Every finding on record at Neodesha Care and Rehab

Based on observation, interview and record review, the facility failed to provide eight consecutive hours of registered nurse staff on a daily basis for the residents of the facility. Findings included:- The 01/01/2026 Facility Assessment 2026, documentation included Staff/Personnel requirements, which documented:Nursing staffing consists of an equivalent of 24-hour licensed nurse coverage with at least 8 consecutive hours of Registered Nurse (RN) daily.On 04/12/26 at 09:15 AM, Licensed Nurse (LN) I confirmed there was not a Registered Nurse present in the building, and Administrative Nurse D was out of town. LN I identified herself as the only scheduled day shift nurse on location.The Daily Posting of Nursing Hours Sheet for Sunday, 04/12/26, lacked entries for RN coverage.Review of the Nursing schedule for Sunday 03/29/26 through 04/12/26 revealed a lack of scheduled RN coverage for the following dates:Monday, 03/30/26.Wednesday, 04/01/26.Monday, 04/06/26 26.Tuesday, 04/07/26.Wednesday, 04/08/26.Saturday, 04/11/26.Sunday 04/12/26. On 04/14/2026 at 02:35 PM, Administrative Nurse D confirmed the lack of scheduled RN coverage as noted above. She stated she often worked the weekend as the RN on duty for eight consecutive hours. Administrative Nurse D verified the facility lacked auditable or verifiable evidence of her working as the RN on duty for eight consecutive hours and confirmed she was not listed or identified as the RN on the schedule or staff postings for RN coverage. Additionally, she stated Administrative Nurse E worked on weekends on occasion to cover the daily RN eight consecutive hour mandate and confirmed she was not identified as such on the schedule. She reported she had not put her name on the schedule for the 8-hour RN coverage, as she just comes in. The facility policy Nursing Services. dated 04/2025, documentation included:The community provides adequate staffing with appropriate competencies and skill sets to provide nursing and related services to ensure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. facility to maintain adequate staffing on each shift to ensure that residents' needs and services are met, which includes eight consecutive hours of RN coverage daily. Identify any state minimum requirements for staff ratios and compare them to the current staffing.

The facility reported a census of 38 residents and one main kitchen. Based on observation, interviews and record review the facility failed to store, prepare and serve food in a sanitary manner. Findings included:- During the initial kitchen tour on 04/12/26 at 09:18 AM, observation revealed the following concerns: 1. Dry goods storage: One open, undated container of cumin.One open, undated container of Everything Spice.One open, undated container of honey granules.One open, undated container of thyme.One open, undated container of cinnamon.A large non-skid mat was folded over in the middle of the dry storage room.2. Freezer:A sleeve of bagels and English muffins had no label or date.The freezer doors were dirty with fingerprints, food residue, and smudges on and around the handles.3. Preparation areaA tall metal cup with no lid that contained milk sat on the preparation area.An open-to-air, undated loaf of bread sat on a shelf.4. RefrigeratorOne open but undated gallon of milk.One opened undated and unlabeled bottle of Diet Coke.The refrigerator doors were dirty with fingerprints, food residue, and smudges on and around the handles.5. General kitchen areaOne box of cereal was open-to-air and undated on the bottom shelf of a table in front of the dishwashing area.The lower shelf under the steam table where steam table food containers were stored was dirty with crumbs, dried liquid, and sticky residue.The handwashing sink had dried brown and gray areas on the front and back of the sink. During an interview on 04/12/26 at 09:46 AM, Dietary DD stated all items are supposed to be dated. During an interview on 04/12/26 at 11:35 AM, Dietary BB stated it is her expectation that all food items are to be dated upon arrival into the kitchen and when opened. The facility policy Food Preparation and Service, dated 10/2025, states food service employees shall prepare and serve food in a manner that complies with safe food handling practices.

The facility reported a census of 38 residents. Based on observation, interviews, and record review, the facility failed to ensure staff served palatable meals to the residents when the staff served dry, burnt ham to the residents on 04/12/26 for the lunch meal. Findings included:- An observation on 04/12/26 at 12:50 PM revealed residents seated in the dining room eating lunch which included ham. The ham appeared dry and dark on the residents' plates. On 04/12/26 at 12:50 PM, Resident (R) 39 stated he had no issues with his meal, except for the dry, burnt ham he was served for lunch.On 04/12/26 at 12:55 PM, R33 also stated the ham on her plate at lunch was dry and burnt. During an observation of R3 eating lunch in his room on 04/12/26 at 01:11 PM, R3 coughed extensively while eating his lunch. He took a drink of his water while chewing a piece of the dry, burnt ham. He continued to cough until tears ran down his face, and his cough was dry and unproductive. The sips of water did not appear to help and R3 turned on his call light. At 01:20 PM, Certified Nursing Assistant (CNA) M answered R3's call and R3 was still coughing on and off and drinking water. CNA M asked R3 if he would like a sandwich and he said no. CNA M said the residents did complain that the ham was dry and hard to eat today. CNA M walked back down towards the kitchen with R3's lunch tray. On 04/12/26 at 01:24 PM, Dietary Staff BB said the ham was overcooked and it was dry but stated she served it anyway. On 04/12/26 at 03:30 PM, Administrator revealed she expected the staff to serve food that was cooked properly and palatable. Administrative Staff A reported Dietary Staff BB served the ham because she was worried that she would be in trouble if she did not follow the menu during the survey. The facility's Food Preparation and Service policy, dated October 2025, stated residents are provided with meals that are palatable and attractive.

Based on interviews, observation and record review, the facility failed to ensure adequate hand hygiene during medication administration for Resident (R) 28, a tube feeding (administration of nutritionally balanced liquefied foods or nutrients through a tube) for R5, and for hands-on care for R30 and R3. Findings included:1. On 04/13/26 at 08:14 AM, Certified Medication Aide (CMA) R applied her gloves to her hands and applied a topical medication patch to R28's right shoulder. CMA R gathered an inhaler and a nasal spray container, removed her gloves, and without performing hand hygiene she took the medication keys out of her pocket, and opened the medication cart drawer, placed the items in the cart, removed another nasal spray medication bottle then handed that bottle to R28 who spayed the medication into each nostril then handed the nasal spray bottle back to CMA R who placed the bottle back into the cart and then performed hand hygiene. On 04/13/26 at 08:45 AM, CMA R reported that she realized she did not perform hand hygiene when she removed her gloves after the patch was applied and reported she should have sanitized the hands. 2. Observation on 04/13/26 at 09:49 AM, Administrative Nurse L and Certified Nurse Aide (CNA) N assisted R30 to the bathroom to complete incontinent care. CNA N removed R30's soiled brief and pants and bagged those items as Administrative Nurse L applied the wheelchair foot pedals that had laid on the bathroom floor to the wheelchair. Wearing the same gloves, Administrative Nurse L then took some peri wipes out of the packet, asked R30 to stand up from the toilet and cleansed R30 with the wipes using the same gloves she applied the wheelchair pedal to the wheelchair with. CNA N and Administrative Nurse L then assisted R30 to her bed. CNA N did not remove her gloves that she used to remove soiled brief and pants. R30's breakfast tray was delivered and CNA N took the tray from the staff and set up R30 by applying her neck napkin, unrolling the silverware and opened the fruit cup with the same gloves she had on in the bathroom. On 04/13/26 at 11:37 AM, CNA N reported that she did not realize she wore the same gloves that she used to assist R30 in the bathroom and reported she should have removed her gloves, washed her hands, and put on new gloves, especially before she set up the resident's food. 04/14/26 at 11:22 AM, Administrative Nurse L reported that she did not remove her gloves and wash her hands after she applied the foot pedals to R30's wheelchair, and reported that she should have removed those gloves, sanitized her hands, and applied new gloves before she completed peri-care to R30. 3. Observation on 04/13/26 at 10:50 AM, R5 sat in her wheelchair as Licensed Nurse (LN) G prepared items to complete her tube feeding. LN G aspirated about 30 milliliters of R5's stomach content with a piston syringe, then LN G attempted to take a test strip out of a bottle. She removed her glove from her left hand, and without performing hand hygiene she reached up and removed a new glove out of the box. She removed a pH (measures the acidity or alkalinity of an aqueous solution) test strip out of the container and placed that pH test strip on a barrier, she applied her glove on her left hand, and she placed a few drops off the stomach content to the pH test strip. LN G administered the stomach contents back into R5's stomach and proceeded to administer the tube feeding. On 04/13/26 at 11:20 AM LN G reported that she generally removed both gloves and got frazzled when she realized she did not take the test strip out before she removed the stomach contents. LN G reported she should have removed both gloves and sanitized her hands. 4. Observation of 04/14/26 at 08:30 AM, CNA M and CNA O completed catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care on R3. CNA M emptied R3's catheter bag and emptied the urine in the toilet, CNA M removed her gloves and without performing hand hygiene, applied new gloves. CNA M and CNA O positioned R3 onto his left side and CNA M cleansed his buttocks and rectum and applied a new brief and his pants. They assisted R3 onto a sling and transferred him to his wheelchair with a mechanical lift. CNA M grabbed her walkie talkie out of her pocket to communicate with other staff and placed the walkie talkie back into her pocket. CNA M used the same gloved hands that she used to cleanse his buttocks and rectum to wash off R3's eyeglasses, set R3 up for oral care then wiped off his face after he rinsed his mouth with mouthwash. On 04/14/26 at 09:06 AM, CNA M reported that she should have washed her hands after she removed her gloves when she emptied the urine. CNA M reported that she did not realize that she wore the same gloves after she washed his buttocks for the remainder of care and reported that she should have removed the gloves, performed hand hygiene, and applied new gloves. CNA M reported that the staff needed to answer the walkie talkie when they were called and did not even think about her hands when she grabbed the walkie talkie. On 04/14/26 at 12:28 PM, Administrative Nurse D revealed she expected the staff to perform hand hygiene prior to applying PPE and she expected the staff to perform hand hygiene when gloves were removed, before new gloves were applied. Administrative Nurse D revealed she expected the staff to remove both gloves not just one and perform hand hygiene. Administrative Nurse D revealed she expected the staff to remove soiled gloves and perform hand hygiene and apply new gloves when going from dirty areas to clean areas when providing hand on care to the residents. The facility's policy Handwashing/Hand Hygiene, dated 10/2025, documented the facility considers hand hygiene the primary means to prevent the spread of infections. Employees must wash their hands for at least twenty (20) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions:Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice), before and after assisting a resident with toileting (hand washing with soap and water), before moving from a contaminated body site to a clean body site during resident care, and after removing gloves. The use of gloves does not replace handwashing/hand hygiene.

