Every finding on record at Lutheran Senior Services at Breeze Park

Based on observation, interview, and record review, the facility failed to ensure ice and beverage dispensing units in three of three dining rooms/satellite kitchens were free of an accumulation of debris. The facility census was 47. 1. Observation on 3/30/26 at 11:20 A.M. and on 3/31/26 at 10:14 A.M., inside the Lindenwood dining room, showed the following:-A combination ice/water dispensing unit had two separate dispensing spouts. The ice dispensing spout had a buildup of white crusty debris on the exterior of the spout and dark-colored debris inside the spout. The water dispensing spout had a buildup of white crusty debris inside the spout. The exterior of the ice/water dispensing unit had vents on either side with a buildup of fuzzy debris;-A beverage dispensing unit had four dispensing nozzles for orange juice, grape cocktail, lemonade and cranberry cocktail. The nozzles and areas around the nozzles had a buildup of multi-colored liquid and debris. The metal backsplash behind the nozzles had numerous splatters and splashes of purple liquid. Observation on 3/30/26 at 11:30 A.M. and on 3/31/26 at 10:14 A.M., inside the Sycamore dining room, showed the following:-A combination ice/water dispensing unit had two separate dispensing spouts. The ice dispensing spout had a buildup of dark-colored debris inside the spout. The water dispensing spout had a buildup of dark-colored debris inside the spout. The exterior of the ice/water dispensing unit had vents on either side with a buildup of fuzzy debris;-A beverage dispensing unit had four dispensing nozzles for orange juice, grape cocktail, lemonade and cranberry cocktail. The nozzles and areas around the nozzles had a buildup of multi-colored liquid and debris. Observation on 3/31/26 at 8:42 A.M., inside the Cherry Blossom dining room, showed the following:-A combination ice/water dispensing unit had two separate dispensing spouts. The ice dispensing spout had a buildup of white crusty debris on the exterior of the spout and dark-colored debris inside the spout. The exterior of the ice/water dispensing unit had vents on either side with a buildup of fuzzy debris. During an interview on 3/31/26 at 10:20 A.M., the Dietary Manager said the following:-Dietary staff cleaned the ice/beverage dispensing units daily in the evening;-Maintenance staff did not perform any cleaning of the ice/beverage dispensing units;-The facility did not have a policy regarding cleaning the beverage station equipment;-Maintenance staff was responsible for contacting the ice machine vendor for deep cleaning. During an interview on 4/1/26 at 2:32 P.M., the Maintenance Director said the following:-The vendor cleaned the ice/water dispensing units quarterly;-Dietary staff were responsible for cleaning the beverage dispensing units on a regular basis;-Maintenance staff cleaned the exterior vents on the machines quarterly.

Based on observation, interview, and record review, the facility failed to develop a system to monitor the facility's water supply, including assessment of cold and hot water temperatures, to ensure specific control parameters to prevent growth of Legionella (a bacterium that can cause a serious type of pneumonia called Legionnaires' Disease) in accordance with the Centers for Disease Control and Prevention (CDC) and American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRAE)) standards. The facility failed to ensure staff performed hand hygiene when providing incontinence care to two residents (Residents #48 and #6), in a review of 12 sampled residents, and for one additional resident (Resident #35). The facility census was 47.1. Review of the facility policy, Water Management Plan, revised May 2025, showed the following:-The policy is specifically to reduce Legionella risk in healthcare facility water systems to prevent cases and outbreaks of Legionnaires' disease (LD);-Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospital and long-term care facilities;-Transmission can occur via aerosols from devices such as showerheads, cooling towers, hot tubs and decorative fountains;-Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water;d. Infection Control;-Identify and describe the potable and non-potable systems within the building and develop system schematics;-Determine locations where control measure must be applied and establish control limits;-Establish procedures for monitoring whether control measures are operating within established limits and if not, take corrective actions. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17, showed the following:-Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water;-CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of legionellosis was published in 2015 by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In 2016, the CDC and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard (https://www.cdc.gov/Legionella/maintenance/wmp-toolkit.html). Environmental, clinical and epidemiological considerations for healthcare facilities are described in this toolkit;-Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens;-Specify testing protocols and acceptable ranges for control measures and document the results of testing and corrective actions taken when control limits are not maintained. Review of the ASHRAE guidelines, dated December 2020, showed information and recommendations in this section apply to every portion of the hot and coldpotable water systems, including all components and branches, from intake to taps. Methodsfor limiting Legionella growth in potable water systems include the following:-Keeping the system clean and free of sediment;-Controlling hot-water and cold-water temperatures;-Minimizing water age (the residence time of the water in the system);-Maintaining a disinfectant residual. Review of the Centers for Disease Control and Prevention Legionella Environmental Assessment Form, undated, showed Legionella generally grow well between 77 degrees Fahrenheit (F) and 113 degrees F. The optimal growth range for Legionella is between 85 degrees F and 108 degrees F. Growth slows between 113 degrees F and 120 degrees F, and Legionella begin to die above 120 degrees F. Growth also slows between 68 degrees F and 77 degrees F, and Legionella become dormant below 68 degrees F. 2. Review of the facility's weekly water temperature log, dated 12/01/25-03/26/26, showed hot water temperatures were monitored in the following locations:-Hot water supply and hot water supply mixing valve on the Long-Term Care (LTC) and REACH units;-Two resident rooms (#960 and #972);-T-hall office.(Reviewed showed no documentation staff checked the water temperature in any other rooms of the facility.) The facility provided no documentation showing monitoring of cold water temperatures. Observation on 04/01/26 at 11:42 A.M., showed the following:-In room [ROOM NUMBER], the temperature of the hot water was 107 degrees F; -In the spa on Sycamore hall, the temperature of the hot water at the faucet eye wash station was 105 degrees F and the hot water temperature at the handheld shower head was 102 degrees F;-In room [ROOM NUMBER], the temperature of the hot water at the sink was 100 degrees F and the hot water temperature at the handheld shower head was 100 degrees F. During an interview on 04/01/26 at 5:25 P.M., the Maintenance Director said the following:-Staff monitored the hot water temperatures in the hot water heaters, boilers and the mixing valves;-Staff monitored the temperature of the hot water monthly at the beginning of the loop and end of the loop. Staff did not check water temperatures in the middle of the loop; -The range for monitoring hot water temperatures was between 110 degrees F and 120 degrees F;-He did not monitor the temperature of the cold water;-The facility did not have a procedure for monitoring for corrosion buildup and biofilm. During an interview on 04/02/26 at 2:24 P.M., the Administrator said the water management plan followed the state regulations for hot water temperature monitoring. 3. Review of the facility policy, Hand Hygiene, revised September 2022, showed the following:-All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors;-Wash hand with soap and water when hands are visibly soiled;-Use an alcohol-based hand rub containing at least 60 percent (%) alcohol; or alternatively, soap and water for the following situations: -Before and after direct contact with residents; -Before moving from a contaminated body site to a clean body site during resident care; -After contact with blood or bodily fluids; -After removing gloves;-Hand hygiene is the final step after removing and disposing of personal protective equipment;-The use of gloves does not replace hand washing/hand hygiene. 4. Review of Resident #48's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument), dated 01/28/26, showed the following:-Severe cognitive impairment;-Required substantial/maximal assistance from staff for personal hygiene and to roll left and right,-Dependent on staff for toileting hygiene, lower body dressing, and chair/bed-to-chair transfer, Review of the resident's current Care Plan, dated March 2026, showed the resident had an activity of daily living self-care deficit related to decreased mobility and muscle weakness. Staff staff were to transfer the resident with a mechanical lift and to provide incontinence care after incontinence. Observation on 03/31/26 at 7:25 P.M., showed the following:-The resident sat in his/her Broda chair (reclining padded chair on wheels) in his/her room;-Licensed Practical Nurse (LPN) B and Certified Nurse Assistant (CAN) D entered the room, did not perform hand hygiene, and put on gloves;-LPN B and CNA D transferred the resident with a mechanical lift into his/her bed;-CNA D removed the resident's urine-soiled incontinence brief; -CNA D cleaned the resident's frontal and back perineal areas with disposable wipes;-CNA D removed his/her gloves, reached into his/her pocket, and pulled out new gloves;-Without performing hand hygiene, CNA D put on the new gloves, and assisted LPN B to roll the resident back and forth to remove the mechanical lift sling and soiled linens and placed a new incontinence brief on the resident. CNA D touched the resident's clean skin, clothing, brief, sheets and pillow;-CNA D removed the soiled linens from the bed;-CNA D removed his/her gloves, pulled new gloves from his/her pocket, and without performing hand hygiene, put on the new gloves;-LPN B, wearing the same gloves used to roll the resident in bed and off the dirty linens, picked up the resident's water pitcher, and held the straw while the resident took a drink;-CNA D and LPN B placed dirty linens in a bag and trash in a bag, removed their gloves and left the room without washing their hands. During an interview on 03/31/26 at 8:40 P.M., CNA D said staff was to wash their hands before and after providing care to a resident. Staff put on gloves before possible contact with a resident's body fluids and changed gloves between dirty and clean tasks. Staff was to perform hand hygiene between glove changes. He/She did not wash his/her hands or use alcohol-based hand rub when he/she changed his/her gloves because he/she forgot. His/Her gloves could become contaminated when he/she reached into his/her pocket for gloves. During an interview on 03/31/26 at 8:21 P.M., LPN B said staff was to wash their hands before and after physical contact with a resident, especially if body fluids were involved. Staff was to change their gloves and wash their hands when they moved from a contaminated area to a clean area, like after providing perineal care and before touching clean supplies. 5. Review of Resident #6's quarterly MDS, dated [DATE], showed the following:-Partial/moderate assistance required for personal hygiene;-Always incontinent of bladder and bowel. Review of the resident's care plan, dated 12/22/25 to 04/01/26, showed the following:-The resident was always incontinent;-Provide incontinence care after incontinence episodes. Observation on 04/01/26 at 10:15 A.M., showed the following:-CNA G put on gloves and removed the resident's feces-soiled incontinence brief;-CNA G provided peri care to the resident's buttocks with wet wipes;-He/She removed his/her gloves, did not perform hand hygiene, and put on clean gloves;-CNA G placed a clean incontinence brief on the resident;-He/She removed his/her gloves, did not perform hand hygiene, put on clean gloves, and then assisted the resident to put on pants and shoes. During an interview on 04/01/26 at 10:37 A.M., CNA G said the following:-He/She was to wash his/her hands before he/she put on gloves and after he/she removed his/her gloves;-He/She should have washed his/her hands after he/she removed his/her gloves when providing peri care to the resident. 6. Review of Resident #35's quarterly MDS, dated [DATE], showed the following:-Dependent on staff for toileting;-Partial/moderate assistance required for personal hygiene;-Always incontinent of bladder and occasionally incontinent of bowel. Review of the resident's care plan, dated 12/22/25 to 04/01/26, showed the following:-The resident was always incontinent;-Provide incontinence care after incontinence episodes;-Provide peri-care as needed (PRN) for incontinent episodes;-Change resident if wet/soiled. Observation on 03/31/26 at 8:07 P.M., showed the following:-CNA F put on gloves and removed the resident's urine-soaked incontinence brief;-CNA F performed peri care to the resident's frontal area with wet wipes;-CNA F removed his/her gloves, did not perform hand hygiene, put on new gloves, and put a clean incontinence brief on the resident. During an interview on 03/31/26 at 8:52 P.M., CNA F said the following:-He/She was to change his/her gloves, wash his/her hands and put on new gloves when moving from a dirty to clean task;-He/She should have washed his/her hands after he/she removed his/her gloves. 7. During an interview on 04/01/26 at 4:18 P.M., the Infection Preventionist (IP) said the following:-Staff was to wash their hands when hands were visibly soiled, when going from resident to resident, and when going from a clean to dirty task;-Staff should wash their hands when removing gloves after performing pericare and prior to touching a resident's ice water or clean supplies;-Staff was to clean their hands every time they changed their gloves;-Staff should not place a handful of gloves in their pocket to utilize for resident care because they could become contaminated in their pocket. During an interview on 04/02/26 at 5:13 P.M., the Director of Nursing (DON) said the following: -Staff should wash their hands or use a hand sanitizer before and after providing personal care and between glove changes;-It was not appropriate for staff to carry disposable gloves in their pockets; -The facility educator, management and the infection preventionist educated staff on hand hygiene;

Based on observation, interview, and record review, the facility failed to provide restorative nursing services to assist two residents (Resident #3 and #4), in a review of 12 sampled residents, and one additional resident (Resident #45), to attain or maintain his/her highest level of functioning. The facility census was 47.Review of the facility policy, Restorative Nursing, dated 04/26/19, showed the following:-Residents will receive restorative nursing care as needed to help promote optimal safety and independence;-Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (e.g., physical, occupational or speech therapies);-Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care;-Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care;-The resident or representative will be included in determining goals and the plan of care;-Restorative goals may include, but are not limited to supporting and assisting the resident in: -Adjusting or adapting to changing abilities; -Developing,maintaining or strengthening their physiological and psychological resources; -Maintaining their dignity, independence and self-esteem; and -Participating in the development and implementation of their plan of care;-The staff will monitor and discuss the residents' progress with the interdisciplinary team;- Progress notes will be made by the restorative nurse or designee on a monthly basis;-A quarterly evaluation will be completed by the restorative nurse or designee; -An evaluation will be conducted with a significant change;-Upon completion of restorative nursing services, a discharge summary will be completed by the restorative nurse or designee. Review of the facility policy, Range of Motion Exercises, dated 09/16/22, showed the following:-The purpose of this procedure is to exercise the resident's joints and muscles;-Verify there is a nursing restorative care plan for this procedure;-Review the resident's care plan to assess for any special needs of the resident;-Assemble the equipment and supplies as needed;-If the resident becomes weak, or complains of pain, cease the exercise and summon the staff/charge nurse;-Support the extremity at the joint as it is being exercised;-Move each joint through its range of motion three (3) times unless otherwise instructed.-Move each joint gently, smoothly and slowly through its range of motion;-Remember to stop an exercise before the point of pain. 1. Review of the facility's Restorative Aide (RA)'s attendance and assignments for March 2026 showed the RA was pulled from providing restorative nursing services to work as a certified nurse assistant (CNA) on 03/03/26, 03/04/26, 03/13/26, 03/20/26, 03/23/26, 03/25/26, 03/26/26, 03/27/26, and 03/30/26. During an interview on 04/02/26 at 2:00 P.M., the Director of Nursing said there was no one to provide the restorative nursing services if the RA was pulled to the floor or was off work. 2. Review Resident #3's physician's order sheet, dated 01/21/25, showed the following:-Apply left hand splint;-Resident to wear left hand orthotic splint during bedtime hours as tolerated. Encourage 8-10 hours of wear. Review of the resident's significant change in status Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 02/04/26, showed the following:-Severe cognitive impairment;-Impairment in functional range of motion to one upper extremity and both lower extremities;-Dependent on staff for upper and lower body dressing, putting on/taking off footwear, personal hygiene, roll left and right, chair/bed-to-chair transfer;-No therapy or restorative nursing services;-No range of motion (active or passive). Review of the resident's Restorative Nursing Program Evaluation, dated 03/24/26, showed the following:-Date of referral 02/04/26, date of evaluation 03/24/26;-Assist the resident with the following passive range of motion restorative program;-Bilateral upper extremity passive range of motion in all planes;-Tell the resident he/she is dancing and he/she tolerates the activity well;-Bilateral lower extremity passive range of motion all planes for 15 reps with maximum cues;-Focus on bilateral lower extremity hamstring stretches and stretching every 24 hours;-Assist the resident with splint/brace assistance restorative program: ensure hand splint is on and provide passive stretch to all digits in direction and extension every 24 hours. Review of the resident's Care Plan, updated 03/24/26, showed the following:-Restorative - Resident is at risk for decrease in function as evidenced by decreased strength in range of motion;-The resident will not have a decline in function by participating in restorativeprograms: passive range of motion and splint/brace assistance;-Bilateral upper extremity passive range of motion in all planes;-Tell the resident he/she is dancing, and he/she tolerates the activity well;-Bilateral lower extremity passive range of motion all planes for 15 reps with maximum cues;-Focus on bilateral lower extremity hamstring stretches and stretching every 24 hours;-Assist the resident with splint/brace assistance restorative program: ensure hand splint is on and provide passive stretch to all digits in direction and extension every 24 hours. Review of the resident's March 2026 clinical flow sheet (documentation for restorative services) showed the resident did not receive any restorative nursing services from 03/24/26 to 03/31/26. Observation on 03/31/26 at 12:06 P.M. showed the resident sat in a Broda chair (specialized reclining chair on wheels) at the dining room table. The resident had contractures (fixed tightening of muscle, tendons, ligaments, or skin, preventing normal movement) to his/her left hand. Observations on 03/31/26 at 7:25 P.M. and 8:12 P.M. showed the resident lay in bed. He/She did not have a splint or brace on his/her left hand. During an interview on 03/31/26 at 8:25 P.M., Licensed Practical Nurse (LPN) B said he/she did not know why the resident was not wearing his/her brace. 3. Review of Resident #45's undated face sheet showed the resident's diagnoses included stroke. Review of the resident's Restorative Nursing Program Evaluation, dated 06/17/25, showed the following:-Assist the resident with the following active range of motion restorative program;-Bilateral upper extremity passive range of motion exercises 10 repetitions as tolerated two to three times per week;-Bilateral lower extremity passive range of as tolerated two to three times per week. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Severe cognitive impairment;-Required supervision/touching assistance to roll left and right, sit to stand, chair/bed-to-chair transfer, toilet transfer, walk 10 feet, walk 50 feet with two turns, walk 150 feet;-Requires partial/moderate assistance from staff for sit to lying, lying to sitting on side of bed,-Requires substantial/maximal assistance from staff for tub/shower transfer;-No therapy services;-No restorative nursing services or range of motion (passive or active). Review of the resident's quarterly MDS, dated [DATE], showed the following:-Severe cognitive impairment;-Requires supervision/touching assistance to roll left and right, sit to lying, and lying to sitting on side of bed;-Required partial/moderate assistance from staff for chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer;-Required substantial/maximal assistance from staff for sit to stand ant to walk 10 feet;-Dependent on staff to walk 50 feet with two turns;-Unable to walk 150 feet;-No therapy services;-No restorative nursing services, or range of motion (passive or active).(The assessment showed worsening of the resident's ADL self-performance.) Review of the resident's active care plan, undated, showed the resident is at risk for activity of daily living (ADL) decline related to decreased mobility, muscle weakness, and cognitive deficits. The goal was for the resident to maintain ADL self-performance levels as evidence of no decline in stated levels. Provide restorative programs to help maintain ADL self-performance (see restorative plan of care for specific interventions). Review of the resident's March 2026 clinical flow sheet for restorative nursing services showed the following:-Program A - Assist the resident with the following active range of motion restorative program: Bilateral upper extremity passive range of motion exercises 10 repetitions as tolerated two to three times per week;-Program B - Bilateral lower extremity passive range of as tolerated two to three times per week;-No documentation the resident was offered, received or refused Program A and/or Program B restorative services two to three times during the week of 03/08/26 through 03/14/26;-On 03/19/26, the resident completed 15 minutes of upper extremity passive range of motion, with 15 reps, and the resident tolerated well. The resident completed 15 minutes of lower extremity passive range of motion with 15 reps and tolerated well. The resident did not receive restorative services on any other day during the week of 03/16/26 through 03/21/26;-No documentation the resident was offered, received or refused Program A and/or Program B restorative services two to three times during the week of 03/22/26 through 03/28/26. 4. Review of Resident #4's undated face sheet showed the resident's diagnoses included presence of other bone and tendon implants. Review of the resident's Restorative Nursing Program Evaluation, dated 02/14/25, showed the following:-Program A: Assist the resident with the following active range of motion restorative program, bilateral upper extremity active/assistive range of motion exercises in all planes as tolerated two to three times per week;-Program B: Assist the resident with the following active range of motion restorative program, bilateral lower extremity active/assistive range of as tolerated, 20 repetitions two to three times per week;-Program C: Assist the resident with transfer restorative program, standing to grab bar in hallway, bathroom or on sit to stand lift standing for as long as tolerated two to three times per week. Review of the resident's annual MDS, dated [DATE], showed the following:-Severe cognitive impairment;-Impairment of one lower extremity functional range of motion;-Independent with roll left and right, sit to lying, lying to sitting on side of bed, sit to stand,-Set up or clean up assistance from staff for oral hygiene, toilet transfer,-Requires supervision/touching assistance from staff members for upper body dressing, chair/bed-to-chair transfer, -Requires partial/moderate assistance from staff for toileting hygiene, lower body dressing, putting on/taking off footwear, personal hygiene,-Dependent on staff for shower/bathe;-Did not receive physical, or occupational therapy;-No restorative nursing, or range of motion. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Severe cognitive impairment;-Impairment of one lower extremity functional range of motion;-Required supervision/touching assistance from staff members for roll left and right (worsened), sit to lying (worsened), chair/bed-to-chair transfer, and toilet transfer; -Required partial/moderate assistance from staff for lying to sitting on side of bed (worsened) and to sit to stand (worsened);-Required substantial/maximal assistance from staff for personal hygiene (worsened),-Dependent on staff for oral hygiene (worsened), toileting hygiene (worsened), shower/bathe, upper body dressing (worsened), lower body dressing (worsened), and putting on/taking off footwear (worsened);-Did not receive physical, or occupational therapy;-No restorative nursing or range of motion.(The assessment showed worsening in the resident's ADL self-performance.) Review of the resident's March 2026 Flow sheet showed the following:-Program A: Assist the residents with the following active range of motion restorative program, bilateral upper extremity active/assistive range of motion exercises in all planes as tolerated two to three times per week;-Program B: Assist the resident with the following active range of motion restorative program, bilateral lower extremity active/assistive range of as tolerated, 20 repetitions two to three times per week;-Program C: Assist the resident with transfer restorative program, standing to grab bar in hallway, bathroom or on sit to stand lift standing for as long as tolerated two to three times per week;-On 03/19/26, the resident completed 15 minutes of active range of motion in his/her upper extremities, with 15 reps, and the resident tolerated well. The resident also completed 15 minutes of active range of motion in his/her lower extremities with 15 reps, and the resident tolerated well. The resident completed 15 minutes of Part C restorative services with 15 reps, and the resident tolerated well. The resident did not receive restorative services on any other day during the week of 03/16/26 through 03/21/26;-No documentation the resident was offered, received or refused Program A, Program B and/or Part C restorative services two to three times during the week of 03/22/26 through 03/28/26. 5. During an interview on 03/31/26 at 2:04 P.M., the Restorative Aide (RA) said the following:-She worked during the week days;-Today, she worked as the RA. Yesterday (03/30/26), she worked as a CNA on the floor;-The facility tried to keep her as the RA, but if staff called in or there were issues, she was pulled from RA to work as a CNA on the floor;-She was pulled from RA often;-If she was the RA every day, she would be able to get all the restorative nursing services completed. When she was pulled to work as a CNA, she did what she could get done. During an interview on 04/01/26 at 12:43 P.M., the Registered Nurse (RN)/MDS Coordinator said the following:-She oversaw the restorative nursing program until recently; the Director of Nursing was taking over the oversight;-She reviewed the restorative documentation to ensure the restorative nursing programs were getting done and to see if adjustments needed to be made to the program; -She reviewed the restorative documentation and was aware the restorative nursing services were not completed. This is why the DON took over the restorative program so she could review and monitor the program; -There were times when the RA was pulled to work as a CNA which made it more difficult to complete the restorative nursing services. During an interview on 04/01/26 at 5:15 P.M., the Director of Nursing said the following:-She recently took over as the person responsible for providing oversight of the restorative program; -The RA program was tp keep residents at their current ADL levels as much as possible and to prevent decline; -Residents with contractures or at risk for contractures needed a restorative program which included range of motion and some may have splints. -The current RA had some absences from work and was pulled to work as a CNA at times, which made it a challenge to complete the restorative nursing services.

