/skin tears. No outward signs of broken hips can abduct and adduct both legs without problem. No pop/click heard when moving legs, stood and transfers without problems with assist. Resident complains of left leg pain. Hydrocodone 7.5/500 given at this time. Updated Dr-asked if would like x-ray..." The room the resident was found in on 3/29/11 at 7: P.M. was observed on 4/12/11 at 9:00 A.M. to be on the hallway to the right of the nurses station, the residents room was observed to be on the opposite hallway to the left of the nurses station. The post fall reporting form indicated: "3/29/11 7:00 P.M. resident had a history of [REDACTED]. status was weakness and unsteady gait, physician was notified 3/29/11 at 11:00 P.M. Summary of factors contributing to falls: Resident has increased confusion, thought another resident's bed was hers, tried to transfer self from wheelchair to bed by self, future interventions-redirect when needed." Nurse notes, dated 3/30/11 3:30 A.M., indicated "Resident showered with assist of CNA. Noted right elbow-purple bruise, .5 cm right lateral forearm proximal to elbow, small purple bruise .5 cm right mid thigh lateral aspect 3-4 cm 4 red scrapes, horizontal unopened, right upper leg lateral aspect above knee, small purple bruise, day nurses, ADON (assistant director of nursing), MD notified. ...Resident complains of pain in left leg..." Nurses notes dated 3/30/11 8:40 A.M. indicated "complaints of pain left lower extremity given prn (as needed) Hydrocodone 7.5/500 orally at this time. CNA (certified nursing assistant) reported resident cried out in pain when attempted am care to attempt care at a later time..." Nurses notes indicated the physician office was called on 3/30/11 at 12:45 p.m. to request an x-ray order. Nurses notes indicated the x-ray was taken with results at 6:10 P.M. which included an acute fracture of left hip with modest displacement, "...faxed results to physician.." During interview with the Director of Nursing on 4/13/11 at 10:00 A.M., she indicated the resident's alarms did ring on 2/15/11 and 3/29/11, before the fall. She indicated documentation was lacking as to whether the alarm rang on 11/16/10, but had been checked prior to the start of the shift the fall occurred on. 3. Resident #98 was identified on the initial tour of the locked dementia unit, on 4/11/11 at 10:15 A.M., by LPN #19, as being a high risk for falls, requiring a wireless sensor with alarms on wheelchair, bed and floor mat. Resident #98 was observed on 4/12/11 at 8:30 A.M. sitting in his room with his spouse, Resident #97, who resides in the room with him. Resident #98 was sitting in a recliner with an alarming chair cushion and an alarming pad to the floor. Resident #98's clinical record was reviewed on 4/11/11 at 11:00 A.M. [DIAGNOSES REDACTED]. A history and physical, dated 1/8/11, indicated "neuro: He is alert. He has difficulty answering any questions. He does not seem to have good recollection of recent events. Per his primary care physician he is having increasing memory issues, not taking medications regularly, forgetting appointments. His wife's memory issues are advanced to the point that she gets lost driving through town..." The admission MDS(minimum data set) assessment, dated 1/22/11, indicated the resident was interviewable, required assistance with bed mobility, transfers, ambulation, dressing and was frequently incontinent of urine. The assessment indicated the resident had a fall in the past month and the past 2 to 6 months. His balance was unsteady and he was only able to stabilize himself with help with moving from seated to standing, walking, moving on or off the toilet or from surface to surface such as bed to chair. The admission assessment detail report, dated 1/16/11 at 7:35 A.M., indicated for safety, the resident was "disoriented at all times, no falls in past 3 months." The personal alarm assessment, indicated the resident was not able to ambulate independently, gait was unsteady, could not walk to and from bathroom on own, continent of urine and bowel, had memory problems and or confusion and had poor safety awareness and/or impaired decision making. The falls risk assessment, dated 2/13/10 at 7:45 P.M., indicated the resident was at a high risk of falls, related to intermittent confusion, falls in past 3 months, incontinent, and balance problems while walking. Fall risk assessments, dated 2/14/11, 2/21/11, 3/1/11, 