Based on observation, interview, and record review, the facility failed to ensure the physician for Resident (R) 30 was informed when the resident had refused several medications which included an antibiotic for a urinary tract infection (UTI - an infection in any part of the urinary system). Findings included:- R30's Electronic Medical Record (EMR) revealed diagnoses of diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), constipation (difficulty passing stools), and vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain) R30's Quarterly MDS dated [DATE], which documented a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. R30's MDS documented he required total assistance with toileting hygiene and R30 was always continent of bowel. R30's Care Plan instructed staff to administer medications as ordered, and monitor/document for side effects and effectiveness, dated 04/10/25. R30's Care Plan documented a new order for Macrobid (an antibiotic) administer 100 milligrams (mg) twice a day for 14 days for UTI, initiated on 03/23/2026 and revised on 04/01/26. R30's Electronic Medication Administration Record (EMAR) documented an order for Macrobid 100 mg twice a day for 14 days for UTI, ordered on 03/27/26. Review of R30's EMAR, dated from 03/27/26 through 04/09/26, documented refusals of Macrobid on 03/27/26 at 06:00 AM, 03/29/26 at 06:00 AM and 06:00 PM, and 03/03/26 at 06:00 AM. The EMAR lacked documentation that a provider was updated. Review of R30's Progress Notes, dated 03/27/26 through 04/02/26, lacked documentation that a provider was updated of Macrobid refusal and other ordered medications. R30's Provider Note, dated 04/03/26 at 08:00 AM, documented R30 continues to refuse to take most of her medications. On 04/13/26 at 10:11 AM, Licensed Nurse (LN) H entered R30's room with a medicine cup with three pills and some applesauce in another cup. LN H asked R30 if she would like applesauce with her medications. LN G scooped two pills up on the spoon and some applesauce. R30 reported she could not take any pills, but she took them. LN H reported that she took her pain pill and water pill and wanted to give her the anxiety pill. R30 agreed and did accept the pill. R30 then reported she was sick. The LN asked R30 if she was still sick to her stomach and she said always and that no one was doing anything when she reported she was nauseated. LN H reported she would get her medication to help her with her nausea. On 04/13/26 at 10:38 AM, LN H reported that she would try and go back to administer the remainder medications, however, R30 had refusing a lot of her medications for about a month. LN H reported that she would let the charge nurse know when a resident refused medications as she was just at the facility to pass medications. On 04/13/26 at 01:56 PM, Certified Medication Aide (CMA) R reported she would update the nurse in charge if a resident refused medications. On 04/14/26 at 10:48 AM, LN G reported that the staff would let the charge nurse know if a resident had refused their medications and that they would try to re-approach the resident to take their medications, she further stated that they generally wait until the provider comes to the facility for their weekly rounds to update them on residents. She also reported that she might text from her phone to update a provider. She reviewed R30's EMAR note and reported none of the medications which were refused had a note from the staff that the provider was updated. On 04/14/26 at 11:53 AM, Consultant Staff GG (Facility Provider) reported that the facility would generally wait to notify her of residents that refused medications. Consultant Staff GG reported that she was notified on 03/31/26 of R30 refusing most of her medications and reported that she had a discussion with R30's durable power of attorney (DPOA- a legal document that names a person to make healthcare decisions when the resident is no longer able to) and Administrative Nurse D to discuss palliative (treatment designed to relieve or reduce the intensity of uncomfortable symptoms) care after R30 had completed her antibiotic. Consultant Staff GG was unsure whether the staff should update the provider each time a resident refused their medications. On 04/14/26 at 12:45 PM, Administrative Nurse D reported it depended on the type of medication the resident refused as to when a provider should be updated. Administrative Nurse D reported that the resident should be educated when medication is refused. The facility's policy Refusal of Treatment, Discontinue Treatment documented the community staff shall honor a resident's request not to receive medical treatment as prescribed by his or her physician, as well as care routines outlined on the resident's assessment and plan of care. If a resident refuses treatment, the Unit Manager, Charge Nurse, or Director of Nursing Services will interview the resident to determine what and why the resident is refusing to try to address the resident's concerns and explain the consequences. Documentation pertaining to a resident's refusal of treatment shall include at least the date and time the staff tried to give medication or treatment was attempted. The date and time of when the physician was notified as well as the physician's response.

The facility identified a census of 38 residents. The sample included 14 residents. Based on observation, interview, and record review, the facility failed to provide dependent Resident (R) 30 with activities of daily living (ADL) services, including shaving of facial hair. Findings included:- R30's Electronic Medical Record (EMR) revealed diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), and vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain). R30's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. R30's MDS documented he required touching assistance with personal hygiene. R30's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA), dated 04/10/25, documented R30 required assistance with some activities of daily living and would proceed to plan of care. R30's Quarterly MDS, dated [DATE], which documented a Brief Interview for Mental Status (BIMS) score of 10 indicating moderately impaired cognition. R30's MDS documented that she required moderate assistance with personal hygiene and R30 had no refusal behaviors. R30's Care Plan, dated 04/10/25, documented staff instructed R30 required setup assistance for personal hygiene tasks. R30 was able to ask for assistance if needed. R30's Progress Note on 04/08/26 at 10:19 PM documented palliative (treatment designed to relieve or reduce the intensity of uncomfortable symptoms) monitored care symptoms. R30 did not have signs of agitation, anxiety, or restlessness at the time of this assessment. R30 did not have signs of delirium at the time of the assessment and did not display signs of depression at this time. R30's Shower Sheets, reviewed from 03/09/26 through 04/13/26, documented R30 had 15 showers offered, and staff documented R30 was shaved on two days, 03/25/26 and 03/30/26. On 04/13/26 at 09:12 AM, Certified Nurse Aide (CNA) O assisted R30 back down to the hallway from the shower room in her wheelchair and she was dressed. R30 reported she was cold when she entered the room, then CNA O assisted R30 with applying a sweatshirt on her and situated her personal items and call light. On 04/13/26 at 09:15 AM, R30 reported she was waiting for her breakfast, and she was hungry. She rubbed her chin and reported that she had asked for these to come off, and she was noted with approximately 1/8 inch several stubbly white facial hairs. On 04/13/26 at 12:11 PM, CNA O reported that she would remove facial hair during the shower for a resident who could not shave themselves. She reported that R30 could not shave her facial hairs off her chin, and she refused at times. On 04/13/26 at 01:38 PM, Licensed Nurse (LN) H reported she expected the staff to remove facial hair for residents that required assistance with personal hygiene on their scheduled shower days and as needed. 04/14/26 at 03:15 PM, Administrative Nurse E reported she expected the staff to offer shaves and nail care to dependent residents on shower days and as needed. The facility's policy Quality of Life- Activities of Daily Living dated March 2026, documents dependent residents will receive the care and services to maintain good nutrition, grooming and personal and oral hygiene.