Based on observation, interview, and record review, the facility failed to maintain documentation to show staff accurately assessed the risk of entrapment from bed rails and failed to maintain documentation staff obtained informed consent from the residents' representatives prior to bed rail use for four residents (Residents #48, #3, #29, an #12) with bed rails, in a review of 12 sampled resident. The facility census was 47.Review of the facility policy, Proper Use of Bed Assistive Devises, dated 05/19/26, showed the following:-The purposes of these guidelines are to ensure the safe use of bed assistive devices as resident mobility aids and to prohibit the use of bed assistive devices as restraints unless necessary to treat a resident's medical symptoms;-Bed assistive devices include side rails, assist rails, and other bed positioning devices;-An assessment will be made to determine the resident's symptoms or reason for using the bed assistive device upon initiation, quarterly, and as needed;-The use of bed assistive devices will be addressed in the resident's care plan;-Consent for using bed assistive devices will be obtained from the resident or representative and documented per community protocol; -The risk and benefits should be considered for each resident. 1. Review of Resident #48's face sheet showed the resident's diagnoses included dementia, weakness and physical debilitation. The resident had a power of attorney for health care decisions. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 01/28/26, showed the following:-Severe cognitive impairment;-Impaired functional range of motion both upper extremities and one lower extremity;-Required substantial/maximal assistance from staff to roll left and right and to roll side to side in bed;-Dependent on staff for chair/bed-to-chair transfer. Review of the resident's March 2026 physician order sheet showed an order for assist side rail for mobility (original order date 05/15/24). Review of the resident's quarterly Bed Assistive Device Assessment, dated 03/02/26, showed staff marked the resident did not use a bed assistive device. The entrapment risk assessment was not completed. Review of the resident's current care plan showed the resident used an enabler side rail to assist with transfers and bed mobility: half side rails, grab bars. Observation on 03/31/26 at 7:25 P.M., showed the following:-Licensed Practical Nurse (LPN) B and Certified Nurse Assistant (CNA) D transferred the resident with a mechanical lift into his/her bed;-The resident had 1/8 bed rails on both sides of his/her bed in the raised position;-CNA D assisted the resident to roll onto his/her right side. LPN B guided the resident as he/she rolled toward LPN B;-The resident held the bed rail. When CNA D released the pressure to the resident's back side to keep in a turned position, the resident's hand slid off the rail and the resident rolled to his/her back;-The resident held the rail at times as staff provided care but could not pull his/her body weight or maintain a side lying position while using the bed rail. Review of the resident's electronic medical record showed no documentation staff completed an assessment to identify if the resident was at risk for entrapment and no documentation staff obtained informed consent for the bed rails from the resident's representative. During an interview on 03/31/26 at 8:40 P.M., CNA D said the resident could hold the bed rail but could not hold up his/her body weight. The resident could not move himself/herself with the bed rails. If the resident was caught in the bed rails, he/she would not be able to get out by himself/herself. 2. Review of Resident #3's face sheet showed the resident had a power of attorney for healthcare decisions. Review of the resident's significant change in status MDS, dated [DATE], showed the following:-Severe cognitive impairment;-Diagnoses of Alzheimer's disease;-Impairment in functional range of motion to one upper extremity and both lower extremities;-Dependent on staff for roll left and right and for chair/bed-to-chair transfer. Review of the resident's quarterly Bed Assistive Device Assessment, dated 02/07/26, showed staff marked the resident did not use a bed assistive device. The entrapment risk assessment was not completed. Review of the resident's current care plan showed the resident used the right assist grab bar for bed mobility. Review of the resident's March 2026 Physician's Orders Sheet showed no order for bed rails. Review of the resident's electronic medical record showed no documentation staff completed an assessment to identify if the resident was at risk for entrapment and no documentation staff obtained informed consent for the bed rails from the resident's representative. Observation on 03/31/26 at 7:25 P.M. and 8:12 P.M. showed the resident lay in bed. He/She had a 1/8 bed rail in the raised position on the right side of his/her bed. The resident had a bolstered mattress (a mattress with raised edges along the sides of the mattress). During an interview on 03/31/26 at 8:40 P.M., CNA D said the resident did not use his/her bed rail for mobility. 3. Review of Resident #29's face sheet showed the resident had a power of attorney for health care decisions. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Severe cognitive impairment;-Required partial/moderate assistance from staff for sit-to-stand; -Required substantial/maximal assistance from staff to roll left and right, sit to lying, and chair/bed-to-chair transfer;-Dependent on staff for lying to sitting on side of bed. Review of the resident's quarterly Bed Assistive Device Assessment, dated 02/07/26, showed staff marked the resident did not use a bed assistive device. The entrapment risk assessment was not completed. Review of the resident's current care plan showed the resident was at risk for falls related to history of falls, cognitive status, incontinence and impaired safety and risk for loss of balance. An intervention listed to decrease falls was bed rails to assist as an enabler with transfers and bed mobility: half bed rails, grab bars. Review of the resident's March 2026 physician orders sheet showed no order for bed rails. Review of the resident's electronic medical record showed no documentation staff completed an assessment to identify if the resident was at risk for entrapment and no documentation staff obtained informed consent for the bed rails from the resident's representative. Observation on 03/31/26 at 8:30 P.M., showed the resident lay in a low bed. The resident had 1/8 bed rails in the raised position on both sides of his/her bed. During an interview on 03/31/26 at 8:40 P.M., CNA D said the resident used his/her bed rails for mobility. 4. Review of Resident #12's comprehensive MDS, dated [DATE], showed the following:-Severe cognitive impairment;-Upper and lower extremity impairment on one side;-Partial/moderate assistance by staff for rolling left and right in bed;-Dependent on staff for chair/bed-to-chair transfer. Review of resident's care plan, dated 1/29/25, showed the following:-Side rails as an enabler to assist with transfers and bed mobility- half side rails, grab bars;-Encourage use of assist rails to assist turning in bed. Review of the resident's bed assistive device assessment and bed rail safety recommendations, dated 02/04/26, showed the resident did not have bed rails and no consent was needed due to resident not using a bed assistive device. Review of the resident's physician order sheet showed an order, dated 03/11/25, for assist (side) rail/grab bar for mobility. Observation on 03/31/26 at 9:30 A.M., showed the resident sat awake in his/her bed. The resident had a half side rail in the raised position on the right side of the bed. Observation on 04/01/26 at 10:41 A.M., showed the resident lay asleep in his/her bed. The resident had a half side rail in the raised position on the right side of the bed. Observation on 04/02/26 at 9:55 A.M., showed the resident lay asleep in his/her bed. The resident had a half side rail in the raised position on the right side of the bed. 5. During an interview on 04/02/26 at 10:05 A.M., LPN A said the following:-He/She was a charge nurse;-Charge nurses or the nurse managers completed risk assessments, including Bed Assistive Device Assessments, on admission, quarterly and if there was a significant change; -If a resident had a grab bar or bed rail when staff completed the Bed Assistive Device Assessment, the assessment opened another section that reviewed the resident's physical abilities;-Almost all of the residents' beds had bed rails;-When he/she completed the assessment, he/she documented what the resident used to the best of his/her knowledge. If a resident did not use bed rails, he/she marked the resident did not have rails on the assessment;-He/She did not know if anyone reviewed the assessments, orders, consents, and care plans to ensure they all matched and were consistent. During interviews on 04/02/26 at 2:36 P.M. and 5:12 P.M., the Director of Nursing (DON) said the following:-Staff was to complete the Bed Assistive Device Assessment on admission and quarterly; -If the staff picked bed rails are not used, the assessment did not have the staff complete the entrapment assessment;-Staff should fully complete the Bed Assistive Device Assessment for any resident who had bed rails in order to trigger the entrapment risk assessment;-A charge nurse or nurse manager should complete an entrapment risk assessment with any change of condition or decline in physical or mental status;-The assessment should be accurate;-Staff was to obtain informed consent for every resident with bed rails;-Bed rails and risk for entrapment should be listed on the care plan with any interventions needed for the resident; -She recently started a book with the bed rail information and was gathering all of the bed rail assessments, but this was not completed.

Based on observation, interview, and record review, the facility failed to evaluate Broda chairs (a padded reclining chair on wheels) as a physical restraint and failed to ensure the chairs were the least restrictive device while maintaining safety for two residents (Resident #9 and #45), in a review of 12 sampled residents. Staff identified the Broda chairs were utilized to keep the residents in their chair and prevented the residents from standing or propelling without staff assistance. The facility census was 47. Review of the facility's policy, Restraints, last reviewed 03/03/25, showed the following:-The resident has the right to be free from any physical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medication symptoms;-Restraints should only be used when there is no other option for treating a medical symptom;-Restraints will not be used to control resident behavior or as a punishment;-Restraints will only be used when it has been determined that less restrictive interventions are not effective;-An assessment will be completed by the interdisciplinary team (IDT) team in collaboration with the physician to evaluate the need for the use of a restraint;-A physician order will be obtained prior to initiation of the restraint, and the order will specify the period of time to use the restraint;-A care plan will be developed including interventions to minimize or eliminate the medical symptom underlying the restraint use;-The resident and representative will be fully informed on the use of the restraint including but not limited to the potential risks and benefits of all options under consideration including using a restraint, not using a restraint, and alternatives to restraint use;-The community will obtain informed consent from the resident or in the case of a resident who is incapable of making a decision, the resident's representative may give informed consent;-The continued use of restraints will be evaluated with each reassessment to determine if the continued use is appropriate or that less restrictive interventions would achieve the same goal;-The use of restraints will be discontinued as soon as it is determined an alternative would be as effective, or the resident's level of functioning has improved and that the risk factors necessitating restraints have been mediated. Review of the Resident Assessment Instrument (RAI) manual, updated October 2025, showed the following:-Physical restraint is any manual method, physical or mechanical device, material or equipment, attached or adjacent to the resident's body, that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body;-The resident has the right to be free from any physical or chemical restraints imposed for the purposes of discipline or convenience and not required to treat the resident's medical symptoms;- Prior to using any physical restraint, the nursing home must assess the resident to properly identify the resident's needs and the medical symptom(s) the restraint is being employed to address;-If a physical restraint is needed to treat the resident's medical symptom(s), the nursing home is responsible for assessing the appropriateness of that restraint;-Chairs that prevent rising include any type of chair with a locked lap board, that places the resident in a recumbent position that restricts rising, chairs that are soft and low to the floor, chairs that have a cushion placed in the seat that prohibit the resident from rising, geriatric chairs, and enclosed-frame wheeled walkers for example;- For residents who have the ability to transfer from other chairs, but cannot transfer from a geriatric chair, the geriatric chair would be considered a restraint to that individual and should be coded as -Chair Prevents Rising. 1. Review of Resident #9's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 11/01/25, showed the following:-Severe cognitive impairment;-Used a manual wheelchair;-Required partial/moderate assistance from staff to move from a lying position to a sitting position on the side of the bed, to sit to stand, to transfer to chair and bed-to-chair transfers, and to wheel 50 feet and two turns; -Two or more falls with no injury and two or more falls with injury;-Did not use a chair that prevented rising. Review of the resident's care plan, revised 12/11/25, showed the following:-May use Broda chair (a padded reclining chair on wheels); -At risk for falls/injury as evidenced by history of falls, cognitive status/expressions, vision status, continence, mobility, and balance;-On 12/11/25, the resident was found lying on the floor after attempting to self-transfer from Broda chair. The resident fell forward landing face forward. The resident had an injury. Staff cleaned with wound cleanser and applied antibiotic ointment. Nursing staff ordered the Broda chair from hospice to assist the resident with positioning while up in a chair. Review of the resident's significant change in status MDS, dated [DATE], showed the following:-Diagnoses include Alzheimer's disease, non-Alzheimer's dementia, seizure disorder, and repeated falls, -Severe cognitive impairment;-No wheelchair was used;-Independent with sitting to lying,-Required substantial/maximal assistance from staff for roll left and right, lying to sitting on side of bed, sit to stand, and chair/bed-to-chair transfer;-Had two or more falls without injury and two or more falls with injury since last assessment;-Did not have a chair that prevented rising. Review of the resident's care plan, revised 01/13/26, showed the resident was found on the floor on his/her right side, halfway on the fall mat in his/her room. The resident was in his/her Broda chair before the fall. Review of the resident's Physician Order Sheet, dated March 2026, showed the resident had an order for pedal Broda chair (a type of Broda chair with wheels similar to a wheelchair that allowed for mobility). Review of the resident's quarterly MDS, dated [DATE], showed the following:-One no injury fall ;-Required substantial/maximal assistance from staff for roll left and right, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, and sit to lying; -Did not use a chair that prevented rising. Review of the resident's medical record showed no documentation staff evaluated or assessed the restraining properties of a Broda chair for the resident. Observation on 03/31/26 at 7:21 P.M., showed the resident sat in his/her Broda chair in the common television area. The resident's Broda chair sat high in the air, in a reclined position, with a fixed solid footrest that was approximately 10-12 inches off the floor. The resident's Broda chair had caster-style wheels and was not a pedal Broda chair as ordered. The resident lifted his/her body from the chair by pushing up on the arm rest of the chair. The resident moved his/her buttocks to the edge of the seat of the Broda chair. Observation on 03/31/26 at 8:05 P.M. showed the following:-The resident sat in his/her Broda chair in the common television area;-The resident put his/her legs over the right side of his/her footrest and scooted to the edge of the seat of his/her Broda chair;-The resident moved his/her foot around as if to try to touch the ground, while pushing up on his/her armrest attempting to lift his/her body from the chair. Observation on 03/31/26 of the common television area showed the following:-At 8:08 P.M., the resident put his/her leg over the right side of the footrest of the Broda chair and pushed off the armrest of the Broda chair. -At 8:12 P.M., the resident tried to lean over the right side of the Broda chair; -At 8:40 P.M., the resident tried to stand up out of the Broda chair; -At 8:46 P.M., the resident remained in his/her Broda chair. His/Her legs, from the knee down, were off to the right side of the footrest of the chair; -At 8:51 P.M., the resident continued to try to put his/her feet over the right side of the Broda chair footrest. Certified Nurse Assistant (CAN) D told the resident he/she did not want him/her to try to get up out of the chair. During an interview on 03/31/26 at 8:55 P.M., CNA D said the following:-The facility used the Broda chairs to make the residents more comfortable and for safety;-The resident could not get out of the Broda chairs safely without staff's help;-The resident sometimes tried to climb out of his/her Broda chair.-The resident could take a few steps with staff's help to steady himself/herself;-The resident fell from the Broda chair trying to get up on his/her own. 2. Review of Resident #45's care plan, updated 08/05/25, showed the following:-Diagnoses of Alzheimer's dementia and history of a stroke;-At risk for falls as evidenced by history of falls, cognitive status, poor vision, mobility, balance and psychotropic medications;-The resident had a fall 08/05/25. Staff to transfer the resident to the Broda chair as ordered and monitor for comfort, positioning, and safety while seated once the chair arrives;-The resident's Broda chair was added as an intervention to prevent falling. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Severe cognitive impairment;-Diagnosis of Alzheimer's disease;-Required supervision/touching assistance from staff members for roll left and right, sit to stand, chair/bed-to-chair transfer, walk 10 feet, walk 50 feet with two turns, and walk 150 feet-Required partial/moderate assistance from staff for sit to lying, lying to sitting on side of bed,-One non-injury falls since last assessment;-Two or more injury falls since last assessment;-Did not use a chair that prevented rising;-No restraint used. Review of the resident's care plan, updated 01/13/26, showed the following:-The resident sat on the foot of his/her Broda chair and then sat on the floor;-Nursing staff to monitor the resident and his/her positioning while he/she is in the Broda chair. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Severe cognitive impairment;-Requires supervision/touching assistance from staff members for roll left and right, sit to lying, lying to sitting on side of bed,-Requires partial/moderate assistance from staff for chair/bed-to-chair transfer (worsen), toilet transfer (worsen), tub/shower transfer,-Requires substantial/maximal assistance from staff for sit to stand (worsen), walk 10 feet (worsen);-Dependent on staff to walk 50 feet with two turns (worsen);-Unable to walk 150 feet (worsen);-Two or more non-injury falls since last assessment;-Two or more injury falls since last assessment;-Chair that prevents rising was not used;-Frequently incontinent (worsen).-No restraint used;-Chair that prevents rising is not used. Review of the resident's medical record showed no documentation staff evaluated or assessed the restraining properties of a Broda chair for the resident. Observation on 03/31/26 from 7:21 P.M. to 8:04 P.M., of the common television area, showed the resident sat in his/her Broda chair, in a reclined position, at an approximate 70-degree angle. The resident's Broda chair had caster-style wheels. The resident's Broda chair sat higher off the ground than a standard chair, with the footrest approximately 12 inches or more off the ground with the leg rest extended out. Observation on 03/31/26 of the common television area showed the following: -From 8:01 P.M. to 8:06 P.M., the resident sat in his/her Broda chair. The resident was fidgety and put his/her leg over the right side of his/her footrest and raised himself/herself up where his/her body lifted off the seat; -At 8:51 P.M., the resident said he/she was trying to go to the house. Observation showed the resident threw his/her leg over the side of the foot rest and pushed off the arm rest to raise his/her body. The resident could not reach the floor with his/her feet and sat back in the chair. During an interview on 03/31/26 at 8:55 P.M., CNA D said the resident sometimes tried to climb out of his/her Broda chair. The resident could take a few steps with staff's help to steady himself/herself. The resident fell from the Broda chair trying to get up on his/her own. 3. During an interview on 04/02/26 at 2:53 P.M., CNA I said the following:-The residents were in Broda chairs for comfort, and the chairs kept them in the chair;-Resident #45 can walk. His/Her family wanted the resident in the Broda chair and not to walk because he/she was falling;-The residents fell from the Broda chairs. -He/She didn't think Broda chairs were a restraint. During an interview on 04/01/26 at 4:00 P.M., Licensed Practical Nurse (LPN)/Infection Preventionist (IP) said the following:-She worked at 11:00 P.M. on 03/31/26 to 6:00 A.M. on 04/01/26 (this morning);-Resident #9 and Resident #45 tried to climb out of the Broda chairs most of the night during his/her shift; -The facility utilized the Broda chairs for Resident #9 and Resident #45 to keep the residents in their chairs;-He/She didn't think Broda chairs were a restraint. During an interview on 04/01/26 at 9:18 A.M., the Director of Nursing (DON) said the following:-The facility utilized the Broda chairs for Resident #9 and Resident #45 to keep them in their chairs;-The facility did not have an assessment to determine if a Broda chair was a restraint;-The residents could not stand from the Broda chairs unassisted because the chairs were higher off the ground and had fixed foot rests. The residents could not propel the Broda chair to move around without help; -Staff had to propel the Broda chair and assist the residents to transfer out of the Broda chairs;-She didn't think Broda chairs were a restraint.