3/19/11, 3/21/11, 4/2/11 indicated the resident at high risk for falls and had intermittent confusion. The bowel and bladder assessment, dated 1/19/11, indicated the resident was "disoriented and required extensive assistance with transfers, had urge incontinence (requires resident needing to go when feels the urge)." The assessment was not completed to indicate if the resident was able or unable to participate in a retraining or timed voiding program. During interview with the DON on 4/13/11 at 9:30 A.M., she indicated the resident had been continent at the time of the assessment. She indicated staff would increase the times when the resident was taken to the bathroom. The care plan, dated 1/16/11, included "fall/safety risk" 1/16/11-keep call light in reach of resident, encourage and reminders to use call light, reminders for safety, need to ask for assistance with mobility, assess residents foot wear-proper fit and non skid soles, therapy as needed, fall safety/risk reminder in residents room, 1/17/11 bed sensor, chair sensor, 1/24/11 change rooms to closer to nurses station, 1/29/11 15 minute checks, do not leave in bathroom alone. Another problem, dated 2/13/11, risk for falls, Fall 2/13/11, fall 3/19/11, fall 3/21/11 included interventions of " 15 minute checks, remind and coach resident to summon aid or nurse for help, discourage spouse from turning off alarms, 2/15/11 chair pad sensor in recliner, 2/21/11 room change, toilet at bedtime, 3/1/11 keep room clutter free, 3/21/11 keep urinal at bedtime, leave door partially open when in room, encourage res to rest in recliner in lounge after supper, 4/2/11 assure chair pad sensor in place in recliner." The CNA assignment sheet for the resident indicated: "remind resident and spouse to summoned for assist with ambulation...keep urinal at bedside to keep resident from going to bathroom after supper and frequently ask if need to go to bathroom, toilet at bedtime..." A Post Fall Reporting Forms indicated: "Date of fall 1/23/11, time of fall 4:30 A.M. history of falls-yes, observed on the floor in resident's room, was getting out of bed, non skid socks on, mechanical devices in use- bed alarm, bed rails-2 upper, low bed at lowest level, walker, summary of factors contributing to fall resident sleeping in bed. Res was getting out of bed to go to restroom unassisted. Alarm sounded when CNA arrived in room resident was on 1 knee by side of bed. Resident lifted self off floor very well was able to demonstrate to staff what happened, how he slid of bed.'" Fall Follow Up documentation indicated: 1/23/11 2 p.m. - "res continues to get up unassisted throughout the day today" interventions-"will move res Monday or place floor sensor" "1/24/11 250 p.m. "resident still getting up without calling for assistance" and interventions "moved to room (closer to station)." "Date of fall 2/13/11, time of fall 6:50 P.M. has a history of falls, Resident's response to why do you think you fell -ambulated to bathroom on his own-chair sensor had basket sitting on it bent over to pick up paper from floor lost balance and fell on right side, observed on the floor, location bathroom, probable cause- balance, lost strength, other cause- short staffed, activity during-ambulating to and from bathroom, what mechanical devices-had basket sitting on alarm-in off position, unsteady gait, based on evaluation what are possible care plan interventions to prevent a future fall from occurring-counseled spouse and resident on importance of alerting staff for assistance; also asked that she not turn off alarms, she admitted to turning off chair sensor. Add to 15 minute checks, is already on every 15 minute checks." "2/14/11 6:00 PM has history of falls, came back from bathroom and missed recliner, observed on floor in resident's room, tried to sit but missed chair, ambulating to and from bathroom, what mechanical devices were in use - chair alarm, has in wheelchair not used turned off by wife, floor mat by chair. Based on your evaluation what are possible care plan interventions to prevent a future fall from occurring-additional sensor-wife takes (resident name) from wheelchair to bathroom, bathroom to recliner without telling staff." "2/20/11 11:40 p.m. getting up to use restroom, observed on floor in resident's room, slipped, ambulating in bedroom, chair and floor mat alarm-both sensors were turned off, physical status at time of fall-incontinence, summary- spouse