Based on observation, interview, and record review the facility failed to monitor and respond to Resident (R) 30's lack of bowel movements. Findings included:- R30's Electronic Medical Record (EMR) revealed diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), constipation (difficulty passing stools), and vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain). R30's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognition. R30's MDS documented that he required total assistance with toileting hygiene, and he was always continent of bowel. R30's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA), dated 04/10/25, documented R30 required assistance with some activities of daily living and would proceed to plan of care. R30's Urinary Incontinence and Indwelling Catheter CAA, dated 04/10/25, documented R30 had occasional bladder incontinence and required assistance with toileting and episodes of incontinence and would proceed to plan of care. R30's Quarterly MDS, dated [DATE], which documented a Brief Interview for Mental Status (BIMS) score of 10 indicating moderately impaired cognition. R30's MDS documented he required total assistance with toileting hygiene and R30 was always continent of bowel. R30's Care Plan, dated 04/10/25, documented staff instructed to Monitor for possible signs and symptoms of adverse drug reaction: falls, weight loss, fatigue, incontinence, agitation, lethargy, confusion, agitation, depression, poor appetite, constipation, gastric upsetting. R30's Care Plan, dated 04/13/26, lacked documentation regarding her constipation diagnosis and instructions for the staff. R30's Physician Orders documented Colace 100 milligrams (mg) capsule, administer one capsule two times a day, for constipation, date ordered 07/15/25. R30's Physician Orders documented bisacodyl rectal suppository 10 mg, insert one suppository rectally every 24 hours as needed for constipation, date ordered 04/05/26. Review of R30's bowel movement frequency in the EMR, dated 03/17/26 through 03/22/26, revealed the resident exceeded three days/72 hours without a bowel movement 03/17/26 through 03/22/26 (six consecutive days) with no response until 03/22/26. Review of R30's bowel movement frequency in the EMR, dated 03/29/26 through 04/03/26, revealed the resident exceeded three days/72 hours without a bowel movement 03/29/26 through 04/03/26 (six consecutive days) with no response until 04/04/26. R30's 03/22/26 at 01:30 PM Electronic Medication Administration Record Note (EMAR), documented Milk of Magnesia Concentrate Suspension Give 30 milliliters (ml) by mouth every 24 hours as needed for constipation for 14 days daily. R30 was on the no bowel movement list. R30 refused to take medication or prune juice. R30 had not voiced any abdominal pain or discomfort. Bowel sounds present. R30's 03/23/26 at 03:25 PM EMAR Note documented Milk of Magnesia Concentrate Suspension Give 30 milliliters (ml) by mouth every 24 hours as needed for constipation for 14 days. R30 refused Milk of Magnesia. R30 had not voiced any abdominal pain or discomfort. Bowel sounds present. R30's 04/04/26 at 12:20 PM EMAR Note documented Milk of Magnesia Concentrate SuspensionGive 30 ml's by mouth every 24 hours as needed for constipation for 14 days daily. Medication was administered as needed for no bowel movement. Review of R30's Providers Note 03/17/26 through 04/03/26 documented on 03/17/26, 03/24/26, 03/31/26, and 04/03/26 soft abdomen, and normal bowel sounds. On 04/13/26 at 09:12 AM, R30 was assisted back down to the hallway from the shower room in her wheelchair by Certified Nurse Aide (CNA) O. CNA O assisted R30 apply a sweatshirt on her and situated her personal items and call light. R30 reported she was sick to her stomach and CNA O reported she would let the certified medication aide know, then R30 commented that would not help as they don't believe her when she is sick. On 04/13/26 at 11:37 AM CNA N reported the staff would document in the EMR after a resident had a bowel movement. On 04/14/26 at 10:48 AM, Licensed Nurse (LN) reported that charge nurse was responsible for reviewing the 72-hour no bowel movement report from the computer program, along with offering as needed medications for no bowel movement. LN G reported that if a resident did not have an as needed order, an order would be obtained. LN G reported an abdominal assessment would be completed also. LN G reported if a resident does not have a bowel movement for several days the provider would be updated so further orders could be obtained. LN G reported the 72-hour bowel movement program report only would state that the resident did not have a bowel movement in three days it does not state anything higher than 72 hours. On 04/14/26 at 11:53 AM, Consultant Staff GG (Facility Provider) reported she expected the staff to document when a resident had a bowel movement. Consultant Staff GG reported that she expected the staff to administer as needed bowel medications, and follow-up and assess the resident. Consultant Staff GG reported she expected the staff to update her if a resident did not have a bowel movement for several days. 04/14/26 at 12:45 PM Administrative Nurse D reported she expected the staff to monitor bowel movements and administer medications as needed, to follow up and assess residents that have not had a bowel movement after 72 hours or longer. Administrative Nurse D revealed she expected the staff to communicate with the provider when a resident has not had a bowel movement for several days. The facility's policy Fecal Incontinence-Assessment and Management, dated 10/2025, lacked documentation of monitoring for bowel movements and management of constipation.

Based on observation, interview, and record review, the facility failed to provide adequate care and services for Resident (R) 22's peripherally inserted central catheter (PICC - a thin, flexible tube that is inserted into a vein in the upper arm and threaded into a large vein above the heart) when staff failed to perform the PICC dressing change every seven days. Findings included:- R22's Electronic Medical Record (EMR) included diagnosis of osteomyelitis (local or generalized infection of the bone and bone marrow) right femur (thigh bone). R22's Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of 14, indicating intact cognition. R22's MDS documented she required total assistance with most of her activities of daily living (ADLs). R22's Functional Abilities Self-Care and Mobility Care Area Assessment (CAA), dated 11/25/25, documentedresident required increased level of assistance with ADLs related to recent fracture (broken bone) and surgical repair of right femur. R22's Quarterly MDS, dated [DATE], documented a BIMS score of 14 indicating intact cognition. R22's MDS documented she received antibiotics, had received intravenous (IV-administered directly into the bloodstream via a vein) medications, and had an intravenous catheter (IV-catheter placed in a vein in order to administer medications or fluids directly into the blood stream). R22's Care Plan documented staff instructed to change the PICC line dressing weekly per order, dated 03/23/26. R22's Physician Orders, dated 04/14/25, lacked an order to change the PICC line dressing weekly. R22's Progress Note, dated 03/16/26 at 09:43 PM, documented PICC line dressing changed as dressing was peeling up. R22's Progress Note, dated 03/29/26 at 02:31 PM, documented dressing changed to PICC line right arm as dressing was peeling up. Redness noted at insertion site of the PICC line, no warmth noted to right arm. On 04/12/26 at 11:30 AM, R22 was seated in her wheelchair with her oral care supplies in front of her on the table. R22 reported she was on an IV antibiotic and showed her PICC line as she held up her right arm. Observed a dressing on right upper arm, dated 04/05/26. R22 reported she could not remember if the staff changed the PICC line dressing every week. On 04/13/26 at 09:00 AM, R22 was seated up in her bed eating ice cream and reported she was just trying to wake up. Observed the PICC line dressing on right arm dated 04/05/26 and that the dressing was peeling up. On 04/13/26 at 03:20 PM Licensed Nurse (LN) G assessed R22's dressing on her right arm and commented that the dressing would need to be changed as it was peeling up. LN G reported that a PICC line dressing would be changed every seven days and as needed and reported that a Registered Nurse was required to change the dressing. LN G reported that a physician's order would be in a residents EMR. LN G opened R22's EMR and reported that R22 did not have a physician's orders to change the PICC line dressing, so it would not be on the electronic medication administration record (EMAR) to alert staff that she required a dressing change. LN G reported that the dressing that was currently on R22's right arm documented 04/05 and she believed she was the nurse that changed that dressing. LN G reported that the dressing should have been changed on 04/12/26. On 04/14/26 at 12:45 PM, Administrative Nurse D reported she expected the nurse to complete a dressing change every seven days and as needed. Administrative Nurse D expected all residents with PICC lines to have an order for a PICC line dressing change. The facility's policy Central Vascular Access Device Dressing Change, dated 06/01/24, documented staff were to perform sterile dressing changes at least weekly or if the integrity of the dressing had been compromised.

Based on observation, interview, and record review, the facility failed to accurately post daily nurse staffing information for Registered Nurses, Licensed Practical Nurses, Certified Nurse Aides, the resident census, and the total number of scheduled hours and actual hours worked by each category for each shift, as required. Findings included:- On 04/12/26 at 09:15 AM, entering the facility, Licensed Nurse (LN) I reported the census of 38 residents and verified she was the charge nurse on duty. The Daily Posting of Nursing Hours Sheet, for Sunday, 04/12/26, documentation included a census of 44 residents and lacked entries for total scheduled hours for all categories of nursing staff. Review of the Daily Posting of Nursing Hours Sheet for 04/2025 through 04/12/26 documentation revealed a daily census of 44 residents and lacked entries for total scheduled hours for each shift by all categories of nursing staff. On 04/14/2026 2:40 PM, Administrative Staff A confirmed the census of 38 residents and the lack of total hours for each shift and category of nursing staff. She reported that she had created another form for posting the daily hours but did not realize the scheduled hours were required to be posted. Additionally, she stated the actual hours were not revised on the daily posting to reflect actual hours worked but were revised at the end of the day. The facility policy F732 Posting Direct Care Daily Staffing Numbers, dated 04/2026, documentation included the facility will post the following, daily for each shift: Facility Name, census, current date, and the total number of actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care each shift to include Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides. At the beginning of each shift, compute the number of direct care staff and complete the form and post.

The facility reported a census of 38 residents. Based on observations, interview, and record review, the facility failed to maintain and/or dispose of kitchen garbage and refuse properly. Findings included: - During a tour of the kitchen on 04/13/26 at 04:35 PM, observation revealed the outside garbage receptacle had three of six lids open. During an interview on 04/13/26 at 04:38 PM, Maintenance U stated the lids are always flying open due to the strong winds and they are supposed to be closed. During an interview on 04/13/26 at 04:45 PM, Administrative Nurse D reported staff are always outside closing the lids to the garbage bins, but the wind is a significant issue. Administrative Staff A stated she was aware of the issue with the garbage receptacle lids, but people eat their lunch in the back of the facility during the day, but the lids should be closed. The facility's policy Food-Related Garbage and Rubbish Disposal, dated 10/2025, states all garbage containers will have tight-fitting and must be kept covered when not in continuous use.

Based on observation, interview and record review, the facility failed to electronically submit complete and accurate staffing information through Payroll-Based Journaling (PBJ) related to weekend staffing. Findings included: - The PBJ Staffing Data Report revealed low weekend staffing for the following timeframes:Fiscal Year (FY) 2025, Quarter (Q) 2 (January 1 - March 31)FY 2025 Q3 (April 1 - June 30)FY 2025 Q4 (July 1 - September 30)FY 2026 Q1 (October 1 - December 31, 2025). On 04/14/2026 at 02:35 PM, Administrative Nurse D confirmed the inaccuracies of the PBJ data for the quarters identified above and stated she often worked the weekend as the RN on duty and said Administrative Nurse E works the weekends as well occasionally but she does not know if that time was accurately reported and reflected in the PBJ reports above quarters. On 04/14/2026 at 2:40 PM, Administrative Staff A reviewed the PBJ data submitted and confirmed the above noted reports flagged for low weekend staffing although she did not feel the report was accurate, due to the staffing they provided was consistent with the weekday staffing with few exceptions on the weekends. Administrative Staff A stated she did not understand why that report kept flagging even with adjustments to scheduling on the weekends. She stated she received reports that PBJ low weekend staffing was a coding issue at the corporate level and thought the issue had been resolved, however, she continues to get flagged for low weekend staffing and she is not sure why. The facility policy Payroll Based Journal F851 documentation, dated 04/2026, included community will submit payroll data in a uniform format to CMS including staffing information for community, agency, and contract staff. The submitted data should include the category of work for each person on direct care staff, including but not limited to whether the individual is a registered nurse, licensed practical nurse, certified nursing assistant, or other types of medical personnel.