Based on interview and record review, the facility failed to follow acceptable standards of practice and their Emergency First Aid policy when staff failed to call Emergency Medical Services (EMS) when one resident (Resident #1), in a review of eight sampled residents, began choking on food during a meal and required emergency treatment. The resident expired. The facility census was 48. The administrator was notified of the Immediate Jeopardy (IJ) on [DATE] at 1:28 P.M., which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite verification. Review of the facility policy, titled Emergency First Aid, revised [DATE], showed it directs staff to contact EMS in the event emergency first aid intervention is required, including choking. Review of the American Red Cross training resources for choking showed the following: - Choking occurs when the airway becomes either partially or completely blocked by a foreign object, such as a piece of food or a small toy; by swelling in the mouth or throat; or by fluids, such as vomit or blood. A person who is choking can quickly become unresponsive and die, so it is important to act quickly. - Risk Factors- Medical conditions (such as a neurological or muscular condition that affects the person ' s ability to chew, swallow or both) can increase risk for choking. So can dental problems or poorly fitting dentures that affect the person's ability to chew food properly. - Signs and Symptoms of Choking- A person who is choking typically has a panicked, confused or surprised facial expression. Some people may place one or both hands on their throat. The person may cough (either forcefully or weakly), or he or she may not be able to cough at all. You may hear high-pitched squeaking noises as the person tries to breathe, or nothing at all. If the airway is totally blocked, the person will not be able to speak, cry or cough. The person's skin may initially appear flushed (red), but will become pale or bluish in color as the body is deprived of oxygen. - Emergency Steps: 1. Check the scene safety, form an initial impression, obtain consent and put on personal protective equipment (PPE), as appropriate. 2. Check for signs and symptoms. -Weak or no cough* - High-pitched squeaking noises or no sound* - Pale or blue skin color* - Unable to cough, speak or cry* - Panicked, confused or surprised appearance* - Holding throat with hand(s)* *Note: Signs and symptoms with a * require immediate emergency medical treatment. 3. Call [DATE] and get equipment if the person requires immediate emergency medical treatment. 4. Give Care. 1. Review of Resident #1's undated Face Sheet showed diagnoses of Parkinson's Disease (a chronic brain disorder that causes movement problems, mental health issues, and other health concerns) and dysphagia (difficulty swallowing). Review of footage from the camera facing the kitchen of the event that occurred in the dining room on [DATE] at 5:24 P.M., showed the following: -The resident choked on the evening meal; -Staff attempted to assist the resident by giving back thrusts. The resident was still visibly breathing; -At 5:26 P.M. staff took the resident to his/her room. The resident's eyes remained open and mouth closed; -At 5:28 P.M. the nurse manager brought the crash cart to the resident's room; -At 5:30 P.M. the Director of Nurses (DON) brought the vital sign machine to the resident's room; -At 5:36 P.M. the DON exited the resident's room. A staff member brought the mechanical lift to the resident's room; -At 5:42 P.M. all staff left the resident's room. Review of the written summary of events for [DATE] regarding the resident, completed by the administrator, showed the following: -At 5:06 P.M. staff assist the resident with the first few bites of the meal without difficulty; -At 5:22 P.M. the resident was in the dining room and appeared to be clearing his/her throat; -At 5:24 P.M. the resident continued to chew and attempted to clear his/her throat; -At 5:26 P.M. staff took the resident to his/her room; -At 5:30 P.M. the resident was still passing air and made sounds. Staff attempted abdominal thrusts; -At 5:33 P.M. staff listened for a heartbeat for one minute and no heart beat was detected. During an interview on [DATE] at 2:10 P.M., Certified Nurse Aide (CNA) B said the following: -On [DATE] CNA B fed the resident supper; -The resident was eating well and was not coughing, but appeared to be gagging; -CNA B alerted the charge nurse who began to administer back thrusts which were unsuccessful; -The charge nurse got the suction machine and CNA B took the resident to his/her room; -The charge nurse applied oxygen. The Heimlich maneuver was attempted without success; -The resident leaned forward in his/her wheelchair and became limp; -Staff placed the resident on the floor and attempted abdominal thrusts; -The resident's color changed to purple and he/she no longer had a pulse; -No one instructed CNA B to call EMS at any point. CNA B did not think any other staff called EMS. During an interview on [DATE] at 2:30 P.M., Licensed Practical Nurse (LPN) A said the following: -On [DATE] around 5:30 P.M. he/she was in his/her office; -The unit nurse came by to get the suction machine; -Staff had already attempted the Heimlich maneuver several times without success; -LPN A grabbed the crash cart. When he/she entered the resident's room, he/she was alert; -The resident's mouth was clear; -Another nurse suctioned the resident and got some small pieces of meat, but were unable to clear his/her airway; -Staff placed the resident on the floor when he/she became unresponsive and attempted abdominal thrusts without success; -Staff continued their attempts until the resident no longer had a heartbeat or respirations; -Staff did not call EMS when the resident was choking. During an interview on [DATE] at 4:30 P.M., the Director of Nursing (DON) said the following: -The protocol for staff to follow if a resident was choking was to start the Heimlich maneuver and call EMS; -Staff did not call EMS when Resident #1 began to choke as they were actively performing the Heimlich and all things that EMS would have done. During an interview on [DATE] at 4:40 P.M., the administrator said the following: -Staff should call EMS if a resident had an emergent need; -The facility policy was to call EMS in an emergent situation. During an interview on [DATE] at 4:20 P.M., the resident's physician said the following: -The physician received a call from the DON the resident had choked and died ; -Staff should call EMS in an emergent situation. NOTE: At the time of the complaint investigation, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO245768

16752 Based on observation, record review, interview, and review of facility policy, the facility failed to ensure that care plans were revised for four residents (R)6, R27, R28, and R44 that experienced changes in their conditions and/or care from a total sample of 13 residents. R6 experienced syncopal episodes (a sudden drop in heart rate and blood pressure leading to fainting) on [DATE], [DATE], and [DATE]. R27's care plan was not revised to reflect a left ankle ulcer and that the left ankle ulcer and right buttock ulcers were healed. R28's care plan was not revised to reflect the resident's suprapubic catheter was draining bloody urine and the interventions to flush the catheter as needed. R44's care plan documented the resident was a full code when the resident's Advance Directive indicated the resident was a Do Not Resuscitate (DNR). Findings include: Review of facility policy titled Care Plans - Comprehensive Person Centered with a review date of [DATE], indicated The comprehensive, person-centered care plan will: identify problem areas; .Incorporate risk factors associated with identified problems Assessments of residents are ongoing and care plans are revised based on information about the residents and the resident conditions change . The policy further stated, Interdisciplinary team must review and update the care plan when there is a change in the resident's condition. Review of the facility policy titled Advance Directives with a review date of [DATE], revealed the Advance directives will be respected in accordance with State Law and community policy. The policy further indicated, The plan of care for each resident will be consistent with their documented treatment preferences and/ or advanced directive. 1. Review of R6's Admission Record located in the resident's electronic medical record (EMR) under the Admission tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease and congestive heart failure. Review of R6's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] located in the resident's EMR under the MDS tab revealed the resident had a Brief Interview for Mental Status (BIMS) of score of three out of 15 which indicated the resident was severely cognitively impaired. Review of R6's Nursing Notes located in the resident's EMR under the Notes tab, dated [DATE], [DATE], and [DATE] revealed resident lost consciousness for less than 45 seconds on these dates. The physician was notified of these events. Review of R6's Physician Orders located in the resident's EMR under the Orders tab revealed the following order dated [DATE], coach resident to look up and breathe when being transferred via sit to stand to help prevent syncope episodes. Review of R6's Care Plan with a revision date [DATE] located in the resident's EMR under the Care Plans tab revealed the care plan was not revised to address the physician's order dated [DATE] and the resident's syncopal episodes. During an interview on [DATE] at 12:33 PM, with Certified Medication Technician (CMT)1 revealed the resident had experienced several syncopal episodes in the past few months. During an interview on [DATE] at 3:06 PM, Registered Nurse (RN)2 stated the unit managers and the MDS nurse are routinely responsible for the care plan development and updates as needed. RN2 stated if the resident experienced any syncopal episodes, the care plan should have been revised to reflect those episodes and any interventions. 2. During an observation on [DATE] at 02:24 PM. R27 was observed to have a healing ulcer on the right buttock and no open areas on the ankles or heels. Review of R27's Admission Sheet located in the resident's EMR under the Admissions tab revealed the resident was admitted with diagnoses that included dementia and venous insufficiency. Review of R27's admission MDS with an ARD of [DATE] located in the resident's EMR under the MDS tab revealed the resident had a BIMS score of six out of 15 which indicated the resident was severely cognitively impaired. Review of R27's Specialized Wound Management Notes dated [DATE] located in the resident's EMR under the Consults tab revealed the left ankle and stage III open area on the right buttocks were healed. Review of R27's Care Plan located in the resident's EMR under the Care Plans did not reflect the resident had open areas on right buttocks and left ankle (with treatment); nor was the care plan revised to reflect the areas as healed. 3. During an observation on [DATE] at 9:15 AM, R28 was seated in his wheelchair and his urinary catheter bag had blood-tinged urine in the catheter tubing. Review of R28's Admission Sheet located in the resident's EMR under the Admission tab revealed the resident was admitted to the facility with diagnoses that included neuromuscular dysfunction. Review of R28's admission MDS with an ARD of [DATE] revealed the resident had a BIMS score 11 out of 15 which indicated the resident had moderately impaired cognition. Review of R28's Physicians Orders located in the resident EMR under the Orders tab included orders dated [DATE] to irrigate the supra pubic catheter with 120 milliliters of saline as needed for bladder discomfort. Review of R28's Care Plan with a revision date of [DATE] located in the resident's EMR under the Care Plan tab revealed the resident's care plan was not revised to reflect the bloody urine with clots and the physician's orders to irrigate the catheter for discomfort. During an interview on [DATE] at 09:51 AM, the Interim Director of Nursing (DON) revealed that she is currently responsible for revising/updating residents' care plans on the Lindenwood Unit. The Interim DON acknowledged R6's syncopal episodes, R27's wounds, and R28's catheter concerns, should have been addressed on the residents' care plan. 4. Review of R44's Diagnosis Sheet located under the Admission tab of the EMR revealed diagnoses of Alzheimer's disease, and type 2 diabetes mellitus. Review of the advanced directive Care Plan with an effective date of [DATE] and date of last review date of [DATE] located under the Care Plan tab of the EMR revealed R44 was a full code and the intervention stated CPR will be initiated. Review of the resident's EMR revealed she was marked as a do not resuscitate on the top of the electronic record screen and in the physician's orders. Review of a paper document titled Outside the Hospital Do-Not-Resuscitate (OHDNR) Order signed by the resident's responsible party on [DATE] and signed by the physician on [DATE] stated the resident wished to not receive cardiopulmonary resuscitation in the event of cardiac or respiratory arrest. On [DATE] at 11:40 AM, the care plan was reviewed with the DON, and she verified the care plan stated full code for the advance directive and was documented as DNR in the EMR and the OHDNR form. The DON verified the advanced directive had not been updated on the care plan to reflect R44's DNR status on the care plan. The DON stated that in the case of an emergency, the staff would have checked the Outside the Hospital Do-Not-Resuscitate Order on the paper/hard chart prior to completing CPR.

Based on observation, record review, interview, and review of facility policy, the facility failed to ensure staff's adherence to use of personal protective equipment (PPE) for three of four residents (Resident (R) 6, R27, and R28) on droplet precautions and enhanced precaution isolations from a total sample of 13 residents. Findings include: Review of the facility's policy titled COVID 19 Infection Control Measures reviewed 01/30/24 revealed .Post visual alerts (e.g. signs, posters) at the entrance and in strategic places (e.g. waiting areas, elevators, cafeterias). These alerts should provide instructions about current IPC [Infection Prevention and Control] recommendations. Review of droplet precautions signage posted on residents' room doors revealed staff were to wear N95 face masks, isolation gowns, gloves, and face shield, and perform hand hygiene after resident care. During an observation on 03/05/24 at 12:09 PM, Certified Nursing Assistant (CNA)1 was observed donning N95 face mask, gown, and gloves. However, CNA1 did not don a face shield. CNA1 proceeded to enter R27's room. During an observation on 03/05/24 at 12:13 PM, CNA1 was preparing to enter R6's room. CNA1 washed her hands and donned gown but was still wearing a face mask and gloves from the previous resident's room. CNA1 did not don a face shield before entering the resident's room. During an observation on 03/06/24 at 08:10 AM, Registered Nurse (RN)1 was observed to don gown, gloves, face shield and wearing a surgical mask, not a N95 face mask before entering R28's room. Review of R6's Admission Record located in the resident's electronic medical records (EMR) under the Admission tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease and dementia. Review of R6's COVID-19 Infection assessment dated [DATE], located in the resident's EMR under the Assessment tab revealed the resident tested positive for COVID. Review of R27's Admission Sheet located in the resident's EMR under the Admissions tab revealed the resident was admitted with diagnoses that included malignant neoplasm of prostate and Alzheimer's disease. Review of R27's COVID-19 Infection assessment dated [DATE], located in the resident's EMR under the Assessments tab revealed the resident tested positive for COVID-19. Review of R28's Admission Sheet located in the resident's EMR under the Admission tab revealed the resident was admitted to the facility with diagnoses that included cerebrovascular accident and depression. Review of R28's COVID-19 Infection assessment dated [DATE] located in the resident's EMR under the Assessments tab revealed the resident tested positive for COVID-19. During an interview on 03/05/24 at 12:21 PM, RN3 revealed staff are expected to don full PPE when entering residents' rooms that are on droplet precautions for COVID-19. RN3 stated full PPE included gown, N95 face mask, face shield, and gloves. During an interview on 03/05/24 at 12:25 PM, CNA1 revealed staff are supposed to perform hand hygiene, then don gown, change from surgical face mask to N95 face, don face shield and gloves. CNA1 also stated once the resident's care has been completed, the staff member should remove the PPE in the resident's room and perform hand hygiene after leaving the resident's room. CNA1 acknowledged that she did not follow this procedure when entering R6 and R27's rooms. During an interview on 03/06/24 at 08:10 AM, RN1 revealed she felt that since she was wearing a face shield that the N95 face mask was not necessary. During an interview on 03/06/24 at 12:41 PM, Infection Preventionist (IP) revealed recent outbreak started on 03/03/24. The IP stated the staff had received retraining on 03/05/24 on donning the appropriate PPE when entering the COVID isolation rooms.

Based on observation, interview, and policy and bed specifications review, the facility failed to ensure that regular inspections of bed rails, mattresses, and bed frames were conducted for 41 of 47 occupied beds with enabler bars attached. Findings include: Review of the facility policy titled Proper Use of Bed Assistive Devices revised on 01/30/24, revealed Plant operations will inspect all beds for safety annually, when new device is installed, and as needed when notified by nursing. Review of the undated bed specifications titled SS Retractabed User Manual, Revision 03 revealed no reference to the placement or inclusion of an enabler as part of the bed system. During an observation on 03/07/24 at 9:15 AM, an enabler bar was observed on Resident(R)38's bed located in the bedroom. During an interview on 03/07/24 at 10:15 AM, the Director of Nursing verified the use of the enabler on R38's bed. During an interview 03/07/24 at 10:30 AM, the Maintenance Director verified the facility has no record of bed side rails, mattress, and bed frame inspections in the past twelve months. During an interview 03/07/24 at 11:00 AM, the Administrator indicated the facility uses bed enablers on 41 of 47 occupied resident beds. The Administrator also confirmed that plant operations had not completed bed inspections in the past 12 months.

Based on observation, record review, interview, and review of facility policy, the facility failed to follow acceptable standards of practice when they failed to follow physician orders for administering medications through one resident of two residents (Resident (R) 28) receiving enteral (tube feeding) tube from a sampled 13 residents. The nurse failed to crush medications separately and mix with the prescribed amount of water. Findings include: Review of the facility policy titled Administering Medications Through an Enteral Tube with a review date 01/20/24, indicated Flush tubing with 15-30 ml [milliliters] of water unless otherwise specified. Dilute the crushed or split medication with 15-30 ml of warm water unless otherwise specified. Administer the medication by gravity flow. If administering more than one medication flush with 15 ml, unless otherwise specified, between each medication. When last medication drains from tubing, use a final flush of 15 ml of warm water (or prescribed amount). Clamp tubing when finished, and/or reattach to pump if continuous feeding. During an observation on 03/07/24 at 08:10 AM, during medication administration, Registered Nurse (RN)1 crushed Eliquis (anticoagulant) 2.5 milligrams (mg) one tablet (tab), Vitamin D 50, units one capsule, and Escitalopram (antidepressant) five mg one tab together. RN1 mixed the crushed medications with the Lagevrio (antiviral) 200 mg capsule together. The nurse mixed the crushed medications mixture with 20 milliliters (ml) of water. RN1 also prepared a Metamucil medication with 120 ml of water. RN1 placed R28's enteral feeding on hold. RN1 did not flush the feeding tube prior to administering the medication mixture. RN1 pushed the crushed pill medication mixture through the feeding tube and then pushed the Metamucil mixture through the feeding tube. RN1 did not flush the feeding tube after administering the medications. Review of R28's Physician Orders for the month of March 2024 located in the resident's electronic medical records (EMR) under the Orders tab revealed the resident was to receive Lagevrio 200 mg capsule, Vitamin D 50, 000 units one tab, Eliquis 2.5 mg, Escitalopram five mg, and Metamucil (with sugar) one packet. The orders gave guidance to flush the feeding with 15 ml of water prior to administration of each medication; then mix each crushed medication with 15 ml of water; then flush the feeding tube with 15 ml of water after administering medications. Interview on 03/07/24 at 10:00 AM with the Interim Director of Nursing (DON) revealed it is an expectation for the nurse to crush each medication separately and mix each medication with 15 ml of water. The Interim DON stated nurses should administer each medication mixture (15 ml) through the feeding tube and after each medication mixture flush the feeding tube with 15 ml of water. During an interview on 03/07/24 at 12:45 PM, RN1 acknowledged that she did not flush the feeding tube before or after administering the medication mixture. RN1 stated that she was never told to crush the medications separately and the amount of water to mix with the medications. Also, RN1 stated she was never told the medications should flow through gravity. RN1 stated she has always slowly pushed medications through feeding tube.

Based on observation, interview, and record review, the facility failed to ensure staff provided grooming and hygiene needs for three residents (Residents #1, #8, and #20), who were unable to perform their own activities of daily living (ADLs), in a review of 12 sampled residents. The facility's certified census was 24. 1. Review of the facility's policy, Perineal Care, dated 5/26/21, showed the following: -The purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition; -For a female resident: a. Wet washcloth and apply soap or skin cleansing agent or use a perineal wipe; b. Wash perineal area, wiping front to back; c. Continue to wash the perineum moving from inside outward to and including thighs, alternating from side to side, and using downward strokes. Do not reuse the same area of the washcloth and/or perineal wipe to clean the urethra or labia; d. If using soap and water, rinse perineum thoroughly in same direction, using fresh water and a clean washcloth, then dry perineum; e. Wash rectal area thoroughly, using a washcloth or a perineal wipe, wiping from the base of the labia towards and extending over the buttocks; f. Rinse and dry thoroughly if using a washcloth; -For a male resident: a. Wet washcloth and apply soap or skin cleansing agent or use a perineal wipe; b. Wash perineal area starting with urethra and working outward. If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter three inches. Gently rinse and dry the area; 1. Retract foreskin of the uncircumcised male; 2. Wash using washcloth/soap or perineal wipe. Then rinse, if using a washcloth and soap, urethral area using a circular motion; 3. Continue to wash the perineal area including the penis, scrotum and inner thighs. Do not reuse the same area of the washcloth/wipe to clean the urethra; c. Gently dry perineum following same sequence; d. Reposition foreskin of the uncircumcised male; e. Wash and rinse, or use perineal wipe, the rectal area thoroughly, including the area under the scrotum, the anus and the buttocks. Review of the facility policy, Supporting Activities of Daily Living, dated 5/26/21, showed the following: -Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). -Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. -Residents will be provided with care, treatment and services to ensure that their ADLs do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable. -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care. Review of the facility policy, Care of Fingernails/Toenails, reviewed 5/26/21, showed the following: -Purpose: The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infection; -Unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulatory impairments; -Perform hand hygiene; -Gently, remove the dirt from around and under each nail with an orange stick; -Do not trim nails below the skin line or cut the skin; -Trim fingernails in an oval shape and toenails straight across; -Smooth the nails with a nail file or emery board, apply lotion as permitted; -Repeat the procedure for the second hand or foot; -Perform hand hygiene. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 3/10/22, showed the following: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Cognition moderately impaired; -Required extensive assistance from one staff for personal hygiene. Review of resident's undated care plan showed the following: -Report changes in activities of daily living (ADLs) self-performance to nurse; -Explain all procedures and purpose prior to performing task and encourage self-performance; -Identify usual patterns of behavior for ADLs to maintain familiar routines. (The resident's care plan did not provide instruction regarding assistance with nail care or grooming.) Review of resident's progress notes showed no documentation of nail care provided to the resident. Observation on 6/14/22 at 11:50 A.M. showed the following: -The resident's fingernails were long and breaking; -The resident had long facial hair on his/her chin. During interview on 6/15/22 at 2:22 P.M., Licensed Practical Nurse (LPN) K said he/she did not know why the resident did not have his/her nails trimmed and cleaned. During interview on 6/16/22 at 8:06 A.M., Certified Nurse Assistant (CNA) N said he/she did not know why the resident did not have his/her nails trimmed and cleaned. During interview on 6/17/22 at 8:45 A.M., the resident said the following: -He/She was bothered by seeing facial hair on his/her chin; -He/She would like to have his/her nails trimmed. Observation on 6/17/22 at 8:45 A.M. showed the resident continued to have long, unclean nails and facial hair on his/her chin. 2. Review of Resident #8 quarterly MDS, dated [DATE], showed the following: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Cognition severely impaired; -Required extensive assistance of one staff for personal hygiene; -Continent of bowel and bladder. Review of resident's undated care plan showed the following: -Breakdown activities into manageable segments; -Staff will provide consistency in routine care. (The resident's care plan did not provide instruction regarding assistance with nail care.) Observation on 6/15/22 at 8:45 A.M., showed the resident's fingernails were long and he/she had debris under his/her nails. Observation on 6/17/22 at 8:53 A.M. showed the resident continued to have long fingernails with debris under them. During interview on 6/15/22 at 11:28 A.M., Activities Assistant M said the following: -Nursing staff cut the residents' fingernails; -Activity staff clean and paint residents' nails as an activity once a month; -He/She can cut the residents' fingernails; -He/She had mentioned to the charge nurse and CNAs that residents' nails need to be cleaned more often. During interview on 6/15/22 at 2:22 P.M., LPN K said the following: -He/She thinks social services staff do the residents' nails; -He/She can cut residents' nails; -He/She had not been told that it was his/her responsibility to cut residents' nails. During interview on 6 /16/22 at 8:06 A.M., CNA N said the following: -CNAs can cut the residents' nails if the residents' will let them do it; -Nurses can cut the residents' nails; -Residents were more relaxed when activities staff did their nails. During interview on 6/16/22 at 8:30 A.M., LPN L said the following: -Staff were to cut the residents' nails in the shower; -Staff should remove residents' facial hair if it bothers the resident; -CNAs can cut the residents' nails unless there is a medical issue (diabetic); -He/She did not know why Resident #1 or Resident #8 did not have their nails cleaned or trimmed. During interview on 6/17/22 at 8:50 A.M., CNA O said the following: -CNAs clean the residents' nails and activities department clean the residents' nails monthly; -CNAs can shave residents' facial hair as needed or when staff see stubble growing; -He/She was not sure why Resident #1 had not had his/her facial hair trimmed. 3. Review of Resident #20's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Required extensive assistance of one staff for transfers and toileting; -Frequently incontinent of bowel and bladder. Review of the resident's care plan, dated 1/31/22 and last reviewed on 6/15/22, showed the following: -The resident is occasionally incontinent; -Assist the resident to empty bladder before meals, at bedtime, and before activities; -Check for incontinence. Change if wet/soiled. Clean skin with mild soap and water. Observation on 6/16/22 at 06:07 A.M., showed the following: -The resident lay bed and had been incontinent of urine; -CNA F removed the front of the resident's incontinence brief, and wiped down the resident's groin (area between the stomach and the thigh) on both sides of his/her body; -CNA F assisted the resident to roll to his/her right side and removed the urine soaked incontinence brief; -CNA F wiped up the resident's gluteal crease; -CNA F positioned a clean incontinence brief behind the resident and secured the brief; -CNA F did not cleanse all of the resident's front genitalia or the resident's buttocks which had been in contact with the urine soiled incontinence brief. During interview on 6/16/22 at 6:58 A.M., CNA F said when providing peri-care, staff should wash the groin areas, the front genitalia, the rectal area and buttocks. 4. During interview on 6/17/22 at 11:15 A.M., Director of Nursing said the following: -CNAs could clean residents' nails; -Staff should clean nails immediately if they notice they are dirty; -Staff should remove residents' facial hair if the resident or the facility want to remove it; -Staff should clean from the pubic bone down to the front genitalia and around to the buttocks including the inside of the thighs and the rectal area when providing perineal care.