helped res to a standing position from recliner. Spouse came out in hallway and summoned our help. Res was on all 4's on floor. Both sensors were turned off. Based on evaluation,what are possible care plan interventions to prevent a future fall-separate the couple or devise a different type of sensor that can't be turned off by spouse..." Fall Follow Up Documentation, dated 2/20/11 at 1140 p.m., indicated the resident was moved closer to the nurse's station and would be toileted at hour of sleep. A nurses note, dated 2/21/11 at 4:45 A.M. indicated: "Noted door shut to room, had opened door at 3:55 a.m. noted res on side partially lying out of recliner. checked sensors to floor and bed alarm (in chair) tucked in pocket of recliner turned on, tried to recline using push button and res stated that chair won't recline. Manually lifted footrest in reclining position and asked res to please leave sensors on. pulled door 1/2 way shut and also asked to not close completely..." "3/1/11 9:45 P.M. Resident response to why do you think you fell ? Wasn't finished with his business-wife giving urinal to him and tripped over chair. Incident- observed on floor in resident's room, ambulating in the bedroom, getting out of chair, mechanical devices-chair and floor mat alarm, summary- Resident standing up to use urinal, tripped over chair in front of him, based on evaluation, what are possible care plan interventions to prevent a future fall from occurring? Reminder to wife to ask staff for help, use call light-keep sensor alerts on, keep room clutter free." "3/19/11 at 10:50 P.M., Resident's response to why do you think you fell ? I sat on edge of bed tried to stand up to urinate, slid off side of bed. observed on floor, resident's room, lost strength/weakness, getting out of bed to urinate, unsteady gait, uses walker,summary-no bed sensor to indicate activity, possible care plan interventions-install bed sensor..." "3/21/11 4:15 P.M. wife involved with care of resident's care, observed on floor, ambulating in bedroom, ambulating to/from bathroom, bear feet left foot, chair alarm turned off per wife, bowel incontinence at time of fall, summary- Res ambulation to/from restroom without staff assistance. one sock on and one sock off. sitting down on floor-no pants on. resident doesn't want to ask for staff help, his wife turns off sensors... possible care plan interventions- encourage resident to stay in lounge area until 9 p.m.,.. frequently ask resident if he needs to use restroom." "4/2/11 4:40 P.M. Resident's response to fall- I was walking to my wheelchair. observed on floor, residents room, ambulating in bedroom, reaching for walker possibly, floor mat alarm were in use, at time of fall resident incontinent, summary of factors contributing to fall-Chair pad alarm sensor was removed by his wife. res got up from chair legs were weak and he fell on floor, possible interventions to prevent future falls- keep chair pad sensor in place in recliner, check frequently, frequent therapy..." The fall follow up documentation, dated 4/2/11 at 4:40 p.m. indicated interventions of keep wireless chair pad in place in recliner, comments-wife removes sensors-staff reminds of importance of asking for assistance, 4/4/11 5:30 a.m. -spouse removed floor sensor pad from next to bed on 2nd shift, was under bed, asked res and spouse to leave in place for safety...' An occupational therapy note, dated 3/13/11, indicated " Patient has experienced recent multiple falls and further decline in function...assessment-Patient presents with deficits in strength, Range of Motion, activity tolerance, balance and cognition influencing ability to participate safely in ADL's and functional mobility...transfer: sit to stand-The patient is able to safely transition from sit to stand requiring moderate assistance with initiation cues..." A social service note, dated 4/4/11, indicated "social service spoke with resident regarding his most recent fall...informed res that he needs to use his call light so that nursing staff can assist him with his needs. Resident was agreeable." Resident #97's clinical record was reviewed on 4/11/11 at 2:00 P.M. [DIAGNOSES REDACTED]." The admission MDS assessment, dated 2/6/11, indicated the resident was cognitively impaired. A fall risk assessment, dated 1/31/11, indicated the resident was disoriented at all times. The facility lacked evidence of having provided ade