The facility reported a census of 41 residents; the sample included four residents. Based on observation, interview, and record review, the facility failed to ensure residents remained free from significant medication errors when staff administered anti-anxiety medications (medications used to treat anxiety, which calm and relax individuals experiencing anxiety) incorrectly for Resident (R)1.Findings included:- R1's Electronic Medical Record (EMR) revealed the following diagnoses: schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R1's Annual Minimum Data Set [MDS], dated 02/26/25, documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. She received anti-anxiety medication during the assessment period. The Psychotropic Drug Use Care Area Assessment [CAA], dated 02/26/25, documented the resident was at risk for side effects related to psychotropic medications (any medication that affects behavior, mood, thoughts, or perceptions). R1's Quarterly MDS, dated [DATE], documented the resident had a BIMS score of 11, indicating moderately impaired cognition. She received anti-anxiety medication during the assessment period. R1's Care Plan, revised 10/31/25, instructed staff to monitor the resident for adverse side effects related to the use of psychotropic medications. R1's EMR under the Orders tab included the following physician's orders:Lorazepam (an anti-anxiety medication) 1 milligram (mg), by mouth (po), every day at bedtime (HS), for a diagnosis of anxiety, ordered 07/03/25.Lorazepam, 0.5 mg, po, twice daily (BID), for a diagnosis of anxiety, ordered 07/03/25. R1's November 2025 Medication Administration Record documented on 11/26/25, the resident received 1 mg of lorazepam at 08:00 AM instead of the 0.5 mg of lorazepam, as ordered by the physician. The facility's investigation noted on 11/26/25, Certified Medication Aide (CMA) R passed medications to R1 at 08:00 AM. Instead of administering the morning dose of lorazepam 0.5 mg for a diagnosis of anxiety, CMA R administered the nighttime dose of lorazepam 1 mg. The facility did not find the medication error until 11/26/25 at approximately 01:00 PM when another staff member prepared to administer R1's afternoon dose of lorazepam 0.5 mg. The facility called CMA R on the phone and had her return to the facility following the discovery of the medication error. CMA R reviewed the resident's medications as well as the Narcotic Count Sheet and confirmed she had given the wrong dose of lorazepam to the resident. On 01/13/26 at 11:03 AM, CMA R stated she gave the resident the wrong dose of lorazepam accidentally on 11/26/25. CMA R stated she had not checked the MAR and the medication card twice before administering the medication. On 01/13/26 at 12:57 PM, Administrative Nurse D confirmed the CMA R gave the resident the wrong dose of lorazepam on 11/26/25 at 08:00 AM. Administrative Nurse D stated that CMA R received re-education before working as a CMA again. Admin Nurse D said there were no further medication errors for R1. The facility policy for Use of Psychotropic Drugs, revised 04/2025, documents that medication shall be given according to the physician's orders.

The facility reported a census of 29 residents. Based on record review and interview, the facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) with complete and accurate direct staffing information based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS i.e., Payroll Base Journal (PBJ), related to licensed nursing licensed and certified nursing staffing information when the facility failed to accurately report weekend staffing for the third quarter 2023 April through June. Findings included: Review of the nursing staff schedule for the third quarter 2023 April through June, revealed lack of completed daily staff postings for May 28, 29 and 30. Review of the PBJ Staffing Data Report for the third quarter 2023, revealed the PBJ triggered for Excessively Low weekend Staffing. Interview, on 06/12/24 at 02:20 PM, with Administrative Staff A, revealed the system used in 2023 for documentation of nursing staff hour may have caused errors in reporting on the PBJ report. The facility utilized a new reporting system and did not have a policy for the system used in 2023. The facility failed to accurately report weekend staffing for the third quarter 2023, April through June 2023 as required.

The facility reported a census of 29 residents. Based on observation, interview and record review, the facility failed ensure a plan to monitor the effectiveness of recommended measures put in place following identification of positive Legionella (a pneumonia [lung infection] bacteria found in water) detected in the facility water system in March 2024 and April 2024. In addition, the facility failed to ensure five combs and one hair brush were stored in a sanitary manner in the beauty shop. Findings included: - The CDC (Center for Disease Control) indicated the following guidelines for significance of Legionella concentrations: Well controlled growth in potable water (drinking water) detectable levels to 0.9 CFU/ml (Colony Forming Units/milliliter) and in non-potable water the detectable level is to 9 CFU/ml. Poorly controlled growth in potable water with measures of 1.0-9.9 CFU/ml and in non-potable water, the level is 10-99 CFU/ml. Uncontrolled growth in potable water greater than 10 CFU/ml in potable water and greater than 100 CFU/ml in non-potable water. Change in concentration over time indicates that Legionella growth appears: Legionella well controlled at concentrations steady at 0.5CFU/ml for two samplings. Poorly controlled if there is a 10-fold increase in concentrations. Uncontrolled if there is a 100-fold or greater increase in concentrations. Review of the Legionella Testing and Remediation, documented the facility obtained water test results for water collected on 02/12/24, on 02/21/24. The testing revealed the following three positive test results for Legionella (Legionella pneumophilia ): 1. Water tested in the Therapy room contained a positive result of 2.2 CFU/ml (Colony Forming Units/milliliter). Results of 1.0-9.9 in potable (drinking) water indicated poorly controlled growth and well controlled CFU/ml in nonpotable water. 2. Water tested in the whirlpool (nonpotable) contained a result of 25 CFU/ml which indicated poorly controlled growth (10-99). 3. Water tested in the kitchen sink contained a positive result of 11 CFU/ml which indicate poorly controlled growth for potable water. The facility routinely flushed the water heaters monthly with previous flush 02/01/24 per the Work History Report Task Completed. Retest of the facility water, 03/13/24, revealed the following two positive test results, reported on 03/22/24 by the water testing company. 1. Results of water tested in the shower room revealed a positive result of 22 CFU/ml which the testing company report indicated uncontrolled growth by the CDC. 2. Results of the water in the water heater, revealed a positive result of 0.2 CFU/ml, which indicated well controlled by the CDC. The testing company recommended a temperature adjustment to 130 degrees Fahrenheit on the water heater and if detected growth persists, to drain the tank, flush and inspect for sediment or mineral buildup. The testing company did not indicate when to retest the water in this report. Interview, on 06/11/24 at 04:20 PM, with Administrative Staff A, revealed the facility drained the hot water tanks, flushed them, cleaned the tanks, and increased the water temperature to 130 degrees Fahrenheit on 03/31/24. Administrative Staff A stated the facility drained the hot water tanks monthly. Interview on 06/12/24 at 12:20 PM, with Administrative Staff A, revealed the facility did not retest the water since the 03/22/24 report, and would contact the water testing company to determine a retesting recommendation date at that time. Interview, on 06/12/24 at 01:30 PM, with Administrative Staff A, revealed the water testing company recommended a three month follow up test in June 2024. Interview, on 06/12/24 at 02:30 PM, with Maintenance Staff U, revealed with the monthly flushing of the hot water heater, he did not notice sediment. The facility policy Water Management, Legionella Testing reviewed 01/2024, instructed staff the facility handles and maintains the water supply in accordance with recommendations of the CDC, Healthcare Infection Control Practices Advisory Committee, and the FDA (Food and Drug Administration). The facility will demonstrate measures to minimize the risk of Legionella and other pathogens in the water system through the water management program. The facility failed staff failed to enact follow up monitoring to ensure the effectiveness of the increase in hot water temperature and monthly draining, flushing and inspection of the hot water heaters, to provide a sanitary water supply for the residents to prevent water borne illness. 36881 - On 06/12/24 at 12:58 PM, during the environmental tour of the beauty shop with Maintenance Staff V, observation identified an unlabeled hairbrush and five unlabeled combs that had hair which remained in the bristles of the brush and teeth. Maintenance staff V confirmed the findings and reported he did not know who was responsible for sanitizing and storing the personal care items stored in the beauty shop. He agreed the items should be labeled, sanitized, and stored to prevent cross contamination and the spread of infection between residents. He reported the facility also used the beauty shop area to provide restorative nursing programs for multiple residents and the beauty shop was available for use by all residents of the facility. On 06/12/24 at 03:37 PM, Administrative Staff A, stated she expected the staff to sanitize, label, and store resident's personal hygiene items such as brushes and combs and to prevent cross contamination and prevent infection. She stated the facility had identified the need to clean the cabinets of the beauty shop on their environmental tour on 05/22/24 but had not implemented the plan to date. Administrative Staff A stated she was not sure who was responsible for maintain the community's beauty shop, to ensure proper sanitation and storage of personal care items. The facility lacked a policy to address sanitizing, labeling, and storage of personal hygiene care items tin the beauty shop to prevent cross contamination and the spread of infection. The facility failed to prevent cross contamination and the spread of infection related to the maintaining sanitary storage of personal hygiene supplies in the beauty shop for the residents of the facility.