Based on observation, interview, and record review, the facility failed to use appropriate infection control procedures for hand hygiene, changing gloves, and use of a barrier to prevent the spread of bacteria or other infection causing contaminants for three residents (Residents #1, #14, and #20) during personal cares and dressing changes, in a review of 12 sampled residents. The facility certified census was 24. 1. Review of the facility's policy, Handwashing/Hand Hygiene, dated last reviewed 4/28/21, showed the following: -Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: a. When hands are visibly soiled; b. After personal use of the toilet or conducting personal hygiene; c. After contact with a resident with infectious diarrhea including, but not limited to infections caused by Norovirus, bacillus antracis, salmonella, shigella and C. difficile; -Use an alcohol-based hand rub containing at least 62% alcohol or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents; e. Before and after handling an invasive device (e.g., urinary catheters, IV access sites); f. Before donning sterile gloves; g. Before handling clean or soiled dressings, gauze pads, etc.; h. Before moving from a contaminated body site to a clean body site during resident care; i. After contact with a resident's intact skin; j. After contact with blood or bodily fluids; k. After handling used dressings, contaminated equipment, etc.; l. After contact with objects (e.g., medical equipment); m. After removing gloves; -Hand hygiene is the final step after removing and disposing of personal protective equipment. Review of the facility's policy, Linen Handling, dated last reviewed 4/28/21, showed the following: -Soiled laundry/bedding shall be handled in a manner that prevents gross microbial contamination of the air and persons handling the linen. All soiled linen is handled as contaminated linen; -All used linen is considered to be contaminated and shall be handled as little as possible and with a minimum of agitation; -All used linen shall be bagged at point of use in a leak-resistant bag and placed in a hamper or taken to the linen holding area. Review of the facility's policy, Clean and Sterile Dressings, dated 5/28/21, showed the following: -Clean bedside stand. Establish a clean field; -Place clean equipment on the clean field. Arrange the supplies so they can be easily reached; -Place a receptacle for waste products within reach; -Position resident and adjust clothing to provide access to affected area; -Perform hand hygiene; -Put on clean gloves. Loosen tape and remove soiled dressing; -Pull glove over dressing and discard into plastic or biohazard bag; -Perform hand hygiene; -Open dry, clean dressing(s); -Using clean technique, open other products; -Perform hand hygiene; -Put on clean gloves; -Assess the wound and surrounding skin for [CONDITION(S)], redness, drainage, tissue, healing progress, and wound stage; -Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area (usually, from the center outward); -Use dry gauze to pat the wound dry; -Apply the ordered dressing and secure with tape or bordered dressing per order. Label with date and initials to top of dressing; -Discard disposable items into the designated container; -Remove disposable gloves and discard into designated container; -Perform hand hygiene. 1. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 6/7/22, showed the following: -Cognition moderately impaired; -Stage III pressure ulcer (full thickness tissue loss; subcutaneous fat may be visible but bone, tendon, or muscle is not exposed; slough may be present but does not obscure the depth of tissue loss; may include undermining and tunneling). Review of the resident's Physician Orders, dated 6/14/22, showed the following: -Cleanse wound with wound cleanser; -Apply wound gel to wound bed; -Pack wound with Aquacell rope (a [MEDICATION(S)] dressing used for packing wounds); -Cover with foam dressing once per day. Observation on 6/14/22 at 2:35 P.M., showed the following: -Licensed Practical Nurse (LPN) K entered the resident's room; -LPN K put on gloves without washing his/her hands; -LPN K removed the foam dressing from the resident's left buttock and then pulled out the packing that was inside the pressure ulcer; -White purulent (a fluid and might be slightly thick in texture) drainage was noted on the packing; -LPN K removed his/her gloves, and without washing his/her hands, put on another pair of gloves; -LPN K obtained a bottle of wound cleanser spray from on top of the resident's bedside table; -LPN K applied wound cleanser spray to the pressure ulcer and wiped the wound bed with a clean gauze; -LPN K touched numerous boxes of dressings with his/her gloves while cleaning the pressure ulcer; -LPN K used scissors to cut a piece of [MEDICATION(S)] dressing (a primary dressing mad of knitted cellulose acetate fabric and impregnated with a specially formulated [MEDICATION(S)] emulsion, designed to help protect the wound while preventing the dressing from adhering to the wound), rolled it up, and inserted it into the resident's pressure ulcer with a cotton tip applicator; -LPN K applied wound gel to the outside of the wound bed with the same cotton tip applicator; -LPN K applied a padded foam adhesive dressing to the outside of the pressure ulcer; -LPN K put the wound cleanser and the unused wound care supplies back on the resident's nightstand; -LPN K removed his/her gloves and left the resident's room without washing his/her hands. During interview on 6/14/22 at 2:45 P.M., LPN K said the following: -He/She did not wash his/her hands before putting on gloves or between glove changes; -He/She should have washed his/her hands when he/she changed his/her gloves; -He/She should not touch other items with soiled gloves. 2. Review of Resident #14's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Required extensive assistance from two staff for bed mobility and toileting; -Required assistance from one staff for personal hygiene; -Had a urinary catheter and a [CONDITION(S)] (an opening in the large intestine); -Had one Stage II pressure ulcer (partial thickness skin loss involving, epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater); -Received pressure ulcer care. Review of the resident's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 6/15/22 at 9:58 A.M., showed the following: -The resident lay in bed; -LPN G entered the room with dressing supplies and laid them directly on the resident's bed without a barrier; -LPN G and Certified Nurse Assistant (CNA) J assisted the resident to roll to his/her right side; -The resident had three dressings on his/her buttocks; -The dressings were soiled with red drainage; -LPN G removed the soiled dressings, and laid the soiled dressings on soiled linen that lay directly on the resident's bed; -Wearing the same gloves, LPN G cleansed the open area with disposable wipes; -Without removing his/her soiled gloves, LPN G picked up a foam dressing and applied it to the open area on the resident's upper right buttock area; -LPN G removed his/her gloves, washed his/her hands, and left the room to get additional dressing supplies; -LPN G re-entered the room, and without washing his/her hands, put on new gloves and applied a foam dressing to the top of the resident's gluteal crease and bottom of the right buttock; -LPN G picked up the soiled dressings and put them in the trash; -Wearing the same gloves, LPN G placed a clean draw sheet on the resident's pad, placed a disposable pad behind the resident, positioned a clean incontinence brief under the resident, and assisted the resident to roll to his/her left side touching the resident's leg and hip with his/her left hand as he/she rolled the resident in bed; -The soiled linens at the foot of the resident's bed came in contact with the resident's legs as staff rolled the resident back and forth in bed; -Wearing the same gloves, LPN G picked up a wet washcloth, sprayed the cloth with skin cleanser and cleansed the resident's groin areas; -LPN G laid the soiled cloth on the pile of soiled linens at the foot of the bed (there was no barrier between the soiled linens and the resident's bed); -LPN G patted the resident's groin area dry; -Wearing the same gloves, LPN G picked up a bottle of antifungal powder, applied the powder to the resident's groin area, sat the bottle on a table and secured the resident's incontinence brief; -LPN G removed his/her gloves, and without washing his/her hands, picked up the hoyer lift (mechanical lift) sling and laid it on the bed. During interview on 6/15/22 at 1:57 P.M., LPN G said staff should wash their hands and put on gloves when going into a resident's room to do a treatment. He/She probably should have washed his/her hands and changed gloves after removing the soiled dressing before applying the new dressing, but he/she wasn't expecting what he/she found (thought there was only one open area and there were three). Staff should wash hands and change gloves before touching anything so not to spread germs. He/She laid the soiled dressings on the bed because he/she wasn't sure what else to do with them at the time. He/She usually laid clean dressing supplies on the bed or table. 3. Review of Resident #20's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Required extensive assistance of one staff for transfers and toileting; -Frequently incontinent of bowel and bladder. Review of the resident's care plan, dated 1/31/22 and last reviewed on 6/15/22, showed the following: -The resident was occasionally incontinent; -Check for incontinence; change if wet/soiled. Clean skin with mild soap and water. Observation on 6/16/22 at 06:07 A.M., showed the following: -The resident lay on his/her back in bed; -CNA F entered the resident's room and without washing his/her hands, put on gloves, moved the fall mat from beside the bed and raised the resident's bed; -CNA F lowered the front of the resident's incontinence brief. The resident was incontinent of urine; -CNA F provided perineal care for the resident; -CNA F removed his/her gloves, and without washing his/her hands, put on new gloves, removed disposable wipes from the container, and assisted the resident to roll to his/her right side; -CNA F removed the soiled incontinence brief from under the resident, laid the brief at the foot of the bed directly on the resident's sheets, and provided perineal care to the resident's gluteal crease; -Wearing the same soiled gloves, CNA F picked up the clean incontinence brief and positioned it behind the resident, picked up the soiled incontinence brief (that had been on the foot of the bed) and put in it the trash; -Wearing the same gloves, CNA F assisted the resident to lay on his/her back and secured the incontinence brief; -The resident placed his/her hand on the wet top sheet (located beside the resident) and said it's damp; -Wearing the same gloves, CNA F put pants and shoes on the resident, rolled up the soiled top sheet, bottom sheet and bed pad (that lay on the bed to the right of the resident), pulled up the resident's pants, lowered the bed, assisted the resident to sit up on the side of bed, removed the resident's wet gown, dressed the resident in a shirt and positioned the resident's wheelchair beside the bed; -CNA F transferred the resident to his/her wheelchair and wheeled him/her to the bathroom; -CNA F removed his/her gloves, and without washing his/her hands, put toothpaste on the resident's toothbrush and handed the toothbrush to the resident; -The resident brushed his/her own teeth; -Without washing hands, CNA F put on gloves and place the soiled linen from on top of the resident's bed into a bag; -Wearing the same soiled gloves, CNA F applied clean linens to the bed; -CNA F removed his/her gloves, and without washing his/her hands, put on new gloves, applied the gait belt around the resident, and transferred the resident to the toilet; -CNA F removed his/her gloves, and without washing his/her hands, put on new gloves, assisted the resident to stand from the toilet and provided perineal care; -Wearing the same soiled gloves, CNA F pulled up the resident's incontinence brief and pants, transferred the resident to his/her wheelchair and buttoned the resident's pants. During interview on 6/16/22 at 6:58 A.M., CNA F said staff should change gloves when going from one body part to another and after handling trash. Staff should wash hands when going in to a room, when changing gloves and when leaving the room. Staff should not touch clean things with dirty gloves or before washing hands because of cross-contamination. During interview on 6/17/22 at 11:15 A.M., the Director of Nursing said if gloves are soiled, staff should change them and use hand sanitizer. She expected staff to at least use hand sanitizer upon entering a resident's room. Staff should change their gloves between dirty and clean tasks, and should wash their hands with glove changes, as well as before leaving the resident's room. Staff should put clean dressing supplies on a barrier on the bedside table. She would not expect staff to lay clean dressing supplies on the bed without a barrier or near soiled linen. Staff should place soiled linen in a plastic bag and should not lay the soiled linen on the end of the bed.

Based on observation, interview, and record review, the facility failed to ensure staff followed physician orders when providing treatment to a pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time) for one resident (Resident #1), in a review of 12 sampled residents. The facility census was 24. Review of the facility policy, Pressure Injury Treatment Protocol, reviewed 5/28/22, showed the following: -Purpose: The purpose of this procedure is to provide guidelines for the care of existing pressure injuries and the prevention of additional pressure injuries; -Interventions/Care Strategies: Pressure injury treatment requires a comprehensive approach, including, debridement, managing infections, managing systemic issues ([CONDITION(S)], [CONDITION(S)], etc.), maximizing the potential for healing, and pain control; -Stage III (full thickness tissue loss; subcutaneous fat may be visible but bone, tendon or muscle is not exposed; slough may be present but does not obscure the depth of tissue loss; may include undermining and tunneling) protocol: -Protect, manage drainage, and promote moist wound healing; -Choose primary dressing from facility wound protocol or care provider orders. 1. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 6/7/22, showed the following: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Cognition moderately impaired; -Stage III pressure ulcer. Review of the resident's care plan, undated, showed the following: -The resident is at risk for developing pressure ulcer due to incontinence and impaired bed mobility; -Obtain and implement orders for wound care; -Treatment care as ordered. See current treatment record and add physician's orders, monitor effectiveness of response to treatment as ordered. Review of the resident's Physician Orders, dated 6/14/22, showed the following: -Cleanse wound with wound cleanser, -Apply wound gel to wound bed; -Pack wound with Aquacell rope (a [MEDICATION(S)] dressing used for packing wounds); -Cover with foam dressing; -Complete once per day. Review of resident's Treatment Administration Record (TAR), dated June 2022, showed to cleanse wound with wound cleanser, apply wound gel to wound bed, pack with Aquacell rope, and cover with foam. Review of resident's Specialized Wound Management assessment, dated 6/15/22, showed the following: -Wound assessment of left buttock showed a Stage III ulcer; -Wound bed description of left buttock: 100 percent granulation (new connective tissue and blood vessels that form on the surfaces of a wound during the healing process); -Wound measurements of left buttock: length 1 centimeter (cm) by width 0.5 cm by depth 1.9 cm, with undermining 2.9 cm; -Plan of care for left buttock: cleanse with wound cleanser, apply [MEDICATION(S)], lightly pack, cover with foam dressing. Change three times weekly and as needed. Observation on 6/14/22 at 2:35 P.M., showed the following: -Licensed Practical Nurse (LPN) K entered the resident's room; -LPN K removed the foam dressing from the resident's left buttock and then pulled out the packing that had been inserted into the pressure ulcer; -White purulent drainage (a thick and milky discharge from a wound that often indicates an infection) was on the packing: -The pressure ulcer on the resident's left buttock had tunneling and had pink tissue to the outside of the wound bed; -LPN K applied would cleanser spray to the pressure ulcer and wiped the wound bed with a clean gauze; -LPN K cut a piece of [MEDICATION(S)] dressing (a primary dressing made of knitted cellulose acetate fabric and impregnated with a specially formulated [MEDICATION(S)] emulsion, designed to help protect the wound while preventing the dressing from adhering to the wound), rolled it up, and inserted it into the resident's pressure ulcer with a cotton tip applicator. (LPN K did not pack the wound with Aquacell rope as ordered); -LPN K applied wound gel (used to create a moist wound environment for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -LPN K applied a padded foam adhesive dressing to the outside of the resident's pressure ulcer. During interview on 6/14/22 at 2:45 P.M., LPN K said the following: -He/She could not find the dressing he/she thought was used on the resident; -The physician order was different than what he/she applied to the resident; -He/She should have looked at the treatment administration record before he/she applied the dressing. During interview on 6/17/22 at 11:15 A.M., Director of Nursing said she expected staff to look at physician's orders in the resident's chart and follow the order.

Based on observation, interview, and record review, facility staff failed to safely transfer one resident (Resident #20), in a review of 12 sampled residents. Staff did not properly apply or use the gait belt (an assistive device which can be used to help safely transfer a person from a bed to a wheelchair or assist with sitting and standing) during the transfer. The facility certified census was 24. Review of the facility policy, Safe Lifting and Movement of Residents, dated 10/14/19 and last reviewed on 5/28/21, showed the following: -Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents; -Nursing staff, in conjunction with therapy staff, will assess individual resident's needs for transfer assistance on an ongoing basis. Staff will document resident's transferring and lifting needs in the care plan. Such assessment will include: a. Resident's preferences for assistance; b. Resident's mobility (degree of dependency); c. Resident's size; d. Weight-bearing ability; e. Cognitive status; f. Whether the resident is usually cooperative with staff; and g. The resident's goals for rehabilitation, including restoring and maintaining functional abilities; -Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, slide boards) and mechanical lifting devices. Review of the Nurse Assistant in a Long-Term Care Facility student reference manual, reviewed 2001, showed the following: -CAUTION: NEVER transfer a resident by lifting him/her under the arms! This can cause nerve damage, fractures, and shoulder dislocation. -The gait belt is a special belt that is placed around the resident's waist and provides the nurse assistant with a handle to hold onto for those who require assistance during transfers; -The nurse assistant should not transfer residents by grasping their upper arms or under their arms. Such a transfer could result in skin tears, damage to nerves and arteries, and possible dislocation of the shoulder. The gait belt increases the comfort and safety of the resident during the transfer procedure and prevents injury to the resident that could be caused by pulling on his/her arms, shoulders or wrist. -The gait belt is applied snuggly around the resident's waist below the ribs so the nurse assistant's fingers may grasp the belt securely. The belt must be applied securely to prevent the belt from sliding above the resident's waist. -The nurse assistant grasps the belt on both sides of the resident's waist. -Gait belts are required for all residents when performing transfers, ambulation, or repositioning in a chair. -When transferring a resident who requires assistance from one nurse assistant, stand directly in front of the resident and grasp the back of the gait belt. Support the resident's knees and feet with your knees and feet. Have the resident lean forward on the chair/bed. On the count of three, have the resident push up as much as possible while you pull him/her up by straightening your legs and hips and holding onto the belt. Pivot your entire body as well as the resident's body. Lower the resident into the chair by bending at your knees and hips as the resident sits down. 1. Review of Resident #20's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 4/26/22, showed the following: -Severely impaired cognition; -Required extensive assistance from one staff for transfers and toileting. Review of the resident's care plan, dated 1/31/22 and last reviewed on 6/15/22, showed the following: -The resident has activity of daily living self-care deficit related to decreased mobility and muscle weakness; -Provide adaptive/safety equipment: walker and wheelchair; -Care plan did not address how the resident was to transfer. Observation on 6/16/22 at 6:07 A.M., showed the following: -The resident lay in bed; -Certified Nurse Assistant (CNA) F assisted the resident to sit on the side of the bed and positioned the wheelchair beside the resident's bed; -CNA F applied the gait belt around the resident's waist, however, CNA F did not tighten the gait belt appropriately so the belt remained loose around the resident's waist; -The resident stood with minimal assist and transferred to the wheelchair; -CNA F did not hold onto the gait belt during the transfer; -CNA F positioned the resident's wheelchair by the toilet; -The resident held on to grab bar while CNA F assisted the resident to transfer to the toilet. CNA F pulled up on the back of the resident's pants and placed his/her forearm under the resident's right armpit during the transfer. CNA F did not use the gait belt which remained loose around the resident's waist; -CNA F transferred the resident from the toilet to his/her wheelchair. CNA F pulled up on the back of the resident's pants and placed his/her forearm under the resident's right armpit during the transfer. CNA F did not use the gait belt which remained loose around the resident's waist; During interview on 6/16/22 at 06:58 A.M., CNA F said the following: -He/She should use a gait belt during transfers and not pull on the back of the resident's pants or lift under the arms; -He/She was not sure how to get the gait belt snug around the resident. He/She was not used to the type of gait belt at the facility with the metal clasps but more familiar with the belts with plastic clips. -If he/she had questions about how to use equipment, he/she should ask the charge nurse. During interview on 6/17/22 at 11:15 A.M., the Director of Nursing (DON) said staff should apply a gait belt properly and use a gait belt during transfers. If staff are unsure how to apply the gait belt, then they should ask the charge nurse. She would not expect staff to transfer a resident but grabbing the back of the resident's pants or lifting under the resident's arm.

Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services consistent with acceptable standards of practice to prevent urinary tract infections (UTIs) for one resident (Resident #14), who had a urinary catheter (a sterile tube inserted into the bladder to drain urine), in a review of 12 sampled residents. The facility reported one resident with a urinary catheter. The facility census was 24. Review of the facility's policy, Perineal Care, dated 5/26/21, showed the following: -The purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition; -If the resident has an indwelling catheter, gently wash the juncture of the tubing from the insertion site down the catheter about three inches. If using soap and water, gently rinse and dry the area. Review of the facility's policy, dated 11/4/19 and last reviewed 5/28/21, showed the following: -The purpose of this procedure is to prevent catheter-associated urinary tract infections; -During personal care, check to make sure the resident is not lying on the catheter and to keep the catheter and tubing free of kinks; -The urinary drainage bag must be held at or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder; -Be sure the catheter tubing and drainage bag are kept off the floor. 1. Review of Resident #14's care plan, last revised 3/15/22, showed the following: -The resident is at risk for infection and/or skin breakdown related to a suprapubic (sterile tube inserted into the bladder through the abdominal wall) catheter; -Clean around catheter with soap and water, per policy, unless contraindicated; -Keep tubing below level of bladder and free of kinks or twists. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 5/12/22, showed the following: -Severely impaired cognition; -Required extensive assistance from two staff for toileting; -Required assistance from one staff for hygiene; -Had a urinary catheter; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 6/15/22 at 9:58 A.M., showed the following: -The resident lay on his/her right side in bed; -The resident's urinary drainage bag was hooked on the bed frame; the bottom of the drainage bag sat directly on the floor; -Certified Nurse Assistant (CNA) J stood on the right side of the bed, picked up the urinary drainage bag, lifted it up and over the resident, and handed the bag to Licensed Practical Nurse (LPN) G; -LPN G raised the urinary drainage bag above the level of the resident's bladder to unkink the tubing and urine flowed back towards the resident. LPN G then hooked the urinary drainage bag on the left side of the bed; -LPN G sprayed a wet washcloth with skin cleanser and wiped around the urinary catheter insertion site multiple times with the same cloth surface; -LPN G did not cleanse the catheter tubing from the insertion site outward. Observations on 6/16/22 at 5:32 A.M., 6:42 A.M., 8:00 A.M. and 8:17 A.M., showed the resident lay in a low bed. The resident's urinary drainage bag was hooked to the side of the bed frame and sat directly on the floor. During interview on 6/15/22 at 1:57 P.M., LPN G said a resident's urinary catheter should be kept below the level of the bladder and off the floor. When providing catheter care, staff should wipe around the urinary catheter insertion site and change the cloth surfaces between each wipe. Staff should not use the same surface of the cloth over and over to cleanse the insertion site. Staff should also clean the catheter tubing from the insertion site outward approximately two inches. During interview on 6/17/22 at 11:15 A.M., the Director of Nursing (DON) said when performing catheter care, staff should clean the area around the insertion site, changing the cloth surfaces with each wipe, and should cleanse the tubing from the insertion site outwards. The urinary drainage bag should be kept below the resident's bladder and off the floor. Staff should ensure no kinks in the catheter tubing. She would not expect staff to raise the catheter bag above the level of the bladder causing urine to flow back towards the resident.

Based on observation, interview, and record review, the facility failed to allow four residents (Resident #1, #2, #3 and #4), in a review of five sampled residents, to make choices about aspects of his/her life that were significant to the resident when Certified Nurse Assistant (CNA) F made the residents go to bed at a time other than their preferred bedtime and completed the residents' cares on his/her schedule and at his/her convenience. The facility census was 78. Review of the facility's Resident Bill of Rights, provided in the Admission Agreement, showed the following: -You are entitled to take part in planning your care and in being informed of all aspects of you care; -You may refuse any treatment you do not want. 1. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 10/10/19, showed the following: -It was very important to the resident to choose his/her bedtime; -It was very important to the resident to keep up with the news. Review of the resident's quarterly MDS, dated [DATE], showed the resident to had no cognitive impairment. Review of the facility investigation, dated 1/13/20, showed at 8:30 A.M. the administrator met with Resident #1 who communicated CNA F came in his/her room at 7:45 P.M. He/She said hi to CNA F and asked him/her what he/she wanted. The resident said CNA F responded, I am going to put you to bed. The resident responded, I do not go to bed until 10:00 P.M. The resident said they argued a bit and CNA F then said he/she would come back at 9:30 P.M. The resident said he/she was not happy about that but did not say anything more. As the night went on, CNA F was in and out of his/her room but did not speak to him/her. At around 9:30 P.M., CNA F came in and put the resident to bed. Record review of the facility social worker's interview with the resident on 1/14/20 showed the resident said CNA F came in his/her room (on 1/12/20), didn't say anything to the resident, but that he/she came to put him/her to bed. The resident said it was 7:45 P.M. and he/she doesn't go to bed until 10:00 P.M. CNA F said, not tonight. The resident said he/she told him/her again he/she goes to bed at l0:00 P.M. CNA F told the resident he/she would come back at 9:30 P.M. Resident #1 said CNA F came back around 9:30 P.M. and he/she put the resident in bed. Review of the resident's care plan, dated 1/22/20, showed the following: -The resident's quality of life is better when he/she is able to do the things that are most important to him/her; -Prefers to keep up with daily news by watching television; -Prefers to retire around 10:00 P.M. During an interview on 1/24/20 at 9:00 A.M., the resident said the following: -An agency staff member, came into his/her room around 7:30 P.M. on the evening of 1/12/20, and told him/her he/she was going to put him/her to bed; -He/She did not go to bed until around 10:00 P.M. and told the staff member that; -The staff member seemed to act like it was going to be his/her way or no way and he/she argued with the staff member saying he/she would not go to bed before 10:00 P.M.; -The staff member told the resident he/she would be back around 9:30 P.M. to put him/her to bed; -He/She still did not like this but he/she became afraid of the staff member and just went along with what he/she said; -He/She would have rather been up to watch the news; -This made him/her angry; -He/She felt like he/she was nobody or nothing and the staff member was everything; -He/She thought he/she was old enough to make his/her own decisions. 2. Review of Resident #2's care plan, date range from 11/1/19 through 1/22/20, did not address the resident's preferred bedtime. Review of the resident's significant change MDS, dated [DATE], showed the following: -No cognitive impairment; -It was somewhat important to the resident to choose his/her bedtime. Review of the facility investigation, dated 1/13/20, showed the following: -The resident rang his/her call light. Licensed Practical Nurse (LPN) A responded to the light. The resident was in pain and requested pain medications. While administering pain medication, the resident began to express his/her dislike for CNA F. The resident said CNA F was mean and rude because he/she was not able to move fast enough. The resident said CNA F told him/her that if he/she did not move quicker he/she was not going to help him/her. The resident communicated CNA F was rough and he/she was afraid of him/her; -On 1/13/20 at 10:40 A.M., the interim director of nursing (DON) interviewed the resident who said CNA F was over the top. He/She seemed angry from the get go. He/She didn't say the words exactly, but he/she wanted me to know he/she was the boss. He/She was intimidating and rushing me. I can't rush. Record review of the facility social worker's interview with the resident on 1/14/20 showed the resident said CNA F was mean, mouthed off and hurtful. The resident said CNA F told him/her it was time to go to bed (on 1/12/20). The resident said he/she responded by telling CNA F he/she was not ready to go to bed, but he/she was going to his/her room. The resident said CNA F told him/her, I said, it's time to go to bed. The resident said he/she told CNA F he/she didn't want to do that and CNA F told him/her, that's what I get paid for. During an interview on 1/24/20 at 9:30 A.M., the resident said the following: -He/She was not used to the type of treatment CNA F treated him/her with; -CNA F told the resident he/she had to go to bed when CNA F came into his/her room early the evening of 1/12/20. He/She could not recall the time, but it was earlier than he/she wanted to go to bed; -He/She was grumpy with CNA F for making him/her go to bed on what seemed to be CNA F's time and not his/hers; -CNA F rushed him/her into getting his/her bedtime cares completed and into bed, saying, I just couldn't seem to move fast enough for him/her; -CNA F seemed angry; -He/She tried to tell CNA F he/she did not want to go to bed yet, but it was like he/she was deaf and did not listen. 3. Review of Resident #3's significant change MDS, dated [DATE], showed the following: -No cognitive impairment; -It was very important to the resident to choose his/her bedtime. Review of the facility investigation, dated 1/13/20, showed on 1/13/20 at 8:15 A.M., the interim Director of Nurses (DON) interviewed the resident, who said, CNA F was rude. Put me to bed before I was ready. He/She accused me of trying to kick him/her in the face when he/she took my socks off. This didn't happen. He/She was just rude, angry. During an interview on 1/24/20 at 8:30 A.M., the resident said the following: -CNA F was rude to him/her one evening when CNA F wanted the resident to go to bed when he/she was not ready to go to bed; -He/She said he/she usually went to bed around 9:30 P.M. CNA F was trying to put him/her to bed at 8:30 P.M.; -He/She told CNA F he/she liked to stay up and watch television until 9:30 P.M. but it was like he/she was having no part of that and he/she was in control of everything; -It made him/her mad he/she could not stay up to watch his/her television show. 4. Review of Resident #4's annual MDS, dated [DATE], showed it was very important to the resident to choose his/her bedtime. Review of the resident's quarterly MDS, dated [DATE], showed the resident had no cognitive impairment. Review of the facility investigation, dated 1/13/20, showed on 1/13/20 at 8:00 A.M., the interim DON interviewed Resident #4 who said, CNA F tried to be the boss. I don't know. I just know I was not happy. I could tell he/she was not happy with me. He/She was just hostile. I would ask something, and he/she replied, You don't have the right to ask. Just not pleasant. He/She was just angry. Review of the resident's care plan, dated 1/24/20, showed the following: -The resident's quality of life is better when he/she is able to do the things that are most important to him/her; -Prefers to retire around 10:00 P.M. During an interview on 1/24/20 at 8:40 A.M., Resident #4 said the following: -CNA F had tried to tell him/her it was time to go to bed one night before he/she wanted to go to bed; -He/She told CNA F he/she was not ready for bed and wanted to stay up a while longer and asked CNA F why it was so important he/she go to bed right that minute; -CNA F told him/her he/she didn't have the right to ask questions, and just needed to get ready to go to bed, it was bed time; -He/She felt like he/she was a child being sent to bed by their parent. During interview on 1/27/20 at 9:25 A.M., CNA F said the following: -He/She worked the evening of 1/12/20 into 1/13/20; -He/She was called to work and arrived around 6:30 P.M. to 7:00 P.M. Most of the residents were still up when he/she arrived for his/her shift; -When he/she arrived for his/her shift, two CNAs gave him/her report on the residents he/she was assuming, including transfer status, incontinent/continence cares and mental cognition. He/She could not recall the specifics he/she was told; -He/She was given a piece of paper, listing the residents' names. He/She took notes on the paper, but he/she could not recall what, if anything, was listed about the residents on the paper; -He/She was the only staff to care for 16 residents on that particular hall; -He/She was frustrated the residents were still up and not in bed when he/she came on duty and he/she felt overwhelmed with the job responsibilities but did not call for help or tell anyone; -He/She was told he/she would have computer access and log-in information was beside the computer that would provide him/her the residents' care plans, but when he/she looked, there was no log-in information there; -He/She was not able to access the residents' information or document the cares he/she provided. During interview on 1/27/20 at 4:38 P.M., LPN A said the following: -He/She was the charge nurse for night shift on 1/12/20 through 1/13/20; -CNA F had not asked for help during the shift, only asked for relief to go to break; -It was during CNA F's break that he/she covered his/her hall assignment and began receiving resident complaints about CNA F's care; -He/She had not had any interaction with CNA F, had not worked with him/her prior and had not checked on him/her during his/her shift to see if he/she needed any help. During interview on 1/24/20 at 10:45 A.M., the interim DON said the following: -The charge nurse gives agency staff a quick, verbal orientation upon arrival for their shift; -At the time of these incidents, there was no facility training for agency staff, the facility relied on the hiring agency to provide that training; -There was no facility policy on agency staff training or orientation; -He/She was not sure what was meant by a nurse report sheet. During interviews on 1/24/20 at 11:00 A.M., 1/27/20 at 11:11 A.M. and 2/4/20 at 9:09 A.M., the administrator said the following: -Residents should be allowed to direct their own cares if possible; -Bed time is a resident preference and choice that staff should try to accommodate for the resident. -CNAs, including agency staff, should have access to the residents' care plans via the facility computers; -The evening of 1/12/20 was CNA F's first shift and he/she did not have computer access set up yet. -CNA F should have been given verbal report/details of residents' care plans during the walk-through with the day CNAs at shift change; -She expected the charge nurse on duty to check in with agency staff during their shift to see how they were doing and if they had any questions. MO 4

Based on interview and record review, the facility failed to report an allegation of abuse involving one resident (Resident #1) to the state survey agency within two hours after the allegation was made. The facility census was 78. Review of the facility's Abuse/Neglect Prevention and Response Policy, revised 10/23/17, showed the following: -Residents and clients of the facility will live and be served in an environment that promotes dignity, respect and strives to be free from abuse, neglect and exploitation. Allegation of potential or actual abuse, neglect or exploitation will be immediately reported to the appropriate leadership and government agency(ies), the resident protected and the allegation investigated; -Staff should call the appropriate number below for all allegations of abuse or neglect: For all living settings and programs in Missouri, call the Missouri Elder Abuse & Neglect Hotline: [PHONE NUMBER]; -Staff shall immediately report to the administrator, or administrator's designee any actual, potential or alleged complaint of abuse regardless of source. Failure to immediately report any such allegation will not be tolerated and appropriate action will be taken; -Staff will be educated on state specific abuse reporting hotlines and such hotlines will be prominently posted; -Administrator or Administrator's designee shall timely report allegation to appropriate authorities in accordance with applicable state law. The authorities will also be timely notified of any changes in condition of the alleged resident victim; -Allegations of abuse, neglect, exploitation or mistreatment, misappropriation of property and serious injuries of unknown origins will be immediately reported to appropriate authorities but no later than two hours after the basis of the allegation occurred. All other reportable events will be reported to appropriate authorities within 24 hours. Review of the Department of Health and Senior Services (DHSS) Facility Self-Report Cover Sheet, received from the facility in the regional office on 1/13/20 at 3:01 P.M., showed the following: -Registered Nurse (RN) Clinical Educator indicated the facility was reporting an allegation of abuse; -The summary of the alleged incident: On 1/13/20 at 12:51 A.M., call received from Licensed Practical Nurse (LPN) A reporting agency staff Certified Nurse Aide (CNA) F improperly transferred Resident #1 from wheelchair to bed. Stated he/she was to be a sit to stand lift, and CNA F did not use a sit stand and just threw him/her in the bed which resulted in a bruise to his/her right arm from being pinned against the positioning rail. LPN A confirmed CNA F had been advised in detailed floor report about the resident's transfer status using the sit to stand. Other residents on the neighborhood had complaints of CNA F being rude, but no physical harm. LPN A received multiple complaints from residents about CNA F's demeanor and roughness. State hotline called at 7:26 A.M. (6 hours and 35 minutes after LPN A reported the abuse allegation to RN Clinical Educator). Review of the facility investigation, dated 1/13/20, showed the following: -At 6:30 A.M. on 1/13/20, on-call RN Clinical Educator notified the administrator (voice mail) of reported complaints of agency aide CNA F, scheduled for a 12-hour night shift 1/12/20; -At 6:49 A.M., the administrator contacted RN Clinical Educator and instructed him/her to contact the staffing agency and notify them CNA F was to not return to the facility, and he/she would be added to the do not return list and requested CNA F's personnel record be provided. The administrator instructed RN Clinical Educator to hotline the allegation as soon as possible; -At 6:52 A.M., the administrator contacted the executive director of the allegations and recommended the hotline be contacted; -At 6:56 A.M., the administrator notified the interim director of nursing (DON) and the director of clinical compliance of the reported allegations. The administrator requested the interim DON speak with the residents; -Around 8:00 A.M., RN Clinical Educator contacted DHSS hotline to report the allegation of CNA F; -At 3:01 P.M., RN Clinical Educator emailed the DHSS Region 5 self-report cover sheet to the regional office email, including the following details: -Call received from LPN A about agency CNA F at 12:51 A.M. LPN A said CNA F improperly transferred Resident #1 to bed without a lift, leaving a bruise on his/her arm. LPN A said CNA F was given detailed report at the beginning of the shift and voiced no questions or complaints about assignment; -LPN A also reported he/she had received several complaints about CNA F from residents who were alert and oriented times three-four. Advised LPN A to send CNA F home when he/she returned from break/lunch and he/she needed to write a statement of the events and pass it on to the administrator; -Administrator notified at 6:30 A.M. of event above. State hotline called at 7:26 A.M. During interview on 1/24/20 at 11:17 A.M., the RN Clinical Educator said the following: -She received the report of CNA F's behavior and conduct from LPN A at approximately 12:51 A.M. on 1/13/20; -She considered the reported behaviors to be abuse; -She thought reports of abuse needed to be reported to DHSS within two hours if there was a serious injury, otherwise, within 24 hours; -She notified the administrator at 6:30 A.M. of the abuse allegation and was instructed to notify DHSS; -She did not think the hotline took calls until 7:00 A.M.; -She called the hotline at 7:26 A.M. and was instructed to make a report; -She faxed the report to the region office at 3:00 P.M. During interview on 1/24/20 at 11:15 A.M., the administrator said the following: -LPN A reported an allegation of abuse involving several residents to RN Clinical Educator on 1/13/20 at 12:51 A.M.; -RN Clinical Educator had made her aware of the allegations at 6:38 A.M.; -She would expect staff or the facility to follow regulations regarding reporting allegations of abuse; -She knew allegations of abuse needed to be reported to DHSS but she needed clarification on the specific timeframes. MO 4

Based on interview and record review, the facility failed to ensure an agency staff transferred two residents (Residents #1 and #2), in a review of five sampled residents, safely, resulting in an injury to Resident #1. The facility had no plan in place for education, training and monitoring for agency staff and did not provide access to resident information on the facility electronic medical record. Facility census was 78. 1. Record review of Resident #1's face sheet showed the resident's [DIAGNOSES REDACTED]. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment tool required to be completed by facility staff, dated 1/10/20, showed the following: -No cognitive impairment; -The resident required extensive assistance from one staff for transfers; -The resident was not steady and was only able to stabilize with staff assistance when moving from a seated position to standing position. Review of the resident's weekly skin assessment, completed by the facility, dated 1/12/20 at 8:58 A.M., showed the resident had no noted bruising. Review of a facility investigation, dated 1/13/20, showed the following: -At the beginning of his/her shift, agency Certified Nurse Aide (CNA) F, was given a very descriptive report of each resident by day shift nursing. CNA F was also given a report sheet with detailed information of each resident; -At approximately 12:00 A.M., CNA F came to Licensed Practical Nurse (LPN) A, while he/she was working another wing of the facility, requesting to take a 30-minute lunch. LPN A agreed and reported to relieve CNA F; -Resident #1 rang his/her light. LPN A responded and the resident communicated CNA F had helped him/her into bed and was very rough and mean. The resident said he/she was hurting all over from CNA F throwing him/her in bed. The resident said CNA F was trying to transfer him/her into bed without the sit-to-stand lift as required. The resident said his/her right arm was pinned against the re-positioning bar of the bed and he/she was screaming out, You are going to break my arm!; -The resident said he/she asked CNA F why he/she did not use the lift and he/she did not respond. LPN A assessed the resident's right forearm and measured a bruise 2 centimeters (cm) by 3 cm. The resident said the bruise was caused by the transfer. The resident was alert and oriented; -At 8:30 A.M., the administrator met with the resident who said CNA F came in his/her room at 7:45 P.M. He/She said hi to CNA F and asked him/her what he/she wanted. The resident said CNA F responded, I am going to put you to bed. The resident responded, I do not go to bed until 10:00 P.M. The resident said they argued a bit and CNA F then said he/she would come back at 9:30 P.M. At around 9:30 P.M., CNA F came in and the resident said he/she was getting himself/herself positioned and was getting ready to get into bed as he/she does. The resident said CNA F stood him/her up but he/she was too far from the bed. The resident then pointed to the right side of the bed and told CNA F they were too far from the bed. The resident instructed CNA F to move closer. The resident said CNA F then got mad and started shoving him/her. The resident told CNA F, You are hurting me. CNA F did not respond to the resident's cry for help and for him/her to stop. The resident said CNA F picked him/her up and threw him/her in the bed which hurt the resident's back. The resident said his/her arm was shoved between the positioning bar and the bed and he/she yelled at CNA F, You are going to break my arm!! The resident said once he/she was in bed, he/she positioned himself/herself and CNA F left. The administrator asked to see where he/she was hurt, and the resident said his/her right arm. The administrator observed a large purple bruise on the resident's right arm, above the wrist on the top. The administrator asked the resident if he/she was in pain, and he/she replied, It hurt when it happened. The resident said when getting into bed, the staff usually use a lift, but CNA F did not use a lift with him/her that night. Review of the resident's skin assessment, dated 1/13/20 (no time), showed the following: -Wound type: bruise on right upper extremity; -Wound acquired in the facility; -Bruise measurements: length equaled two (no specific measurement) and width equaled three (no specific measurement). Record review of the facility social worker's interview with the resident on 1/14/20 showed the following: -The resident said CNA F came to his/her room around 9:30 P.M. and told the resident to pull himself/herself up on the railing. The resident told CNA F he/she could not reach it. The resident said CNA F pushed the wheelchair closer, but he/she still couldn't reach it. CNA F then pushed the wheelchair into the post and the resident couldn't move. The resident said he/she was hollering and CNA F was fighting him/her. The resident said CNA F threw him/her into bed and flipped him/her over. The resident said he/she got a bruise to his/her arm and had pain in his/her back. The resident said he/she was scared and he/she stayed awake in bed until 1:30 to 2:00 A.M. when another familiar CNA came in to help him/her and reposition him/her in a way that his/her back was no longer painful. Record review of the resident's care plan, dated 1/22/20, showed the following: -The resident had actual activity of daily living (ADL) self-care deficit; -Required extensive assistance of two staff with transfers, dressing and toilet use; -May use a sit-to-stand device. During an interview on 1/24/20 at 9:00 A.M., the resident said the following: -An agency staff member came into his/her room around 7:30 P.M., on the evening of 1/12/20, and told him/her he/she was going to put him/her to bed; -The resident told the staff member he/she did not go to bed until around 10:00 P.M.; -The staff member told the resident he/she would be back around 9:30 P.M. to put him/her to bed; -He/She still did not like this but he/she became afraid of him/her and just went along with what he/she said; -CNA F was very rough when he/she transferred the resident to bed by himself/herself; -He/She tried to tell CNA F he/she needed to use the sit-to-stand lift with him/her but he/she said he/she was going to do it his/her way; -CNA F did not use a gait belt for the transfer; -CNA F put his/her arms under the resident's arms and bear-hug lifted the resident; -The resident told CNA F he/she was not doing the transfer right from the beginning but he/she just wouldn't listen; -CNA F pushed and pinned him/her up against the bed positioning rail and caused a bruise on his/her right lower forearm; -The way CNA F treated him/her made him/her feel terrible; it felt like he/she was nobody or nothing and that CNA F was everything and he/she was afraid of CNA F. 2. Review of Resident #2's face sheet showed [DIAGNOSES REDACTED]. Review of the resident's significant change MDS, dated [DATE], showed the following: -No cognitive impairment; -The resident required extensive assist of two staff for transfers; -The resident was not steady and was only able to stabilize with staff assistance when moving from a seated position to standing position, -Functional limitation in range of motion to lower extremity on one side of the body. Review of a facility investigation, dated 1/13/20, showed the following: -At approximately 12:00 A.M., CNA F came to LPN A, while he/she was working another wing of the facility, requesting to take a 30-minute lunch. LPN A agreed and reported to relieve CNA F. While CNA F was on break, LPN A responded to Resident #2's light. The resident was in pain and requested pain medications. While administering pain medication, the resident began to express his/her dislike for CNA F. The resident said CNA F was mean and rude because the resident was not able to move fast enough. The resident said CNA F told him/her that if he/she did not move quicker, he/she was not going to help him/her. The resident communicated CNA F was rough and he/she was afraid of him/her. Review of the resident's care plan, dated 1/22/20, showed the following: -The resident had potential for complications related to long standing cardiac history. Staff was to encourage the resident to change positions slowly; -The resident is at risk for falls/injury due to decreased mobility, weakness and because he/she falls asleep mid-sentence at times; -The resident presents with self-care deficit related to [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. Provide the amount of assistance/supervision that is needed; -Implement safety precautions such as fall management protocols; -Use extra caution with manually transferring the resident. During an interview on 1/24/20 at 9:30 A.M., the resident said the following: -He/She was not used to the type of treatment CNA F treated him/her with; -CNA F told him/her he/she had to go to bed when he/she came into his/her room early the evening of 1/12/20; -CNA F rushed him/her into getting his/her bedtime cares completed and into bed, saying, I just couldn't seem to move fast enough for him/her; -CNA F seemed angry; -He/She told CNA F that it usually required two staff to help him/her into bed. CNA F just transferred the resident using a bear hug by himself/herself. 3. During interview on 1/27/20 at 9:00 A.M., CNA C said the following: -He/She worked the day shift on 1/12/20; -He/She gave agency CNA F report at shift change. He/She believed this shift to be CNA F's first shift at the facility; -He/She gave the nurse report sheet to CNA F that documented specifics for resident care; -He/She completed a walk-through of the residents with CNA F and thought CNA F was taking notes on the nurse report sheet; -He/She could not recall what he/she verbally told CNA F about the residents' care; -Facility staff used the facility computers to access the residents' care plans; -He/She did not think agency staff had computer access; -He/She did not use the sit-to-stand lift when transferring Resident #1 and he/she usually provided care with one staff. This is probably what he/she would have told CNA F. He/She was not aware the resident's care plan directed to transfer the resident with assist of two staff or he/she might require a sit-to-stand lift. During interview on 1/27/20 at 9:25 A.M., CNA F said the following: -He/She worked the evening of 1/12/20 into 1/13/20; -When he/she arrived for his/her shift, two CNAs gave him/her report on the residents he/she was assuming, including transfer status, incontinent/continence cares, and mental cognition, but he/she could not recall the specifics he/she was told; -He/She was given a piece of paper, listing the residents' names. He/She took notes on this paper, but he/she could not recall what, if anything, was listed about the residents on the paper; -He/She was told he/she would have computer access and log-in information was beside the computer that would provide him/her the residents' care plans, but when he/she looked, there was no log-in information there; -He/She was not able to access the resident information or document the cares he/she provided; -He/She could not recall any specific cares he/she provided to residents, but said he/she did it all himself/herself. During interview on 1/27/20 at 4:38 P.M., LPN A said the following: -He/She was the charge nurse for night shift on 1/12/20 through 1/13/20; -CNA F had not ask for help during the shift, only asked for relief to go to break; -It was during his/her break that he/she covered his/her hall assignment and began receiving resident complaints about CNA F's care; -He/She had not had any interaction with CNA F, had not worked with him/her prior, and had not checked on him/her during his/her shift to see if he/she needed any help. During interview on 1/24/20 at 10:45 A.M., RN/interim DON said the following: -The charge nurse gives agency staff a quick, verbal orientation upon arrival for their shift; -At the time of these incidents, there was no facility training for agency staff. The facility relied on the hiring agency to provide that training; -There was no facility policy on agency staff training or orientation; -He/She was not sure what was meant by a nurse report sheet. During interviews on 1/27/20 at 11:11 A.M. and 2/4/20 at 9:09 A.M., the administrator said the following: -CNAs, including agency staff, should have access to the residents' care plans via the facility computers; -The evening of 1/12/20 was CNA F's first shift and he/she did not have computer access set up yet; -CNA F should have been given verbal report/details of residents' care plans during the walk-through with the day CNAs at shift change; -She expected the charge nurse on duty to check in with agency staff during their shift to see how they were doing and if they had any questions; -She would expect staff, including agency staff, to follow residents' care plans regarding resident transfers and cares. MO 4