The facility reported a census of 29 residents with 13 residents sampled, including five residents reviewed for unnecessary medications. Based on interview and record review, the facility failed to ensure appropriate monitoring of psychotropic medications (a medication which affects behavior, mood, thoughts, or perception) for one Resident (R)5, regarding the use of anti-depressant medications (medications used to treat depression). Findings included: - Review of Resident (R)5's electronic medical record (EMR) revealed the following diagnoses: auditory hallucinations (when a person hears voices or noises that don't exist in reality), major depressive disorder (MDD-a major mood disorder) and psychosis (any major mental disorder characterized by a gross impairment in reality perception). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. She received anti-depressant medications (medications used to treat depression) seven days of the seven day look back period. The Psychotropic Drug Care Area Assessment (CAA), dated 06/07/23, documented the resident received anti-depressant medications. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of 15, indicating intact cognition. She received anti-depressant medications during the assessment period. The care plan for anti-depressant medication use, instructed staff to monitor for side effects and effectiveness of the resident's anti-depressant medication. Review of the resident's EMR revealed the following physician orders: Bupropion (an anti-depressant medication), 300 milligrams (mg), by mouth (po), every day (QD) for MDD with psychotic symptoms, ordered 03/09/24. Wellbutrin (an anti-depressant medication), 150 mg, po, QD for MDD, ordered 03/09/24. Effexor (an anti-depressant medication), 150 mg, po, twice daily (BID) for MDD, ordered 04/11/22. Review of the resident's EMR lacked documentation of side effects and/or effectiveness of the anti-depressant medications. On 06/12/24 at 11:03 AM, Administrative Nurse D confirmed the lack of monitoring for the anti-depressant medications for this resident. The facility policy for Psychotropic Drug Use, revised 04/2024, included: Staff shall review each resident's medication regime and initiate the appropriate monitoring for each classification of drug, including targeted behaviors. The facility failed to appropriately monitor the use of anti-depressant medications for this dependent resident.

The facility reported a census of 36 residents, with 12 sampled, including four residents sampled for pressure ulcers. Based on observation, interview, and record review, the facility failed to provide care consistent with professional standards to prevent pressure ulcers (PU, localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) by failure to perform skin assessments under a medical immobilization device for Resident (R) 3, allowing an unstageable (full thickness tissue loss in which actual. depth of the ulcer is completely obscured) PU to develop. Findings included: - The 11/28/22 Electronic Health Record (EHR) documented R3 had the following diagnoses: fracture of the left tibia (bone of the lower leg) and fibula (one of the two bones of the lower leg) shafts on the left side, hemiparesis (muscular weakness of one half of the body) on the left, hemiplegia (paralysis of one side of the body) on the left, and peripheral vascular disease (PVD- abnormal condition affecting the blood vessels). The 10/19/22 Admission Minimum Data Set (MDS) documented a brief interview for mental status (BIMS) of 12, indicating moderately impaired cognition. R3 required extensive to total assistance of two staff for all activities of daily living (ADL). The MDS noted R3 had a pressure reducing device for the chair and the bed, and R3 had one stage two (expands into deeper layers of the skin. It can look like a scrape, abrasion, blister, or a shallow crater in the skin) PU present on admission. The 11/07/22 Interim Payment Assessment MDS documented a BIMS of 13, indicating intact cognition. R3 had no PU. The 10/19/22 ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) documented R3 on admission needed nearly total assistance with ADL but R3 had improved with therapy and required limited to extensive assistance with most ADL. The 10/19/22 Pressure Ulcer CAA, documented R3 admitted with a stage two PU to the right trochanter (hip area) that had healed since admission. Licensed staff should perform a skin assessment weekly and observations of skin by care staff with cares. R3 required an immobilizer to her left lower extremity (LLE). The 11/14/22 Care Plan documented R3 had an actual impairment to skin integrity related to a medical device (immobilizer to LLE). Staff were to perform daily skin and circulatory checks to the LLE related to the immobilizer. The EHR Physician Orders lacked documentation of daily skin assessments from 10/12/22 until an order dated 11/14/22 which instructed staff to loosen the immobilizer to assess skin daily. On 11/09/22, the Daily Skilled Progress Note documented R3 received skilled nursing and skilled nursing services. The resident required assistance of two staff for transfers, bed mobility and toileting. The resident had an immobilizer in place to her left leg. On 11/11/22, the Daily Skilled Progress Note documented R3's skin was warm, dry, and intact, and the immobilizer to right leg remained in place. On 11/12/22, the Daily Skilled Progress Note documented R3 continued to receive skilled services. She required assistance of two staff for transfers and toileting. The immobilizer remained in place to her LLE due to fractures. On 11/13/22, the Progress Note documented the resident had an unstageable pressure injury to her left lateral malleolus (the bony prominence of the ankle), related to a medical device. The resident had a tibia/fibula fracture and had an immobilizer in place. The wound measurements/description documented as 2.3 cm by 1.5 cm (centimeters), circular in dimension. The wound bed had 100 percent (%) firmly adherent yellow/tan slough (dead tissue, usually cream or yellow in color). The wound edges were defined and attached to the wound base. The area cleansed with normal saline, plurogel (wound dressing) applied to the wound bed to promote autolytic debridement (a form of wound removal of dead, damaged, or infected tissue). The wound covered with Opti foam gentle (a foam dressing with a silicone adhesive border). The resident complained of pain during the dressing change, rated six out of 10 (pain scale). Staff administered as needed (PRN) oxycodone (narcotic medication used for severe pain). On 11/28/22, the Progress Note documented R3 started on Keflex (an antibiotic) 500 mg (milligram) for the wound to the LLE. The weekly Skin Assessments documented the following: On 10/22/22, noted the skin was intact. PU to right trochanter healing well. On 10/23/22 the resident has stage two PU to the right trochanter, present on admission is now closed. On 10/29/22, noted R3's skin was intact. On 11/05/22, noted R3 had skin tears, On 11/12/22, noted R3 only had redness behind her left thigh. On 11/29/22 at 08:24 AM, observed Licensed Nurse (LN) G perform a dressing change to R3's left outer ankle. LN G stated she did not measure the wounds because the director of nursing (DON) measured wounds weekly. On 11/29/22 at 02:03 PM, R3 sat in the common area, and wore an immobilizer on her LLE. On 11/29/22 at 08:45 AM, R3 stated she was mad at the facility because they made her get the wound on her leg. On 11/30/22 at 09:45 AM Certified Nurse Aide (CNA) M stated R3 came to the facility with the immobilizer on her left leg and at first the CNAs were not allowed to take it off, even at night. CNA M stated she did know R3 had a wound, and it was on her left, weaker side, so R3 may not have even felt the sore start. On 11/30/22 at 11:46 AM, LN H revealed R3 had little feeling to her left side, so she was probably unable to know the wound was forming. LN H stated when she completed the wound care, sometimes, she would measure it and give it to the DON who measured them weekly. On 11/30/22 at 11:57 AM, Administrative Nurse D revealed she expected her or her staff to have noted the unstageable PU to R3's left outer ankle with the skin assessments. Administrative Nurse D confirmed she did not believe the unstageable PU could have developed in the day or two that the documentation noted in the assessments. Administrative Nurse D stated as soon as it was brought to her attention, she obtained orders for dressings and assessments. On 12/01/22 at 11:51 AM, Physician GG reported the pressure ulcer should not have progressed from intact skin to an unstageable pressure ulcer as it did. The facility's Skin Integrity, Pressure Injuries Nursing Protocol policy, revised May 2022, documented staff were to identify residents at risk for developing PU on admission, and should implement, monitor, and modify interventions to attempt to reduce or remove underlying risk factors. Staff were to implement interventions for the prevention and care of skin issues. The facility failed to identify and provide care consistent with professional standard of practice, to prevent the development of an unstageable pressure ulcers for R3.

The facility census totaled 36 residents, with 12 sampled, including five residents sampled for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure adequate follow-up of the consultant pharmacist recommendations regarding Depakote (anti-convulsant medication, sometimes used for the manic episodes associated with bipolar) for Resident (R) 10, regarding decreasing the dose of this medication. This failure placed the resident at risk for adverse effects related to medication use. Findings Included: - R10's 11/29/22 Electronic Health Record (EHR), documented diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and major depressive disorder (major mood disorder). The 07/15/22 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 99, and per staff R10 had long and short-term memory problems which indicated moderately impaired cognition. The assessment documented the use of an antidepressant and diuretic medication daily for R10. The 10/21/22 Quarterly Minimum Data Set (MDS) documented a BIMS score of eight which indicated moderately impaired cognition. The assessment documented the use of an antianxiety medication once during the seven day look back period and antidepressant and diuretic daily for R10. The Physicians Orders documented an order dated 04/14/21 for Depakote, 250 milligrams (mg) three times a day for anxiety. Review of the monthly Pharmacy Medication Record Review (MRR) for May 2021 through November 2022 documented a recommendation on 05/17/22 to reevaluate the dose of Depakote and consider a reduction to 250 mg twice a day. The provider signed the recommendation in agreement on 06/16/22, 30 days after recommendation made. Review of the EMAR (Electronic Medication Record), from 06/16/22 thru 11/30/22 documented that R10 received Depakote 250 mg three times daily, the dosage was never implemented. On 11/29/22 at 03:37 PM, R10 sat in her wheelchair in the common area, was pleasant and visited with both staff members and other residents. On 11/29/22 at 02:08 PM, Licensed Nurse (LN) G stated the director of nursing (DON) should handle the MRR's for R10. On 11/30/22 at 07:38 AM, Administrative Staff D confirmed she was responsible for completion of the MRR's. She stated she had some issues with the timeliness of the providers processing the MRRs. She stated she would get them to the provider and the nurses would process the signed orders. She confirmed the 05/17/22 recommendation had been signed by the provider and not implemented for R10. On 12/01/22 at 02:36 PM, Consultant Staff HH confirmed the facility had issues with timely responses to the recommendations. He stated the facility had an issue with getting documents scanned into their EHR in a timely manner. The facilities May 2022 Pharmacy Services policy documented the facility staff were to work with the consultant pharmacist in the collaboration to ensure each resident received the appropriate medications for the appropriate diagnosis and length of administration. The facility failed to act upon the consultant pharmacist identified recommendations for a gradual dose reduction in a timely manner for R10 by the failure to decrease the Depakote when recommended.