Based on interview and record review, the facility failed to ensure two residents, (Resident #2 and #3) remained free of physical abuse and sexual abuse from Agency Staff CNA (Certified Nurse Aide) A, in a sample of four residents. The census was 78. The administrator was notified on 10/11/19 of the Immediate Jeopardy (IJ) Past Non-Compliance which occurred on 8/25/19. The facility immediately escorted the staff member out of the building and called the ADON (assistant director of nursing) and police. The facility assessed residents on the unit, started an investigation and began inservicing facility staff on 8/26/19 on the abuse/neglect policy and procedures. The IJ was removed and corrected on 8/26/19. Record review of the facility policy for Abuse and Neglect Prevention and Reporting dated 10/23/17 showed: -Residents and clients of the facility will live and be served in an environment that promotes dignity, respect, and strives to be free from abuse, neglect and exploitation. Allegations of potential or actual abuse, neglect or exploitation will be immediately reported to the appropriate leadership and government agency, the resident protected and the allegation investigated; -Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with the resulting physical harm, pain, or mental anguish, as well as the deprivation of goods or services that are necessary to attain or maintain physical, mental or psychosocial well-being; -Sexual abuse if defined as, but not limited to sexual harassment, sexual coercion, and sexual assault; -To ensure an environment that encourages respectful and dignified treatment of [REDACTED]. The facility will provide proper supervision to insure that staff are providing care in an appropriate manner and that staff assess, care plan and monitor the care of all residents. The facility will ensure that staff pay special attention to those residents and clients with needs and behaviors that may make them more likely targets for abuse or neglect; -Staff shall immediately see to the safety of an alleged victim, upon an allegation of abuse. This includes, but is not limited to removing accused staff from contact with all residents, providing necessary medical treatment to the alleged victim, and all other actions deemed necessary by the circumstances. Record review of the facility investigation dated 8/26/19, showed the following: -At 5:00 [NAME]M. the Assistant Director of Nurses (ADON) reported the following to the administrator: -At 11:23 P.M. (8/25/19) the ADON received a call from Licensed Practical Nurse (LPN) A, working on the unit where Resident #2 and Resident #3 resided, stating he/she sent Agency Staff CNA G home; -LPN A said Agency Staff CNA G arrived to work at 7:18 P.M. and LPN A went to another unit to pass medications; -When he/she returned to the residents' unit Agency Staff CNA G asked LPN A to go to Resident #3 (room) because he/she (the resident) was making racist comments and said that he/she was raped and hit; -When LPN A entered Resident #3's room the resident was laying on the bed and had an angry look on his/her face; -When asked if there was anything he/she could do to help the resident, the resident said no; - LPN A asked if the resident would like to go to bed and if he/she would allow his/her brief to be changed, again the resident said no; -Agency Staff CNA G left the room, Resident #3 said, He/She is not nice; -LPN A told Resident #3 the rest of the night someone else would help him/her; -LPN A completed a medication pass and went back to the other unit to do chart checks; -At 10:30 P.M. LPN A returned to the residents' unit; -Agency Staff CNA G was coming out of Resident #2's room and said LPN A needed to go talk to the resident because he/she is saying that someone hit and raped him/her; -LPN A entered the room and found Resident #2 sitting on the side of the bed; -The resident was quiet; -LPN A asked the resident what was wrong and he/she replied that nothing was wrong; -Agency Staff CNA G then left the room and LPN A asked Resident #2 if he/she could help the resident change his/her brief and go to bed, the resident replied, I don't know if I ever want to go to bed again; -The resident let LPN A help him/her lay down and change his/her brief; -LPN A noted the (resident's) right eye was purple and red; -LPN A asked the resident what happened, he/she replied, I don't know and said Agency Staff G hit him/her; -LPN A went to the common area and found Agency Staff G at the table and asked if he/she knew what happened to the resident's eye and Agency Staff CNA G said, He/She didn't look at the resident's eye, and didn't know that there was anything wrong with it; -Agency Staff CNA G said that he/she did not know what happened to the resident's eye and that he/she did not even notice the bruising; -There was no documentation of bruising to Resident #2's eye prior to this incident; -LPN A called for assistance from facility staff; -While LPN A was on the phone, Agency Staff G said, He/She almost just wanted to go home, everything here is racist; -LPN A told Agency Staff CNA G that he/she could go home and he/she asked to use facility phone; -Noticed a bruise to Resident #2's right foot around 11:30 P.M.; -Resident #2 told CNA [NAME] and CNA F that Agency Staff G hit him/her three or four times; -LPN A told Agency Staff G to go home at 11:00 P.M. and Agency Staff G exited the building at 11:15 P.M.; -LPN B, CNA [NAME] and CNA F arrived to the unit the resident resided on and the CNAs went to all the rooms and provided care for residents; -The LPNs escorted Agency Staff CNA G to the door; -CNA [NAME] and CNA F found another bruise to Resident #2's right foot around 11:30 P.M.; -LPN C brought head phones believed to be from Agency Staff G to the DON which were found in Resident #2's bed linens; the head phones were broken. 1. Record review of Resident #2's quarterly MDS dated [DATE], showed the following: -The resident had severe cognitive impairment; -The resident required extensive assistance of one staff for transfers. Record review of the resident's physician's order sheet dated (MONTH) 2019, showed the resident's [DIAGNOSES REDACTED]. Record review of the resident's nurse note dated 8/26/19 at 2:00 [NAME]M., showed the following: -As the nurse entered the unit the resident resided on, Agency Staff G was coming out of the resident's room and said the nurse needed to go talk to the resident because, He/She is making racist comments and is saying that someone hit him/her and raped him/her; -The nurse and Agency Staff CNA G entered the resident's room and found the resident sitting on the side of the bed; -The nurse asked the resident what was wrong and the resident said nothing; -Agency Staff G left the room and the nurse asked the resident if he/she could help the resident get in bed; -The resident said, I don't know if I will ever want to go to bed again; -While giving care the nurse noticed the resident's right eye was red and purple; -When the nurse asked what happened to the resident's eye, the resident said, I don't know, that Agency Staff G hit him/her; -The nurse went to the common area and asked Agency Staff G about the resident's eye. Agency Staff CNA G said he/she didn't look the resident in the eye and didn't know there was anything wrong with the resident's eye; -The LPN A called another unit for staff assistance; -Agency Staff CNA G said, He/She wanted to go home, everything here is racist; -LPN B, CNA C, and CNA D arrived on the unit; -Bruising was noted to the resident's right eye, right foot and left cheek. Record review of the resident's emergency room History and Physical dated 8/26/19 at 12:23 P.M., showed the following: -The resident was seen for concerns of new bruising; -The resident has a right black eye, bruise on left forearm, right thumb, right wrist and chest wall; -When the resident was asked how he/she got the bruises, the resident said, Maybe someone beat me up?; -The resident's family member who was with the resident said, The resident was found in bed last night crying, and told the nurse that he/she was beat up and raped; -The family member says the resident always sleeps in a recliner at the facility, the recliner is not in his/her room; -The family member visited the resident at the facility 8/25/19 and the resident had no bruising; -The resident had ecchymosis (bruising) to the right eye, base of right thumb and right foot. Record review of the resident's emergency room progress note dated 8/26/19 at 3:00 P.M., showed the following: -The resident reports last evening he/she was beat up and raped by an agency CN[NAME] The resident was found in his/her room by a nurse in bed and crying; -The resident is not ambulatory and it would be unusual for the resident to be in bed as he/she could not get there by himself/herself; -The resident usually sleeps in a recliner; -The resident has bruising that was not present 8/25/19 per the resident's family member; -The resident is alert, and knows his/her name and that he/she is at the hospital; -When asked about his/her bruising the resident said, Someone beat me up, someone was standing on my foot; -The resident had bruising to his/her right eye, cheek and jaw, inner corner of his/her left eye, right wrist and thumb, breast, left forearm, top of right foot, bottom of right foot, right great toe, chest wall, left scapula (shoulder blade), and external genitalia excoriation. Record review of the resident's Skilled Nursing Facility Follow up Visit by the nurse practitioner dated 8/26/19 at 4:39 P.M., showed the following: -The resident was evaluated urgently due to allegations of physical and possible sexual abuse last evening; -The staff reports the resident was being tended to by an evening CNA; -When the nurse arrived to the unit, the CNA came out of the resident's room and said the resident was making allegations that someone hit and raped him/her; -The nurse examined the resident and noted redness and bruising to the resident's right eye, left cheek, and left foot; -Today the resident has obvious signs of injury, with right sided periorbital (around the eye) ecchymosis and [MEDICAL CONDITION] (swelling); -Bruising was noted to the resident right chin and left cheek; -There is bruising and tenderness on the right foot; -The resident had no recollection of last night's events and does not recall the injury; -The resident is alert to self only; -The resident does not consent to a full body examination today; -The resident was sent to the hospital for evaluation and returned with no new orders. Record review of the resident's weekly skin assessment dated [DATE] at 7:00 P.M., showed the resident had bruising present on his/her face, chest, buttocks, left and right hand, right arm, right foot, right and left eye, right jaw, right foot, right forearm, right thumb, top of buttocks, and left and right chest. Observation on 8/28/19 at 12:00 P.M., showed the resident had purple bruising around the orbit (socket of the skull) of the right eye including the eye lid. During an interview on 8/28/19 at 12:40 P.M., the resident's family member said the following: -The facility contacted the family member at 2:30 [NAME]M. on 8/26/19; -The nurse said the resident was sitting on the side of the bed and the resident was upset; -The resident said a staff member beat and raped him/her; -The resident was crying; -The resident went to the hospital at 10:00 [NAME]M. (8/26/19); -The resident had a bruise on the right eye, the right side of his/her jaw, the right hand between the thumb and forefinger, foot, chest, and shoulders; -There were no bruises on 8/25/19 when the family member visited the resident. 2. Record review of Resident #3's quarterly MDS dated [DATE], showed the following: -The resident had moderate cognitive impairment; -The resident required extensive assistance of one staff for transfers. Record review of the resident's physician's orders dated (MONTH) 2019 showed the resident's [DIAGNOSES REDACTED]. Record review of the resident's emergency room provider note dated 8/26/19 at 11:55 [NAME]M., showed the following: -The resident presents with an alleged sexual assault; -A SANE (sexual assault nurse examiner) exam was performed. Record review of the resident's nurses note dated 8/26/19 at 1:51 P.M., showed the following: -LPN C and LPN A spoke with the resident and assessed the resident's skin; -The resident said he/she was sexually assaulted, touched inappropriately and hit; -The resident identified Agency Staff G by race and gender, and said the staff member was wearing an eye patch over one eye and a white [NAME]et and pants; -The resident said Agency Staff G bit the resident's nipples, pulled at his/her pubic hair, pinched the resident all over the resident's body, and touched the resident's genitalia; -The resident had small fading bruises on his/her left thumb, knuckles, and left forearm. Record review of the resident's Skilled Nursing Facility follow up visit by the nurse practitioner dated 8/26/19 at 4:38 P.M., showed the following: -The resident identified the race and gender of Agency Staff G and said last evening a CNA was physically aggressive, and touched the resident inappropriately; -The resident said he/she was screaming and no one heard him/her; -The CNA slapped the resident in the face and spat on the resident; -The CNA pinched the resident's breasts, pulled the resident's pubic hair and penetrated the resident vaginally with his/her fingers; -Agency Staff CNA G told the resident the cops would never be able to prove the assault; -The resident said he/she kicked, slapped and knocked the CNA down; -The assessment of the resident showed the resident had healing bruises on the resident's left thumb and left shin. Record review of the resident's weekly skin assessment dated [DATE], showed the following: -The resident had bruising present on his/her chest, left arm, right hand, right arm, left lower leg, right thumb, left forearm and right breast; -A scratch was noted to the resident's right chin. During an interview on 8/28/19 at 3:15 P.M., CNA H said the following: -Resident #2 and Resident #3 were fine on 8/25/19 between 6:45 [NAME]M. and 6:45 P.M.; -There were no bruises or marks and they had not complained of being hurt; -Agency Staff G came in late at 7:15 P.M.; -Agency Staff G had a band aide on the side of his/her face; -CNA H took Agency Staff G from room to room to give him/her report; -CNA H told Agency Staff G that Resident #2 slept in the chair; -When CNA H left the facility Resident #2 was in the recliner chair; -CNA H told Agency Staff CNA G that Resident #3 was able to stand with assistance; -Resident #3 had never made these allegations before; -Today Resident #3 said he/she should have screamed louder and Agency Staff G tried to rape him/her; -Resident #3 identified Agency Staff G's gender and race and said he/she had a band aide on his/her face. During interview on 8/28/19 at 3:30 P.M., CNA I said the following: -Resident #2 and Resident #3 had no complaints or bruises on 8/25/19 when CNA I worked; -When Agency Staff G came to work, he/she was late, CNA I asked Agency Staff CNA G if he/she had worked the unit before and he/she didn't answer, he/she had ear buds on and a band aide on his/her face; -CNA H made rounds with Agency Staff G; -Resident #2 is not combative with care; -Resident #3 had not made these allegations before. Review of a written statement dated 8/28/19 at 3:37 P.M. signed by CNA I showed the following: -CNA I worked on 8/25/19; -When Agency Staff CNA G arrived late, CNA H made rounds with him/her; -When CNA I left the facility the residents were fine; -The next day Resident #2 had a bruise to his/her eye. During interview on 8/28/19 at 1:10 P.M., CNA [NAME] said the following: -LPN A called for assistance at 10:59 P.M. (8/25/19); -When he/she got to the unit, the nurses were talking to Agency Staff G; -CNA [NAME] saw Resident #2 in bed; -Resident #2 had a black eye and said Agency Staff G hit him/her; -CNA [NAME] went to find the nurses who were walking Agency Staff G out of the facility a little after 11:00 P.M.; -Resident #2 usually slept in the recliner in the common area; -Resident #2 had a bruise on his/her foot. Review of the written statement dated 8/29/19 and signed by CNA [NAME] showed the following: -CNA [NAME] was asked to go to the unit to help; -When CNA [NAME] arrived, Agency Staff G sat at the table arguing with the nurses; -When CNA A went to Resident #2's room, the resident was in bed; -The resident's eye was purple; -The resident said Agency Staff G hit him/her three to four times for no reason, He/She just kept hitting me; -The resident had a big bruise on the top of his/her right foot; -Resident #3 complained of Agency Staff CNA G being mean and loud; -CNA [NAME] said Agency Staff G was gone, and the resident said, Thank God. During interview on 8/28/19 at 2:55 P.M., CNA F said the following: -CNA [NAME] and CNA F went to the unit to help when LPN A called for assistance; -CNA [NAME] and CNA F went to Resident #2; -The resident had a black eye, a bruise on his/her left foot which was purple, and CNA [NAME] saw a bruise on the resident's jaw; -The resident said Agency Staff CNA G hit him/her numerous times; -They went to find the nurse and the nurse was talking to Agency Staff G; -Resident #3 said he/she was slapped around and sexually assaulted, but there were no injuries. Record review of the written statement dated 8/28/19 at 3:14 P.M., signed by CNA F showed the following: -Around 10:30 P.M. CNA [NAME] and CNA F went to the unit to assist getting residents in bed; -Resident #2 had a black eye and bruising on his/her right foot and made allegations of physical abuse; -Resident #3 made allegations of physical and sexual abuse. During an interview on 9/13/19 at 12:43 P.M., Agency Staff G said the following: -Agency Staff CNA G did work on 8/25/19 on the unit the residents resided on, on 2nd shift; -Agency Staff CNA G was the only staff on that shift, he/she was responsible for the residents' care; -At about 6:45 P.M. Agency Staff CNA G started asking the residents who was ready to go to bed? -Agency Staff CNA G doesn't remember any of the residents by name; -Agency Staff CNA G asked one resident if he/she wanted to go to bed and rolled the resident to the resident's room and tried to transfer the resident to bed; -The resident started fighting. Agency Staff CNA G let the resident know what he/she wanted to do; -Agency Staff CNA G was rushing to finish, so he/she could have down time; -The resident was hitting Agency Staff CNA G in the face and throwing his/her hands around and being combative; -Agency Staff CNA G put his/her foot between the resident's legs to do the pivot (transfer); -He/She put his/her arms under the resident's arms and grabbed the resident's pants and got the resident in bed; -The resident was kicking and swinging; -Agency Staff CNA G told the resident he/she wanted to change the resident's brief; -Agency Staff CNA G took the resident's pants off, and the resident really got to hitting and swinging; -The resident's brief was soiled, the resident was kicking, spitting and yelling; -Agency Staff CNA G got the resident's brief changed and went to the linen room, when he/she came back the resident had put himself/ herself back in the chair and was rolling out of the room; -Agency Staff CNA G was wearing head phones. They probably did get ripped off that night because the resident was pulling on Agency Staff CNA G's clothes. During an interview on 8/28/19 at 1:30 P.M., LPN A said the following: -LPN A worked on 8/24/19 and Resident #2 had no bruises; -When LPN A arrived to work on 8/25/19 Resident #2, and #3 were sitting in the common area and had no visible injuries; -Agency Staff CNA G arrived to work at 7:18 P.M.; -LPN A was off the unit and came back to the unit and Agency Staff G said come to Resident #3's room, the resident is making racist statements and said someone hit him/her; -LPN A went into the resident's room with Agency Staff CNA G. The resident said he/she was fine; -When Agency Staff G left the room, Resident #3 said he/she didn't like Agency Staff G because he/she was mean; -LPN A again left the unit and came back at 10:30 P.M. and Agency Staff G said Resident #2 was saying someone hit and raped the resident; -When LPN A went to Resident #2's room with Agency Staff CNA G, the resident was sitting on the side of the bed with his/her pants off (wearing a brief); -LPN A talked to Resident#2, when Agency Staff CNA G left the room, the resident said I don't know if I can ever go to bed again; -LPN A said he/she felt the resident was afraid, but didn't ask why; -LPN A changed the resident's brief and saw the resident's right eye was red; -Resident #2 said Agency Staff G hit him/her; -Agency Staff G was in the dining room and said he/she didn't notice anything wrong with the resident's eye; -LPN A called for help, and CNA E, F and LPN B came to the unit; -The nurses asked Agency Staff G to leave the building. He/She made a phone call and left by cab at 11:15 P.M.; -In the morning LPN A and C assessed Resident #3's skin and the resident said that man hit him/her; -Resident #3 identified the person's gender and race, and said the person had a bandage on his/her face; -The resident said he/she was sexually abused, hit, and he/she bit the resident's nipples. During interview on 8/28/19 at 2:30 P.M., LPN C said the following: -LPN A and LPN C talked to Resident #3 on the morning of 8/26/19 at 7:00 [NAME]M.; -The resident said he/she was sexually assaulted, someone had touched the resident's genitalia, bit his/her nipples, pulled his/her pubic hair, slapped his/her face, and pinched him/her all over; -LPN A and LPN C reported to their supervisor; -LPN A and LPN C assessed the resident's skin after the resident came back from the emergency room and the resident had bruises on the right breast (faint), the left thumb, and the left forearm; -The resident described Agency Staff G by gender and race, and said he/she wore a white [NAME]et and had a patch over his/her eye. Record review of the written statement dated 8/28/19 at 3:00 P.M., and signed by LPN C showed the following: -LPN C and LPN A spoke with Resident #3 on 8/26/19 at 7:30 [NAME]M.; -Resident #3 identified Agency Staff CNA G's race and gender and said he/she was sexually assaulted by Agency Staff G who was wearing a patch over one of his/her eyes, white [NAME]et and white pants; -Resident #3 said he/she was bitten on his/her nipples, his/her pubic hair was pulled, he/she was pinched all over his/her body, and touched with fingers in his/her genital area; -Agency Staff G said he/she was touching the resident in a way that would not be tracked. During interview on 10/8/19 at 2:25 P.M., Resident #2 and #3's physician said the following: -The nurse practitioner assessed Resident #2 and Resident #3 after the allegations were made; -Resident #3 did have bruises, but refused a physical exam from the neck down; -Both residents went to the hospital for evaluation. During an interview on 9/6/19 at 3:00 P.M., the Police Detective said the following: -Agency Staff CNA G wanted to hurry up and put the residents in bed, so he/she would have no more work to do (not know the residents' names); -Agency Staff CNA G told the resident it was time to go to bed; -Agency Staff CNA G rolled the resident into his/her room, the resident kicked, hit and screamed; -The resident kicked Agency Staff G's teeth out (dentures); -Agency Staff CNA G said he/she had no sexual contact with any residents and described the residents as gross; -Agency Staff CNA G said he/she doesn't remember a lot, but thinks the resident may have hit his/her own head; -Agency Staff CNA G said he/she does have a tattoo that he/she covers. During an interview on 10/8/19 at 2:25 P.M., the Director of Nurses (DON) said the following: -The DON interviewed LPN A and LPN C at about 8:30 [NAME]M. on 8/26/19; -The LPNs said Resident #2 had bruising on his/her right foot; -The resident's thumb, eye, and jaw were bruised; -Resident #3 had small bruises to his/her left forearm and described the assault and Agency Staff CNA G; -The DON expected staff will not abuse any resident. Record review of the written statement dated 10/8/19, and signed by the DON showed the following: -On 8/26/19 at 8:30 [NAME]M., the DON and administrator met with LPN A and LPN C who said Resident #2 had bruising and [MEDICAL CONDITION] (swelling) to the top of his/her right foot, bruising to the right thumb, right jaw, and both eyes; -LPN A said Resident #3 had a small bruise to the left forearm and left thumb; -Resident #3 said during the exam, He/She bit the resident's nipple, touched the resident inappropriately and it hurt; -Resident #3 said, It was sexual assault, and was able to describe Agency Staff CNA G's race and gender and he/she wore red pants, white shirt and a band aid on his/her right eye. During an interview on 8/27/19 at 12:47 P.M., the administrator said the following: -LPN A said Agency Staff G came to work at 7:18 P.M. on 8/25/19; -LPN A was passing medications on another unit until 9:00 P.M.; -When LPN A came back to the unit Agency Staff G asked LPN A to go to Resident #3's room because the resident was making racist comments and said Agency Staff G raped him/her; -LPN A found the resident in bed; -Resident #3 said Agency Staff G was not nice and nothing else; -LPN A left the unit and returned again at 10:30 P.M.; -LPN A said Agency Staff G was coming out of Resident #2's room; -Agency Staff G reported Resident #2 was racist and said Agency Staff G raped him/her; -LPN A entered the room and found the resident's pants on the floor, brief intact (wearing a brief) and the resident was sitting on the edge of the bed; -LPN A talked to the resident and observed the resident's right eye was bruised; -LPN A changed the resident's brief; -The resident said Agency Staff G hit him/her; -LPN A talked to Agency Staff G and asked how the resident's eye became bruised; -Agency Staff G said he/she didn't look at the resident's face; -LPN A contacted the ADON around 10:30 P.M. and notifications were made; -When the police officer talked to Resident #2, the resident told the police officer the same story; -Both Resident #3 and Resident #2 went to the hospital for evaluation; -Later in the day LPN C found Agency Staff G's head phones by Resident #2's bed when the linens were changed and they were broken into two pieces; -The detective took the headphones; -The residents have the right to be free from abuse and the staff should meet that expectation; -He/She and the DON felt Agency Staff G had abused Resident #2 and #3. MO# 0