The facility census totaled 36 residents, with 12 sampled, including five residents sampled for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure reduction in Depakote (anti-convulsant medication, sometimes used for the manic episodes associated with bipolar) for Resident (R) 10, by not decreasing the medication as ordered. This failure placed the resident at risk for adverse effects related to medication use. Findings Included: - R10's 11/29/22 Electronic Health Record (EHR), documented diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and major depressive disorder (major mood disorder). The 07/15/22 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 99, and per staff R10 had long and short-term memory problems which indicated moderately impaired cognition. The assessment documented the use of an antidepressant and diuretic medication daily for R10. The 10/21/22 Quarterly Minimum Data Set (MDS) documented a BIMS score of eight which indicated moderately impaired cognition. The assessment documented the use of an antianxiety medication once during the seven day look back period and antidepressant and diuretic daily for R10. The Physicians Orders documented an order dated 04/14/21 for Depakote, 250 milligrams (mg) three times a day for anxiety. Review of the monthly Pharmacy Medication Record Review (MRR) for May 2021 through November 2022 documented a recommendation on 05/17/22 to reevaluate the dose of Depakote and consider a reduction to 250 mg twice a day. The provider signed the recommendation in agreement on 06/16/22, 30 days after recommendation made. Review of the EMAR (Electronic Medication Record), from 06/16/22 thru 11/30/22 documented that R10 received Depakote 250 mg three times daily, the dosage was never implemented. On 11/29/22 at 03:37 PM, R10 sat in her wheelchair in the common area, was pleasant and visited with both staff members and other residents. On 11/29/22 at 02:08 PM, Licensed Nurse (LN) G confirmed R10 took Depakote 250 mg three times daily. On 11/30/22 at 07:38 AM, Administrative Staff D confirmed the 05/17/22 recommendation had been signed by the provider and not implemented for R10. The facilities May 2022 Pharmacy Services policy documented the facility staff were to work with the consultant pharmacist in the collaboration to ensure each resident received the appropriate medications for the appropriate diagnosis and length of administration. The facility failed to act upon the provider signed recommendation for a gradual dose reduction in a timely manner for R10 by the failure to decrease the Depakote when ordered, that resulted in an increased risk for adverse effects related to medication.

The facility reported a census of 35 residents and identified two as elopement risks who were reviewed for accidents. Based on record review and interview, the facility failed to provide adequate supervision and/or assistive devices, to prevent one of the two sampled residents, Resident (R)1, from leaving the facility without staff knowledge, when she went through the unlocked/cracked open door into the kitchen, which was previously disarmed, then on through the kitchen, and exited through the unlocked back kitchen exit door. Findings included: - R1's signed Physician Orders (PO), dated 09/09/21, documented the resident had a diagnosis of dementia with behavioral disturbance (a chronic or persistent disorder of the mental processes caused by brain disease marked by memory disorders, personality changes, and impaired reasoning). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident with short and long term memory problems, moderately impaired cognitive skills for daily decision making, and fluctuating disorganized thinking. The resident was ambulatory and had wandering behaviors one to three days during the seven-day assessment period. The Baseline Care plan, dated 09/09/21, documented the staff identified the resident as a fall risk, but did not identify her as an elopement risk at that time. An Admission Elopement Evaluation, dated 09/08/21, documented the resident lacked safety awareness of her current situation. The resident had not attempted to elope from the facility and was given a score of 10 or low risk of elopement. An Elopement Evaluation, dated 09/14/21, documented the resident with a history of wandering in the facility, lacked safety awareness of current situations and staff placed a Wanderguard on the resident for safety. A Nursing Note, dated 09/14/21 at 12:20 PM, documented by Administrative Nursing Staff D, revealed the resident with paranoid delusions and she attempted to elope (leave the facility) twice. The staff placed a Wanderguard (personal alarm activator bracelet) on the resident's right wrist and she was kept in visual contact of staff. A Social Services Admission Note, dated 09/15/21 at 12:09 PM, documented by Social Services Staff (SS) X, revealed the resident wandered in the facility on one to three days. R1's wandering behaviors placed her at risk for getting into a potentially dangerous place. Review of the facility's video footage, dated 09/17/21, with Administrative Staff A, revealed at approximately 06:53 PM, R1 sitting in a recliner by the nurse's station watching tv. The staff performed various duties with other residents within the camera's view and walked back and forth. R1 remained calm and continued to watch tv until 06:57 PM, when she got up out of the chair and walked toward the dining room area and out of view by the camera's range. At that time, staff were not in the area. At 07:08 PM, Certified Medication Aide (CMA) R escorted R1 back into the facility through the service entrance door which exited to the back of the facility. The resident walked in independently with CMA R and sat down in a chair by the nurse's station. She appeared to be calm and without injury. Interview, on 10/04/21 at 10:22 AM, with Administrative Staff A, revealed after the resident got up from the chair, she walked to the dining room door which entered into the kitchen. The door had a Wanderguard alarm attached to it, but at the time she went through the door, someone had previously unplugged and disarmed the alarm. The kitchen door sat unlocked and cracked open, allowing the resident direct access into the kitchen without staff knowledge. The kitchen staff left around 07:00 PM and no staff were in the kitchen at the time R1 exited through the kitchen. R1 entered the kitchen and walked straight to the kitchen's back exit door, also unlocked, and out of the facility, without staff knowledge. Administrative Staff A further explained that the kitchen staff should have locked the outside kitchen door before leaving at the end of their shift. When the resident exited through the back door from the kitchen. She walked approximately 150 yards through a backyard to the apartment building next door. Certified Medication Aide (CMA) R happened to go outside through the staff's side service door for a break and noticed R1 standing in the backyard of the apartment building. CMA R alerted Licensed Nurse (LN) G, who immediately responded and assisted CMA R to escort R1 back into the building. LN G assessed the resident and found no signs of injury. Facility policy did not address residents eloping from the facility due to disarmed door alarms and unlocked doors. The facility failed to provide adequate supervision and/or assistive devices to prevent R1 from exiting the building without staff knowledge, after going through an unlocked/cracked open door into the kitchen where the Wanderguard alarm was previously disarmed, going through the kitchen, and then out the unlocked back door exit of the kitchen, placing the resident at risk for accidents outside of the facility.

The facility reported a census of 34 residents. Based on observation and interview, the facility failed to store, prepare, and serve food under sanitary conditions to the residents of the facility. Findings included: - During a tour of the dietary department on 06/23/21 at 08:52 AM, dietary staff BB revealed the following items/areas in need of cleaning: 1.) The microwave had food debris on the glass plate turntable and the area above the turntable had food debris. 2.) The air conditioner unit near the food prep area had a thick layer of brown dust. 3.) The metal shelves located on each side of the dishwasher had rust and grime buildup, and chipping paint. On 06/29/21 at 02:30 PM, dietary staff BB stated the facility had a dietary cleaning schedule, and the dietary staff should follow the cleaning schedule. She confirmed these areas required cleaning. The facility policy, Sanitization, dated 02/21, documented all kitchen areas shall be kept clean .Kitchen surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. The facility failed to store, prepare, distribute, and serve food under sanitary conditions for the residents of the facility.