Based on interview and record review, the facility failed to recognize a significant change in status for two residents (Resident #6 and #31) out of 18 sampled residents. The facility census was 78. Record review of Change in Resident Condition Policy, reviewed 5/06/19, showed: - If a significant change in the resident's physical or mental conditions occurs, an assessment of the resident's condition will be conducted; - A significant change of condition is a decline or improvement in the resident's status that: - Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions; - Impacts more than one area of the resident's health status; - Requires interdisciplinary review and/or revision to the care plan; and - Ultimately is based on the judgement of clinical staff and/or guidelines outlined in the Resident Assessment Instrument. 1. Record review of Resident #6's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/29/19, showed: - Bed mobility - support of one person physical assist; - Transfer - extensive assistance; - Locomotion on unit (how the resident moves between locations) - supervision - oversight, encouragement or cueing; - Toilet use (how the resident uses the toilet room) - extensive assistance. Record review of Resident #6's quarterly MDS, dated [DATE], showed: - Bed mobility - two plus person physical assist; - Transfer - total dependence of full staff; - Locomotion on unit - total dependence of full staff; - Toilet use - total dependence of full staff. A MDS significant change assessment should have been completed after 6/29/19. 2. Record review of Resident #31's quarterly MDS, dated [DATE], showed: - Verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others) - Behavior not exhibited; - Behavioral symptoms not directed toward other (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) - Behavior not exhibited; - Rejection of care - Behavior not exhibited; - Bed mobility - support of one person physical assist; - Transfer - support of one person physical assist; - Walk in room (how resident walks between locations in his/her room) - support of one person physical assist; - Urinary continence - Occasionally incontinent; - Bowel continence - Always continent. Record review of Resident #31's quarterly MDS, dated [DATE], showed: - Verbal behavioral symptoms directed toward others - Behavior of this type occurred one to three days; - Behavioral symptoms not directed toward other - Behavior of this type occurred one to three days; - Rejection of care - Behavior of this type occurred one to three days; - Bed mobility - No setup or physical help from staff; - Transfer - No setup or physical help from staff; - Walk in room - No setup or physical help from staff; - Urinary continence - Frequently incontinent (seven or more episodes of urinary incontinence); - Bowel continence - Frequently incontinent (two or more episodes of bowel incontinence). A MDS significant change assessment should have been completed after 5/03/19. During an interview on 10/10/19 at 9:30 [NAME]M., the Assistant Director of Nursing (ADON) said it takes two areas of decline or improvement to have a significant change. During an interview on 10/10/19 at 2:00 P.M., the Director of Nursing (DON) said she expected a significant change MDS to be completed when a resident had a significant change in two or more areas.

Based on observation, record review, and interview, the facility failed to monitor and implement identified interventions to prevent additional falls for one resident (Resident #6), who fell and sustained multiple fractures, in a review of 13 sampled residents who the facility had identified at risk for falls and had history of falls and failed to ensure provision of safety and adequate monitoring after the facility hired a sitter for one discharged resident (Resident #15) who had multiple falls with injury. The facility census was 76. 1. Review of the undated facility policy Falling Star Program showed the following: -The program was designed to alert all members of the interdisciplinary team (IDT) that resident was at high risk for falls and facilitate a reduction of falls; -Residents scoring high risk on the Morse Fall Scale would be placed on the Falling Star Program; -Residents could be placed on the program at the discretion of the nurse or other members of the IDT; -The nurse would alert the Director of Nursing or designee of the Morse Fall Scale Score and the need to add the resident to the program; -A yellow star would be place on the resident's walker and ore wheelchair; -A yellow star would be placed on the doorframe of the resident's room; -Resident's sustaining two or more falls in a 30-day timeframe would have a red star placed indicating the resident required increased monitoring and supervision due to fall risk; -Non-clinical team members would summon help from nursing staff if the resident on the program was unattended or attempted to get unassisted; -Falling Star Program would be added to the Resident Care Summary and Care Plan. 2. Review of the facility policy Falls and Fall Risk, Managing dated 1/22/17 showed the following: -Based on previous evaluations and current data, the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling; -Each resident would be assessed for the risk factors for falling on admission, quarterly and change of condition upon return from a health care facility and after a fall; -The staff, with the input of the attending physician, would identify appropriate interventions to reduce the risk of falls; -In conjunction with the consultant pharmacist and nursing staff, the attending physician would identify and adjust medications that may be associated with an increased risk of falling; -If falling recurred despite initial interventions, staff would implement additional or different interventions or indicate why the current approach remained relevant; -In conjunction with the attending physician, staff would identify and implement relevant interventions to try to minimize serious consequences of falling; -The staff would monitor and document each resident's response to interventions intended to reduce falling or the risks of falling; -If interventions had been successful in preventing falls, staff would continue the interventions or reconsider whether these measures were still needed if a problem that required the intervention resolved; -If the resident continued to fall, staff would re-evaluate the situation and whether it was appropriate to continue or change current interventions. As needed, the attending physician would help the staff reconsider possible causes that may not previously have been identified; -The staff and/or physician would document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls; -Each time the resident returned from a stay in another health care facility, a nurse should reassess the resident to determine if the risk for falls had changed. The care plan would be reviewed and amended as needed based on the reassessment. The facility had no policy or procedure related to sitters, their duties or qualifications. 3. Review of Resident #6's Nursing Admission Assessment-Initial, dated 8/8/17 showed the following: -admission date of [DATE]; -Required wheelchair mobility; -Extensive assistance of one person with transfers, bed mobility, and toileting; -Walk in room, corridor, locomotion on and off unit not assessed/no information for self performance or support. Review of the resident's care plan dated 8/8/17 showed the following: -[DIAGNOSES REDACTED]. -The resident had altered thought processes, was at risk for injury. Staff should monitor for safety by assessing risk for falls and initiate appropriate interventions, provide assistive devices to steady gait and provide ambulation support and ensure the resident wore appropriate footwear to facilitate safe ambulation; -The resident was at risk for falls/injury as evidenced by history of falls, cognitive status/behavior, vision status, continence, mobility and balance. Staff should complete fall risk assessment per facility protocol and provide environmental adaptation of low bed, call light within reach, adequate lighting and area free of clutter. Staff should reinforce safety awareness and lock brakes on bed and chair before transfers, educate and remind the resident and/or family to request assistance for all ambulation and transfers, wear non-skid socks and appropriate footwear; -The resident had potential or actual Activity of Daily Living (ADL) self care deficit as evidenced by needing assistance with transfers, walking, locomotion, bed mobility, and/or at risk of developing complications associated with decreased ADL self-performance. Staff should provide only the amount of assistance/supervision that was needed. Review of the resident's Admission Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 8/15/17 showed the following: -Severely impaired cognition; -Required extensive assistance of one staff member with transfers, locomotion on and off the unit and toileting; -Required limited assistance of one staff member to walk in the room and in the corridor; -Not steady, only able to stabilize with staff assistance while moving from seated to standing position, walking (with assistive device if used), turning around and facing the opposite direction while walking, moving on and off the toilet, and surface-to-surface transfer (transfer between bed and chair or wheelchair); -Required a walker mobility device; -History of falls in the last month prior to admission; -History of falls in the last two to six months prior to admission; -Two or more falls without injury since admission. Review of the resident's nurses' note showed on 8/9/17 at about 7:15 P.M. the resident was seen sliding out the wheelchair to the floor by the nurse. The resident said he/she was looking for his/her spouse. The resident denied pain and no new injuries were noted. Staff member took the resident around until the resident got tired and went to bed, the call light was in reach, the bed was in the low position and staff would continue to monitor. Review of the resident's Care Plan updated 8/9/17 showed the resident fell . Staff should provide frequent checks when resident in room and without assistance. Review of the resident's Morse Fall Scale dated 8/10/17 showed the following: -The Morse Fall Scale was a rapid and simple method of assessing six variables indicating the resident's likelihood of falling. Staff score the six areas, the resulting score range indicated the resident's fall risk. No fall risk range 0-14, low fall risk range 25-50,high fall risk range greater than or equal to 51; -History of falling, immediate or within last three months, facility staff scored 25 points; -Secondary diagnosis, facility staff scored 15 points; -Ambulatory aids, facility staff scored 15 points; -Intravenous device, facility staff scored 0 points; -Gait/transfers, facility staff scored 10 points (weak gait); -Mental status, facility staff scored 15 (forgets limitation); -Total Morse Fall Scale of 80 indicating high fall risk. Review of the resident's nurses' note dated 8/10/17 at 3:32 P.M. showed an activity department staff member came to the nurses station and said the resident fell in his/her bathroom. Staff entered the bathroom and noted the resident sat on the wheelchair foot rests. He/she slid off the wheelchair on the foot rests. No apparent injuries were noted. The resident did not complain of pain or discomfort. Review of the resident's Care Plan updated 8/10/17 showed the resident fell from the wheelchair to the wheelchair peddles. Implement the Falling Star Program. Review of the resident's activity staff note dated 8//141/7 showed the resident was alert with confusion, was pleasant and cooperative. The resident used both a wheelchair and wheeled walker with assistance for transportation. He/she often declined planned activities other than spiritual programming. Staff would continue to invite, assist and encourage the resident to join and participate in activities daily and provide an escort to and from activities of his/her choice. Review of the resident's 8/17/17 IDT meeting showed the following: -Nursing skilled services related to status [REDACTED]. -Progress to goal, sustained fall on 8/10/17; -Teaching regarding safety; -Functional limits related to cognition, needs help to complete tasks. Review of the resident's nurses' note dated 8/22/17 at 6:50 A.M. showed the nurse heard help me and banging on the door. Staff entered the room and found the resident sat on the floor near the door. The resident said, I scooted from my bed, I had to go to the bathroom. No injuries were found. The resident said he/she did not hit his/her head, denied pain and asked for help back to bed. Review of the resident's care plan showed no updated fall interventions regarding the 8/22/17 fall. Review of the resident's Morse Fall Scale dated 8/22/17 showed the following: -History of falling, immediate or within last three months, facility staff scored 25 points; -Secondary diagnosis, facility staff scored 15 points; -Ambulatory aids, facility staff scored 15 points; -Intravenous device, facility staff scored 0 points; -Gait/transfers, facility staff scored 20 points (impaired); -Mental status, facility staff scored 15 (forgets limitation); -Total Morse Fall Scale of 90 indicating high fall risk (10 points higher than previous assessment completed on 8/10/17). Review of the resident's nurses' note dated 8/23/17 at 3:55 A.M. showed the resident remained on incident follow up regarding a fall. The resident had no complaints of pain or distress. Resident had gotten up by his/herself to the bathroom a few times during the shift. The call light was in reach and staff would continue to monitor and redirect. Review of the resident's care plan showed on 9/14/17 the resident was found on the floor in his/her bedroom. Staff should remind the resident to use pendant call light (resident assessed with [REDACTED]. Review of the resident's nurses' notes dated 9/14/17 showed no documentation of the resident's fall. Review of the resident's Morse Fall Scale dated 9/14/17 showed the following: -History of falling, immediate or within last three months, facility staff scored 25 points; -Secondary diagnosis, facility staff scored 15 points; -Ambulatory aids, facility staff scored 15 points; -Intravenous device, facility staff scored 0 points; -Gait/transfers, facility staff scored 10 points (weak gait); -Mental status, facility staff scored 15 (forgets limitation); -Total Morse Fall Scale of 80 indicating high fall risk. Review of the resident's nurses' noted dated 9/26/17 at 2:52 P.M. showed Licensed Practical Nurse (LPN) A received a call from the chapel stating the resident had fallen and was hurt. The activity assistant stated the resident fell on his/her left side. The resident's left hip was visibly rotated outward, visibly shorter than the other leg and the resident experienced severe pain in the left hip and wrist. He/she was transported by ambulance to the hospital. Review of the resident's Hospital Summary of Care showed the following; -admitted [DATE]; -Fall initial encounter; -[DIAGNOSES REDACTED]. Review of the resident's Physician's Order Sheet dated 10/5/17 showed the following: -Admit to facility; -[DIAGNOSES REDACTED]. -Hydrocodone (narcotic pain medication) 5 milligrams (mg)/Acetaminophen (Tylenol) 325 mg one tablet every six hours as needed for pain related to fractured left femur; -Physical therapy, Occupational therapy and Speech therapy evaluate and treat as indicated; -Non-weight bearing to the left wrist, may bear weight on left elbow; -Weight bear as tolerated to left lower leg. Review of the resident's nurses' note dated 10/5/17 showed the resident was readmitted status [REDACTED]. Review of the resident's care plan updated 10/6/17 showed the following: -The resident had potential or actual Activity of Daily Living (ADL) self care deficit as evidenced by needing assistance with transfers, walking, locomotion, bed mobility, and/or at risk of developing complications associated with decreased ADL self-performance. Staff should provide pummel seat cushion (cushion with elevated wedge placed between the resident's legs preventing the resident from sliding forward in the chair) and elevated leg rests while in the wheelchair. The resident was non-weight bearing to the left wrist and weight bear as tolerated to left lower leg. Staff should provide a platform walker (flat arm rest to place his/her left arm) for walking; -The resident had a cast to the left arm related to fractured bone. Staff should monitor the cast for areas of drainage, odor or complaints of pain/burning under the cast and provide pain management; -The resident had impaired physical mobility due to recent hip, pelvis and femur fracture. Staff should provide physical, occupational and speech therapy, provide only the amount of assistance/supervision required and utilize task segmentation as indicated to help improve ADL participation. Observation on 10/31/17 from 5:00 P.M. to 5:30 P.M. showed the resident sat in a high back wheelchair with a pummel seat cushion. His/her left arm was casted from below elbow to hand. Staff rolled the resident to the dining area and to his/her room. The resident was unable to propel wheelchair independently. Staff provided assistance with meals and all ADLs. Observation on 11/1/17 showed the resident sat in a high back wheelchair with a pummel seat cushion for meals and in the common areas. One staff member provided gait belt transfers from the bed to wheelchair. During interview on 11/2/17 at 9:12 A.M. Activity Assistant B said the following: -He/she was with the resident when the resident fell on [DATE] in the chapel area; -He/she asked the nursing staff on the resident's neighborhood if the resident required a wheelchair to go to chapel that day and was told no, the resident could walk with a walker; -He/she checked with the nursing staff when unsure if the residents required additional assistance with ambulation to activities; -He/she took the resident to chapel and walked along beside the resident without a gait belt in place; -Following the activity, the resident stood and walked approximately 10 feet along beside him/her; -He/she turned to address another resident and the resident fell backward; -The resident was not wearing a gait belt; -He/she called for the nurse, the resident was obviously injured; -If a resident required assistance with ambulation, nursing staff provided the assistance and took the resident to the activity; -He/she had no training regarding providing residents' assistance with ambulation and was not a Certified Nurse Assistant. During telephone interview on 11/3/17 at 10:07 A.M. Licensed Practical Nurse (LPN) A said the following: -The falling star program informed staff the residents at high risk for falls; -The resident was on the falling star program and needed someone close by to ensure safety; -All staff knew who was high risk based on the color of the indicator on the resident's door frame. Yellow was low risk, red was high risk. The resident was high risk for falls; -Prior to the fall in the chapel, the resident had a good morning and walked with a walker with assistance of one staff member on the neighborhood. He /she had impaired balance at times and a history of falls. He/she could not remember to wait for staff; -He/she received a call from the chapel and was informed a resident fell and was injured. He/she knew it was Resident #6 because he/she was the only resident who walked to chapel; all others from the neighborhood were in wheelchairs; -He/she went immediately to the chapel and found the resident on the floor with obvious injuries to the left leg and left wrist. The resident was transferred the hospital; -Nursing staff should have walked the resident to the chapel with a gait belt and returned to bring the resident back to the neighborhood. During interview on 11/3/17 at 7:10 A.M. the Director of Nursing (DON) said the following: -Following a resident's fall, the nurse should assess the resident's condition, notify the physician and provide appropriate treatment; -A post fall huddle (staff group meeting) was conducted to attempt to determine the root cause of the fall and implement interventions to prevent additional falls; -The nurse should do a fall risk assessment (Morse fall scale) and update the care plan accordingly; -The resident was in activity at the chapel when the fall occurred and activity staff turned away from the resident attending to a different resident; -The resident fell and sustained injuries; -The activity department staff was aware of residents' ambulatory status and who required assistance with ambulation for safety; -Staff should have assisted the resident one on one with ambulation because he/she was a known fall risk. 3. Review of Resident #15's admission MDS, dated [DATE], showed the following: -admitted to the facility on [DATE]; -Severely impaired cognition; -Inattention and disorganized thinking that fluctuated; -Physical behaviors one to three days per week; -Walked with limited assistance of one staff; -Occasionally incontinent of bowel and bladder; -History of falls; -Unable to determine if resident had a fall in last month prior to admission (a prior admission MDS dated [DATE], showed the resident had falls and had at least one fall in the month before admission); -Unable to determine if resident had a fall any time in last two-six months prior to admission; -[DIAGNOSES REDACTED]. Review of the resident's care plan dated 8/2/17, showed the following: -At risk for falls due to history of falls, cognitive status and behavior, vision, incontinence, mobility, and balance; -Provide environmental adaptations, maintain bed in lowest position while in bed, pendant (call light necklace) provided, call light within reach, area free of clutter; -Provide/monitor use of adaptive/assistive devices-splint/brace, walker, cane, wheelchair; -The resident has exhibited wandering behavior. Staff to assess potential physical causes for wandering (need for toilet, water, food, pain relief). Place in special care unit. Ensure all door alarms/locks are armed to reduce the risk of the resident leaving secure area; -The resident is at risk for elopement as evidenced by confusion, independently mobile, wandering behavior, and exit-seeking behaviors; -The care plan did not address how much assistance needed for transfers and walking. Review of the resident's Morse fall score (fall risk assessment) dated 8/10/17, showed a score of 80 indicating high risk for falls. Review of the resident's clinical notes report (nurse's notes) dated 8/10/17, showed the following: -At about 6:20 A.M., the charge nurse, LPN C, came from Bayberry to Willow Way and noted someone's feet on the floor in the resident's room; -The sitter was out of the room; -LPN C called the sitter and the sitter said they just left the resident's room and the resident was sleeping; -LPN C walked into the room and found the resident lying on the floor on the right side. The bed was in the low position; -The resident was not able to walk or respond to any question, and leaned to his/her right side; -LPN C notified the physician at 6:30 A.M., and the physician requested to monitor the resident and see if the resident could eat breakfast and would call back in 15 to 20 minutes. The physician called back and spoke to the day charge nurse. Review of the resident's clinical notes report dated 8/10/17 at 10:33 A.M., showed the following: -Staff found the resident on the floor at approximately 6:20 A.M.; -The night staff notified the physician, and they were instructed to monitor the resident and to call if any changes; -At 8:15 A.M., the resident's blood pressure was 164/90 (A reading of blood pressure over 140 on the systolic (top number) and over 80 diastolic (number on the bottom) is considered high); -Staff assisted the resident to the wheelchair and required four staff members to transfer the resident when the resident was usually able to transfer self, or required one person assist with getting up from a chair; -The resident leaned to the right side while in the wheelchair, would not open his/her eyes upon command, although this can be a behavior the resident had daily; -Staff notified the physician; -Staff called the family who felt the resident should go to the emergency room for an evaluation; -The resident went to the emergency room for right-sided weakness. Review of the resident's incident report dated 8/10/17, showed the following: -The charge nurse observed the resident's feet on the floor in the resident's room and the sitter was not present; -The resident was on the floor on his/her right side; -No injuries; -The resident was unable to explain what happened; -Summary of interview findings: Staff noted the resident leaned to the right side and they sent the resident to the emergency room for an evaluation; -Final determination: Sent the resident to the emergency room for suspected CVA (cerebral vascular accident which is a stroke) and the hospital was unable to confirm due to unable to perform an MRI (Magnetic resonance imaging to form pictures of the organs in the body) and CT (computed tomography which looks at different angles inside the organ) scan. Review of the resident's care plan updated 8/10/17, showed the following: -Staff found the resident on the floor with no injuries. During routine monitoring, staff observed the resident leaning to the right side and became difficult to transfer. Staff sent the resident to the emergency room for an evaluation and returned the same day with a [DIAGNOSES REDACTED]. -Intervention: Continue with one on one sitter at designated times and notify the physician of new or worsening symptoms of CVA/TIA (transient ischemic attacks- mini strokes). Review of the resident's hospital history and physical examination [REDACTED] -The resident was oriented to him/herself only; -Per nursing home staff, the resident fell out of bed at approximately 2:00 A.M., put back into bed, and fell out of bed again at 6:00 A.M. (There was no documentation regarding a second fall); -At that time, staff noted the resident leaned toward the right with gait (walking), and his/her speech was more nonsensical than normal; -In the emergency room , the resident's initial blood pressure was 189/129, and was measured as high as 248/205 and 240/226 (extremely high blood pressure); -The emergency room physician assessed right upper and lower extremity weakness and the resident's gaze deviated to the right (could indicate an acute stroke); -The resident was admitted for further evaluation and treatment; -Past medical history included advanced Alzheimer's dementia and hypertension; -Assessment and Plan: transient ischemic attack versus cerebrovascular accident; -Discharge [DIAGNOSES REDACTED]. Review of the resident's clinical notes report dated 8/23/17, showed the following: -LPN D, day charge nurse, was on another neighborhood as the charge nurse, and was called over to Willow Way by an unidentified certified nurse aide who said the resident's private duty sitter told the CNA that the resident had fallen; -The resident lay on the right side on the floor at the foot of the bed; -There was no injury noted; -Four staff members assisted the resident with the gait belt; -The resident was resistive to care and yelled at staff when trying to assist the resident; -The resident's blood pressure was 180/100 (high blood pressure); -The resident had a private duty sitter 24/7 who said the resident was coming out of the bathroom, parked the walker against the wall across from the bathroom, stumbled backwards, and hit the back of his/her head on the foot of the bed frame; -Staff notified the DON at 7:45 A.M.; -On call physician asked LPN D to call the nurse practitioner (NP) after 9:00 A.M., the NP called LPN D at 8:45 A.M.; -No new orders but to continue to monitor neurological checks and report any changes. Review of the resident's incident report dated 8/23/17, showed the following: -Resident was walking unassisted, stumbled, and fell backwards onto the floor; -Private duty caregiver notified nursing staff the resident had fallen; -The resident was unable to state what happened; -The resident was laying on the floor at the foot of the bed upon entering the room; -LPN went to the resident's room after being notified by private duty that the resident had fallen. The resident was lying on the floor at the foot of the bed upon entering room; -Private duty caregiver stated resident was coming out of bathroom and parked the walker against the wall, lost their balance, and stumbled backwards on to the floor. -Final determination: The resident was walking without assistance. Review of the resident's care plan updated 8/23/17, showed the following: -The resident fell backwards and hit his/her head while up walking without assistance; -Intervention: continue with one on one sitter at designated times and notify the physician of new or worsening symptoms of CVA/TIA; -Encourage staff and sitter to keep wheelchair close by due to resident frequently pushing walker out of the way and not using it. During interview on 11/3/17 at 9:55 A.M. and 11:25 A.M., the Director of Nursing said the following: -The resident had multiple falls and behaviors; -The facility staff had to provide more one on one time with the resident and it took time away from their other nursing duties and other residents' care; -The resident was very combative, wandering unassisted into other resident's rooms, and was difficult to redirect; -On August 3, 2017, the facility hired a one on one private duty sitter to sit with the resident to help decrease restlessness and behaviors. When the resident would try and get up on his/her own, the sitter was to alert staff; -He/she expected the sitter to remain with the resident at all times and not leave the resident unattended; -The sitter was informed of the resident's condition and care information; -The sitter was a home health aide companion and not a certified nurse aide; -The private duty sitter was not to provide care but sit with the resident, redirect them, talk to them, and quiet them, but it was nearly impossible; -They felt the sitter was appropriate for the resident because of the behaviors; -The sitter was working when both falls occurred on 8/10/17 and 8/23/17; -The sitter notified the staff of the resident's fall on August 10; -On the second fall on August 23, 2017, the sitter had left the resident's room, came back to the room, and found the resident on the floor; -When a resident had a [DIAGNOSES REDACTED]. -Staff were to do a fall risk assessment on all residents on admission to the facility.