The facility reported a census of 31 residents, which included three residents reviewed for neglect. Based on interview and record review, the facility failed to provide toileting assistance in a timely manner for Resident (R) 1, who was left on a bedpan for an extensive amount of time (approximately seven hours), placing the resident in immediate jeopardy. This deficient practice resulted in a large deep tissue injury (DTI - a pressure-related injury to subcutaneous tissues under intact skin. Initially, these [MEDICAL CONDITION] have the appearance of a deep bruise. These [MEDICAL CONDITION] may indicate the subsequent development of a stage 3-4 pressure ulcer even with optimal treatment,) which measured 17 centimeters (cm) x 25 cm. Findings included: - R1's signed Physician Order, dated 12/20/20, documented the resident admitted to the facility on [DATE], with [DIAGNOSES REDACTED].) The Significant Change Minimum Data Set, (MDS), dated [DATE], assessed R1 with a Brief Interview of Mental Status (BIMS) score of 99, which indicated the resident did not complete the interview. R1 did not reject care and required extensive assist of two or more staff for bed mobility, transfers, dressing, toileting, and personal hygiene. The ADL (activities of daily living) Care Area Assessment (CAA), dated 12/10/20, revealed R1 required extensive to total assist with ADLs. R1 required a mechanical lift for transfers at that time. Resident had a right above the knee amputation. Resident was able to reposition self slightly with help. The Urinary Incontinence and Indwelling Catheter CAA, dated 12/10/20, revealed the resident needed extensive assist with toileting. R1 wore incontinence products for dignity, was frequently incontinent, asked to toilet at times, and asked specifically for a bedpan at times. The Pressure Ulcer/Injury CAA, dated 12/10/20, revealed R1 needed assistance with bed mobility, at times refused to reposition, and then would not stay in the position very long. R1 liked to lie on her back. The resident had incontinence and history of excoriation to her buttocks. She had two wounds with vascular concerns to the left lower extremity. She had a pressure relieving mattress on the bed and cushion to her wheelchair. She currently had one stage one (pressure injuries characterized by superficial reddening of the skin, that when pressed does not turn white) pressure area to her left buttock, a stage three (full thickness skin loss potentially extending into the subcutaneous tissue layer.) to her coccyx, and a stage three to right buttock. The Care Plan, dated 12/03/18 and revised on 12/28/20 revealed R1 was at risk for skin breakdown related to dementia, diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), impaired mobility, and pressure ulcers. The Care Plan listed the following interventions: 1. Assess for and provide appropriate pressure-relieving devices as per physical and occupational recommendations-chair cushion and mattress. 2. Conduct weekly skin inspection and complete weekly wound report if indicated. 3. Continue to encourage repositioning every 2 hours to relieve pressure to buttocks and feet though she frequently chooses not to. 4. Continue air mattress and lay resident down frequently between meals to offload pressure from buttocks. (resident not always compliant with this.) Keep buttocks dry and open to air at night. 5. Monitor buttocks every shift for redness and report to doctor with any problems. 6. Complete Braden Scale per facility policy, 7. R1 is to be last up, and first down for all meals. No longer than one hour per meal. 8. R1 was to be turned and repositioned every two hours, utilizing pillows. 9. Observe skin daily with cares and notify the charge nurse of any concerns. 10. Provide thorough skin care after incontinence episodes and apply barrier cream as needed. The care plan lacked any instruction to facility staff regarding the residents use of a bed pan. 11. Deep Tissue Injury to right buttock and sacrum: skin prep twice daily and turn and reposition hourly utilizing wedge. Update: discontinue skin prep and provide treatment as ordered to the wound. Updated 01/18/21: Buttock area of wound has resolved. Sacral area is now a stage four (full thickness tissue loss with exposed bone, tendon, or muscle). Continue to treat as ordered. The Progress Note, dated 12/28/20 at 01:15 PM indicated R1 had a right buttock wound measuring 17 cm (centimeters) by 25 cm, a right buttock blister measuring 1 cm by 1 cm; no staging noted. Date first observed 12/27/20, no exudate (drainage), the surrounding skin reddened, treatment changed, see the physician orders, specialty bed and positioning device in place. The Progress Note, dated 12/28/20 at 01:24 PM documented a new wound/bruising obtained on 12/27/20 assessed by Administrative Nurse D. R1 had an area of bruising shaped in an inverted L. Bruising is deep red/purple with no blanching noted. Resident exhibited no signs or symptoms of pain upon assessment. Also noted to right buttock was an intact fluid filled blister. Staff applied skin prep to all areas. On 01/27/21 at 07:48 AM, Certified Nurse Aide (CNA) R, reported she and CNA S checked the resident on 12/26/20 at approximately 09:15 PM. They changed R1's bed linen. R1 was not on the bed pan at that time. CNA R reported R1 was found on the bed pan at approximately 05:30 AM. CNA R reported R1's buttocks appeared black/blue from sitting on the bed pan so long. On 01/27/21 at 10:16 AM, CNA T, reported she came to work at 10:00 PM and did not complete a bed check. CNA T and CNA R found R1 at approximately 05:30 AM on 12/27/20 on a bedpan. CNA T revealed R1's buttocks were bluish and with reddened areas to the hip. On 01/27/21 at 10:18 AM, CNA P reported staff answered R1's call light at 02:00 AM on 12/27/20. R1 requested a drink of water. CNA P did not reposition resident or check for incontinence, at that time. On 01/27/21 at 10:20 AM, CNA S reported she and CNA R completed a bed check on R1. CNA S reported they changed the bed linens at approximately 09:15 PM. R1 did not wear a brief at nighttime per the care plan. R1 was not on the bed pan at that time. Per a Witness Statement, dated 01/27/21, Licensed Nurse (LN) I, documented during 04:00 AM rounds, the CNAs called me to R1's room to see she had been left on the bedpan all night and there was a large non-blanching L shaped red mark across her sacrum and buttocks. On 01/27/21 at 07:14 AM, LN J reported the resident's health declined and should not be left on the bed pan unattended. On 01/27/21 at 09:30:00 AM, Administrative Nurse D reported she expected staff to reposition the resident every two hours. R1 should not have been left alone on the bedpan. The wounds appeared to be from sitting on a bedpan . On 01/27/21 at 09:45 AM, Physician GG reported facility staff notified him of the incident and he referred R1 to the nurse practitioner for wound care. On 02/01/21 at 10:35 AM, Physician Extender HH reported R1 had an area consistent with being left on the bedpan for an extended amount of time. She revealed the wound progressed to a stage four. The facility policy, Bedpan/Urinal, Offering/Removing, dated 01/2020, documented to not allow the resident to sit on a bedpan for extended periods. (Note: This is not only uncomfortable to the resident, it also caused skin breakdown.) The facility failed to provide toileting assistance in a timely manner for resident (R) 1, who was left on a bedpan for an extensive amount of time (approximately seven hours), placing the resident in immediate jeopardy. This deficient practice resulted in a large deep tissue injury, which measured 17 cm x 25 cm. This deficiency was cited as past non-compliance, as of 12/30/20 at 12:00 PM when the facility completed the following: 1. Education to nursing staff began at approximately 11:00 am on 12/28/20 and nursing staff educated by 10:30 PM. Statements and questioning obtained from staff related to incident by Nursing Administration with ongoing education. 2. New orders processed; interventions put into place for resident R1 by approximately 11:00 am on 12/28/20. 3. Nursing Administration completed audit of residents in house for complete skin assessment on 12/29/20 by approximately 2:00 PM. 4. A Quality Assurance Performance Improvement meeting held with Medical Director at approximately 12:00 PM on 12/30/20 with root cause analysis being that resident was unintentionally left on the bedpan by evidence of investigation.