Based on observation, interview, and record review the facility failed to assess one resident's (Resident #1) skin around his/her cervical collar (medical device used to support a person's neck, also known as a neck brace) and failed to notify the resident's physician when the resident had increased pain and swelling on the left side of his/her jaw resulting in a Stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling), in a review of five sampled residents. The facility's census was 77. 1. Record review of the facility's Pressure Ulcer Protocol, dated 2/21/2013, showed the following: -Policy: This protocol will be incorporated into the resident's individualized plan of care and implemented when it is identified that a resident has a pressure ulcer; -Assessment: A skin inspection will be conducted each time the resident is bathed and when clothing is changed. Special attention will be given to bony prominences. Report to the nurse any observed changes in the skin (i.e. redness, rash, irritation, break in skin) and changes in the ulcer (drainage, increased size, loss of scab or skin covering a blister); -Use protective devices following Interdisciplinary Care Team and manufactures recommendations to protect bony prominences and care plan as needed. 2. Record review of the facility's Pressure Ulcer Prevention and Management Policy, dated 2/22/13, showed the following: -Policy: It is the policy of the facility that all residents are considered to have some risk for the development of pressure ulcers. A licensed nurse will perform an observation of skin condition on the day of move in, quarterly and as needed based on identified risk and/or change in condition. A skin observation will be conducted prior to move-out based on individual needs (i.e., if move-out is based on emergent need for transfer, the nurse may deem the observation unsafe due to time or inability to move the resident); -A risk assessment using the Braden Scale Risk Assessment Tool will be done on move-in, quarterly, and with significant change in condition to identify risk factors for the development of pressure ulcers. An immediate plan to reduce a resident's risk of pressure ulcers or to treat an existing pressure ulcer will be developed and implemented; -Licensed nursing team will follow current standards of practice related to wound care including the National Pressure Ulcer Advisory Panel (NPUAP) guidelines for assessment and treatment of [REDACTED]. 3. Record review of the National Pressure Ulcer and Advisory Panel Prevention and treatment of [REDACTED]. -Risk for Medical Device Related Pressure Ulcers: Consider adults with medical devices to be at risk for pressure ulcers; -Recommendations for Assessment of the Skin and Medical Devices: Inspect the skin under and around the medical devices at least twice daily for the signs of pressure related injury on the surrounding tissue. Conduct more frequent (greater than twice daily) skin assessments at the skin-device interface (common boundary of two bodies, spaces, or phases) in individuals vulnerable to fluid shifts and/or exhibiting signs of localized or generalized [MEDICAL CONDITION]. Pressure ulcers related to medical device use are not a new category of pressure ulcer, and should be classified according to the level of tissue loss; -Recommendations for Prevention of Medical Device Related Pressure Ulcers: Keep skin clean and dry under medical devices. Rotate or reposition medical devices when possible. Consider using a [MEDICATION NAME] dressing for preventing medical device related pressure ulcers. It is important to select a dressing that is appropriate to the individual and the clinical use. 4. Record review of Resident #1's discharge orders from an area hospital, dated 9/25/17, showed the following: -Discharge Diagnosis: [REDACTED]. -The resident has been examined and does not have any emergency medical conditions; -Bed to chair transfers with assistance only until cleared by physician. Keep cervical collar on at all times- Do not remove; -Follow up with orthopedic surgery in two to three weeks. Record review of the resident's Nursing Admission Assessment, dated 9/25/17, showed the following: -Time of admission: 1:00 P.M.; -The resident was not experiencing pain. He/she was able to communicate; -Oriented to time, place, person, and event; -Skin: Moist; -Skin Color: Normal; -Skin temperature: Warm; -No wounds; -Activity level: Mobility by wheelchair; -Musculoskeletal: Cervical collar on at all times due to C1 fracture. Record review of the resident's Braden Scale for Predicting Pressure Ulcer Risk, dated 9/25/17, showed the resident was not at risk for developing a pressure ulcer. Record review of the resident's care plan, dated as effective 9/25/17, showed the following: -Problem: The resident is at risk for developing impaired skin integrity; -Goals: The resident will have no alteration in skin integrity; -Approaches: Complete weekly skin assessment. Report changes in skin status to the physician. Notify the nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, or discoloration noted during bathing or daily care. Minimize pressure over bony prominences. Record review showed no documentation on the care plan to address risk of the collar causing pressure or skin breakdown. There was no direction for staff to assess the resident's skin around the collar. Record review of the resident's facility admission history and physical, dated 9/26/17, showed the following: -History: The resident was transferred from hospital on [DATE] after an admission for a fall complicated by C1-C2 fractures, treated conservatively with a cervical collar and activity limitation; -Physical exam: Neck: supple and trachea midline; Cervical collar, no cervical lymphadenopathy. Skin: ecchymosis (a discoloration of the skin resulting from bleeding underneath, typically caused by bruising); -Plan: Multiple fractures of the cervical spine- per the resident, cervical collar needs to be on 24/7 until cleared by orthopedic surgeon. Limited to bed to chair transfers for at least four to six weeks. Record review of the resident's Daily Skilled Progress Notes, dated 9/26/17 to 9/30/17, showed the resident had no complaints of pain and he/she had no wounds. Record review of the resident's Daily Skilled Progress Note, dated 9/30/17 at 1:36 A.M., showed the resident had complained of pain in his/her neck and rated the pain a 4 on a pain scale of 1 to 10 with 1 being the least pain and 10 being the worst pain. The resident was given Tylenol and it was effective. The note showed the resident did not have any wounds. Record review showed no documentation the resident's physician was notified of the resident's new complaints of pain. Record review of the resident's Medication Administration Record [REDACTED].M. for complaints of pain. Record review of the resident's Clinical Note, dated 10/1/17 at 9:40 A.M., showed the resident alert and oriented times four with complaints of pain located at the left shoulder and left temporal area (area to the side of the head by the eye). The resident rated his/her pain a 5 out of 10 and described it as an ache. He/she said it was due to his/her cervical collar and asked for Tylenol. The resident also complained of discomfort at the clavicles (collarbone) due to the cervical collar, the nurse placed a piece of gauze sponge under the collar for comfort. The resident received Tylenol as ordered and reported this as being effective. Record review showed no documentation staff notified the physician of the complaints of pain from the cervical collar. Record review showed no documentation of skin assessments around the resident's cervical collar. Record review of the resident's progress note, dated 10/2/17 at 9:33 A.M., showed the nurse practitioner documented the following: -Chief complaint: Skilled follow-up visit; -History: The resident reports receiving [MEDICATION NAME] last night for inability to sleep and feels that he/she had a very bad reaction to it. He/she felt very confused and out of it. He/she had a difficult time making sentences and thought that his/her spouse was next to him/her in bed. He/she does not want this medication ever again. He/she did not have difficulty sleeping at home prior to admission. He/she does not take any medications other than Tylenol. He/she complained that his/her jaw and the back of his/her neck were very sore from the cervical collar; -Physical exam of the skin: Inspection and palpation- ecchymosis; -Plan: Tylenol Extra Strength 500 mg- two tablets at bedtime. Record review of the resident's Admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 10/2/17, showed the following: -The resident was cognitively intact; -Had received PRN (as needed) pain medication; -Pain present frequently; -Pain had not made it hard to sleep at night; -Pain had not limited day to day activities; -Verbally described pain as mild; -At risk for developing pressure ulcers; -Had no unhealed pressure ulcers. Review of the resident's Daily Skilled Progress Notes skin section, dated 10/2/17 at 5:20 A.M., 10/3/17 (entered into the system at 3:55 A.M. on 10/04/17), and 10/4/17 at 12:39 A.M., showed the resident had no wounds. Record review of the resident's progress note, dated 10/5/17 at 1:43 P.M., showed the nurse practitioner documented the following: -Chief complaint: Skilled follow-up visit; -History: The resident is doing well today, he/she is extremely anxious to be able to get up and walk. He/she remains wheelchair-bound due to the neurosurgeon's orders. He/she is due to follow up with the neurosurgeon on 10/13/17. He/she is sleeping better at night. He/she has been receiving a gram of Tylenol which does him/her much good. The pain seems to be worse later in the day; -Physical exam of the skin: Inspection and palpation- ecchymosis; -Plan; Continue Tylenol one gram at bedtime and Tylenol 325 mg- two tablets every six hours as needed for pain. Further review of the resident's PRN MAR, dated October 2017, showed the resident received Tylenol 650 mg on: -10/7/17 at 9:17 A.M. for complaints of dull neck pain, unrated and at 10:17 A.M. it was effective; -10/7/17 at 5:49 P.M. for pain, unrated and at 6:49 P.M. it was effective; -10/8/17 at 2:20 P.M. for pain, unrated and at 3:20 P.M., rated pain level at a 3. Record review showed no documentation of the location or description of the resident's pain. Review of the resident's Daily Skilled Progress Notes skin section, dated 10/6/17 at 4:57 A.M., 10/7/17 at 4:47 A.M., and 10/8/17 at 1:12 A.M., showed the resident had no wounds. Record review of the resident's Daily Skilled Progress Note, dated 10/9/17 at 1:04 A.M., showed the following: -The resident complains of pain. Location: his/her neck. Rated: 4. Description: Ache. Comments: Tylenol given; -Skin: Warm. Wounds: No. Record review of the resident's progress note, dated 10/9/17 at 1:14 P.M., showed the nurse practitioner documented the following; -Chief complaint: Skilled Discharge Summary; -History: The nurse practitioner went to see the resident today for discharge and unfortunately he/she complained of swelling to the left side of his/her face which was painful as well for the last three days. His/her cervical collar has not been removed since it was placed which has been over two weeks ago. The nurse practitioner did pull the brace back some and found a pressure ulcer noted to the left side of his/her jaw line, fairly large, measured 1.6 centimeters (cm) by 1.2 cm by 0.2 cm with a large amount of slough and a foul odor. A call was placed to his/her surgeon regarding this and the surgeon continues to order the brace not be removed at all, until he sees the resident on 10/13/17; -Physical exam of the skin: Inspection and palpation- ecchymosis and ulcer to left jaw line with large amount of slough; -Plan: Pressure Ulcer Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but one, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling). Place Santyl ([MEDICATION NAME] enzymatic debrider, it selectively removes necrotic tissue without harming granulation tissue) with Allevyn (absorbent foam dressing) for now and have wound specialist see tomorrow. Start [MEDICATION NAME] (antibiotic) [MEDICATION NAME] with [MEDICATION NAME] ([MEDICATION NAME]). Stat mandible x-ray to rule out osteo[DIAGNOSES REDACTED] (inflammation of bone caused by infection); -The facility documented 10 minutes prior the resident had no wounds. Record review of the resident's Daily Skilled Progress Note, dated 10/10/17 at 4:41 A.M., showed the following: -The resident complains of pain. Location: his/her neck. Rated: 4. Description: Ache. Comments: Tylenol given; -Skin: Warm. Wounds: No. (The nurse practitioner identified a Stage III pressure ulcer on 10/09/17). Record review showed no documentation by facility staff regarding the wound identified on 10/09/17 by the Nurse Practitioner. Record review of the resident's Wound Specialist report, dated 10/10/17, showed the following: -Chief complaint: Consult to assess the resident's wound; -History: Wound culture performed today; -Wound #1: Medical Device Pressure Ulcer- Left mandible (jaw); -Pre Debridement Length: 2.0 cm by 1.5 cm with a depth of 0.6 cm; -Exposed structure: Bone; Odor: None; Drainage amount: Small; Drainage color: Serosanguineous (yellowish with small amounts of blood); [DIAGNOSES REDACTED] (skin redness): Present; Maceration (softening and braking down of skin resulting from prolonged exposure to moisture): Absent; -Dressings: Clean wound with wound cleanser. Apply skin prep to skin. Apply Santyl nickel thick layer to wound bed, then apply Calcium alginate (water-insoluble, gelatinous, cream-colored substance) and cover with gauze and secure with Allevyn dressing. Dressing to be changed by staff daily and as needed for soiling. Record review of the resident's progress note, dated 10/10/17 at 11:29 A.M., showed the nurse practitioner documented the following; -Chief complaint: Skilled Follow-up visit; -History: Follow up for the development of a new pressure ulcer under the resident's left mandible due to the pressure of his/her cervical collar. The wound specialist was here and did a thorough assessment of the wound and classified it as a Stage IV (Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcer with exposed bone. It measured 2.0 cm by 1.5 cm with a depth of 0.6 cm with slough and a foul odor present. Wound specialist recommended a daily dressing change of Santyl, calcium alginate, and secured with an Allevyn. Also placed an Allevyn dressing on the right side for [MEDICATION NAME] measures and and ABD (moisture resistant barrier which provides padding and protection) pad on the anterior (front) clavicle region. The resident doesn't have any complaints aside from the tenderness to the affected left side. Observation on 10/24/17 at 11:30 A.M. showed: -The resident had an open area to his/her left mandible with bone exposed; -The resident also had a dressing to the right mandible. During an interview on 10/24/17 at 10:50 A.M., the resident said the following: -He/she informed staff that his/her face felt swollen on the left side about three days prior to the nurse practitioner finding the pressure ulcer; -He/she had pain in the left side of his/her jaw for about a week prior to the finding of the pressure ulcer; -He/she denied anyone ever pulling back his/her cervical collar to examine his/her skin prior to 10/9/17 when he/she was getting ready to be discharged . During an interview on 10/24/17 at 2:15 P.M., the Director of Nursing said the following: -The resident's surgeon would not allow the cervical collar to be removed for skin checks; -She would consider the cervical collar the same as a splint or cast and she would expect staff to assess the skin as they would if the resident had a splint or cast on; -The facility did not have a policy for splint or cast care; -She would expect staff to notify the surgeon if the resident had increased neck pain, swelling, or overall change in condition. During an interview on 10/26/17 at 2:41 P.M., the resident's orthopedic surgeon said the following: -He would have expected licensed facility staff to have examined the skin around the cervical collar by pulling lightly back on the cervical collar; -He would have expected staff to notify him of increased pain and swelling around the cervical collar; -The cervical collar was not so rigid that licensed staff could not have pulled collar back and examined the resident's skin. During an interview on 10/26/17 at 3:20 P.M., the administrator said the following: -She would expect nursing to provide standard nursing care, including assessment of extremities below the cast/splint, assessing for odor/drainage from under the cast/splint, and routine vital signs; -She said nurses are instructed to contact the physician upon admission and with resident change of condition. MO 1