The facility reported a census of 42 residents with three residents reviewed for skin conditions. Based on observation, interview, and record review the facility failed to ensure one of the three residents reviewed, Resident (R)3, received care to promote healing and prevent further breakdown when facility staff failed to provide timely treatment for two facility acquired stage two pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with hear and /or friction), failed to ensure placement of preventative devices on the resident's bed, failed to notify the facility the resident transferred to of the resident's pressure ulcers, and failed to provide timely treatment to the pressure ulcers when R(3) readmitted to the facility. The pressure ulcers advanced to stage three areas (full-thickness loss of skin usually over a bony prominence, as a result of pressure, or pressure in combination with hear and /or friction) when R3 readmitted to the facility. Findings included: - The Order Summary Report, dated 10/15/20, for Resident (R)3, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set, (MDS), dated [DATE], assessed R3 with a Brief Interview of Mental Status (BIMS) score of five, indicating severe cognitive impairment. R3 did not reject care and required extensive assistance of two or more staff for bed mobility. R3 required total dependence on staff for transfers, required extensive assist of two or more staff for toilet use, and was frequently incontinent of bowel and bladder. She had a pressure ulcer/injury/scar over a bony prominence or a non-removable dressing/device and a risk for development of pressure ulcers. R3 had no pressure ulcers present at the time of the assessment, had a pressure reducing device for her bed and chair, was not on a turning and repositioning program, and received application of ointments/medications other than to her feet. The ADL [activities of daily living] Care Area Assessment (CAA), dated 07/20/20, revealed R3 required extensive to total assistance with ADLs and staff used a mechanical lift for transfers, she repositioned herself with help, but required extensive to total assistance for transfers, mobility, and toileting. The Pressure Ulcer/Injury CAA, dated 07/20/20, revealed R3 required assistance with bed mobility and at times she refused to be repositioned, or allowed repositioning and then did not stay in the position for very long. She liked to lie on her back and was encouraged to turn from side to side. R3 also enjoyed sitting in her wheelchair, had incontinence, and a history of excoriation to her buttocks. The resident had a pressure relieving mattress on her bed and a cushion to her wheelchair. She had a risk for development of pressure ulcers and had no pressure areas present. Licensed Nursing (LN) staff completed a weekly skin assessment and Certified Nurse Aide (CNA) staff completed daily observations. The Quarterly MDS, dated [DATE], assessed R3 with a BIMS score of 5, which indicated severely impaired cognition. R3 did not reject care and required extensive assistance of two or more staff for bed mobility, transfers, and toilet use. She was occasionally incontinent of urine and always continent of bowel. R3 was at risk for development of pressure ulcers and did not have any pressure ulcers present. The resident had a pressure reducing device to her bed and chair, was not on a turning/repositioning program, and received application of ointments/medications other than to her feet. The Care Plan, dated 12/03/18 and revised 10/23/19 revealed R3 was at risk for skin breakdown related to dementia, diabetes mellitus, impaired mobility, and history of diabetic and pressure ulcers. The Care Plan listed the following interventions: 1. Assess for and provide appropriate pressure-relieving devices as per physical and occupational therapy recommendations-chair cushion and mattress. 2. Check air mattress setting every shift and use R3's current weight to determine inflation setting. 3. Continue to encourage repositioning every two hours to relieve pressure to buttocks and feet though she frequently chose not to. 4. Continue the air mattress and lay resident down frequently between meals to offload pressure from buttocks (not always compliant with this). Keep buttocks dry and open to air at night and monitor buttocks every shift for redness and report to the physician any problems. 5. Provide thorough skin care after incontinence episodes and apply barrier cream as needed. 6. R3 was often noncompliant with lying down and turning onto side. 7. Conduct weekly skin inspection and complete a weekly wound report if indicated. 8. Observe skin daily with cares and notify the charge nurse of any concerns. 9. On 09/06/19, R3 had a pressure ulcer to her buttocks that was open on re-admit from the hospital, provide treatment as ordered, and encourage resident to be off buttocks as able. The Care Plan, revised on 04/03/17, for impaired physical functioning deficit, included the following interventions revised on 10/23/19: 1. R3 required assistance of one to two staff for bed mobility. 2. R3 required assistance of two staff and the mechanical lift for transfers. 3. R3 required toileting assistance of two staff and the mechanical lift, at times would choose to use the bed pan. The Care Plan, for alteration in elimination of bowel and bladder, related to incontinence, revised on 08/17/19, included the following interventions dated 10/23/19: 1. The staff were to provide assistance with incontinence care as needed. 2. R3 wore briefs for incontinence. 3. Monitor and report changes in skin integrity. The Weekly Skin Condition Report, under the assessment tab in the electronic medical record (EMR), dated 11/04/20 revealed R3 had facility acquired stage two pressure ulcers to her coccyx and her right buttocks that was not present on the 10/29/20 weekly skin evaluation. The area to the coccyx measured 1centimeter (cm) length by 1 cm width, and depth was less than 0.1 cm. The wound had a moderate amount of serous (mostly clear or slightly yellow) drainage and the surrounding skin had maceration (softening and breaking down of skin as a result from prolonged exposure to moisture, such as sweat, urine, feces, or wounds for extended periods). The right buttocks measured 1.5 cm by 1 cm and had a moderate amount of serous drainage and the surrounding skin had maceration. The documentation lacked evidence staff notified the physician. Review of the EMR lacked treatment orders for the area to the coccyx and right buttocks, which the resident acquired on 11/04/20. The care plan further lacked new interventions for treatment and risk of further breakdown. The EMR included a Physician Order, dated 05/05/20, for barrier cream to the bilateral buttocks every shift until wound resolved, and to check the air mattress setting twice daily, using current weight to determine inflations setting every day and evening. Review of the EMR revealed R3 had a stage two pressure area that developed to the left buttocks on 05/05/20 and resolved on 05/20/20 and a stage two to the right buttocks that developed on 05/05/20 and resolved on 05/27/20. The barrier cream order was not discontinued on 11/08/20. The EMR, dated 11/08/20, revealed an MDS Discharge Assessment that documented R3 discharged from the facility with return anticipated. The Progress Note, dated 11/08/20 at 02:01 AM indicated R3 left the facility at 01:45 AM with EMS (emergency medical service) to the local hospital The eInteract Transfer Form, dated 11/08/20, lacked any skin condition documentation for R3. The facility failed to communicate to the receiving facility that R3 had pressure ulcers present. An Entry MDS, dated [DATE], indicated R3 returned to the facility. The Weekly Skin Condition Report, dated 11/10/20, indicated R3's pressure area to her coccyx advanced to a stage three area. The area measured 1 cm by 1 cm and was 0.2cm deep. The wound had a moderate amount of serosanguinous (yellowish fluid with small amount of blood) drainage, the wound bed had slough present (dead tissue, usually cream or yellow in color), and the surrounding skin was red. The report lacked documentation the staff notified the physician. The report indicated R3's pressure area to her right buttocks also advanced to a stage three area. The area measured 2.8 cm by 2 cm and was 0.2 cm deep. It had a moderate amount of serosanguinous drainage and slough present in the wound bed. The report lacked documentation the staff notified the physician. R3 also returned with a stage one pressure area (area or redness to the skin that is not open that indicates a pressure ulcer is forming) to the left buttocks. The admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Treatment Administration Record (TAR), for November 2020, with no initiation date, included a treatment for barrier cream to bilateral buttocks, every shift for wound until resolved. The TAR lacked any treatment order for the coccyx until 11/14/20. The Daily Pressure Ulcer Documentation, dated 11/11/20 included stage three areas to the coccyx and right buttocks. Staff were to cleanse areas with normal saline or wound cleanser, pat dry, apply foam dressing, and secure with tape. The TAR lacked evidence staff completed this treatment. The Weekly Skin Assessment, dated 11/12/20 included R3 had an open area to the coccyx and right buttocks and that a treatment was in place. The TAR lacked a treatment for the coccyx but continued to have the treatment in place for the barrier cream to the bilateral buttocks. A Physician Order, dated 11/13/20, included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . For the right buttocks staff would cleanse the area with normal saline/wound cleanser, pat dry, cover with foam dressing, and secure with tape one time a day and as needed. Review of the TAR, dated November 2020, indicated the treatment to the right buttocks and coccyx started on 11/14/20, four days after the resident returned to the facility. The Weekly Skin Condition Report, dated 11/18/20, indicated the resident's coccyx wound increased in size to 2.0 cm by 1.1 cm, and the depth remained the same. The right buttock wound length decreased to 2.7 cm, the width increased to 3.0 cm and the depth improved to 0.1 cm. The left buttock remained as a stage one and the size increased to 1 cm by 1.1cm. The Weekly Skin Condition Report, dated 11/25/20, included the stage one pressure area to the resident's left buttocks resolved. The coccyx area length and depth remained the same, but the width increased to 2.0 cm. The right buttocks had improvement to the length and width, but the depth increased to 0.3 cm. The report further indicated there was no slough to the wound, but did not specify if that was the coccyx, the right buttocks wound, or both. Review of the Progress Notes, dated 11/01/20 -12/01/20, located in the EMR, lacked documentation of the stage three pressure areas, the stage one pressure area, notification of physician and family, treatments, and/or any other new interventions related to current breakdown and/or prevention of further breakdown. On 12/01/20 at 09:57 AM, R3 was laying in bed on a mattress that was not an air mattress, on her left side with a pillow in place behind her back. On 12/01/20 at 10:17 AM, R3 turned on her call light and requested the bed pan. Certified Nurse Aide (CNA) P and CNA M assisted R3. On 12/01/20 at 10:23 AM CNA M reported R3 had a sore on her bottom and they had to turn her every two hours. CNA M reported the resident had the area when she came back from the hospital. She did not have a dressing in place because she had a shower around 07:30 AM and the nurse had to put a dressing back in place. CNA M confirmed the resident was currently positioned on her back and she should lay on her sides. R3 refused observation of pericare and the dressing remained off. On 12/01/20 at 11:53 AM, Licensed Nurse (LN) G, revealed R3 had breakdown to her coccyx and to the right on her buttocks, and that she came from the hospital with those areas. Staff treated the areas with a foam pad and the staff tried to move her side to side when in bed. R3 did not always want to go to bed. She had a cushion in place to her wheelchair and a pressure reducing mattress to her bed, but not an air mattress. On 12/01/20 at 04:19 PM, further interview with LN G, revealed that R3 had a scar on her right buttocks and it opened up from time to time. The resident acquired the coccyx area wound on 11/04/20. R3 was to be the last one up before meals and the first one to lay down after meals, turned side to side when in bed, and have an air mattress, which was ordered. The resident had a cushion in her wheelchair. New interventions were added to the care plan by Administrative Nurse F. Staff were made aware of new interventions during report and with the use of a communication board. The request for an air mattress was put into place on 11/25/20 when the size increased. The resident did not refuse treatments. The resident did not allow LN G to do her wound treatment today, but LN G would check again with R3. The resident refused to lay down every once in a while, but not like she used to. She does like to sit up and does not like to be on her side, it is awkward to her due to the amputation for her to lay on that side. She has had more incontinence episodes since the last hospital stay. On 12/02/20 at 10:13 AM, CNA M revealed that R3 had an air mattress several months ago when she had a wound on her bottom, then the staff removed the mattress when the wound healed. She had an area on her bottom before she went to the hospital that was worse when she returned. R3 had to be repositioned every two hours and staff offered to lay her down after meals, but sometimes she did not want to lay down. R3 should be side positioned when in bed and before she went to the hospital she liked to be up in her chair and color and did not like to lay down. She did better about positioning on her sides because her bottom hurt and bothered her when staff put her on the bed pan. Before she went to the hospital the nurse applied Calmosetpine (medicated ointment), and we would let the nurse know if her bottom was red. On 12/02/20 at 10:26 AM, CNA O revealed that R3 was to lay down between meals if she allowed, she does not always want to. When she was in bed, she was to be side to side because of the issue on her rear, she does not always comply because she does not like the side positions very well. She used to have an air mattress, it was on her care plan, but she switched back to a regular mattress. We try to encourage her to lay down more and get off of the area and to reposition more. No new interventions were put into place since the areas on her rear developed. On 12/02/20 at 11:21 AM, Administrative Nurse E revealed she ordered an air mattress on 12/01 or 12/02/20. She stated we followed an algorithm and she did not have a stage three pressure area, so we had to return the air mattress. Any new skin condition that occurred, the nurse would put in an order, even if it was temporary, until they got an order back from the doctor. Administrative Nurse E confirmed there was not a treatment order in place for the coccyx and right buttocks until 11/13/20 and did not see any orders for treatment when the areas developed on 11/04/20. The staff removed the air mattress from R3's bed on 10/14/20, and she should have had an air mattress in place when she returned from the hospital on 11/10/20. On 12/02/20 at 11:52 AM, LN G revealed that when staff discovered the pressure area to the right buttocks and coccyx, a new intervention was not placed. She told the CNAs they needed to keep her off of her buttocks and hoped between the barrier cream and positioning, the areas would improve. The Interact transfer form was done, and skin conditions should be marked on there as well. LN G confirmed she could not find an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R3 should have had an order put in place on 11/10/20 and the Interact form should have had the areas on it. These areas should be on the care plan along with the treatment provided. On 12/02/20 at 12:28 PM, Administrative Nurse F confirmed that 10/23/19 was the last time R3's care plan update was done. When the staff removed the air mattress, the intervention should have been removed from the care plan. On 12/02/20 at 12:4 PM, Administrative Nurse D revealed he expected a treatment to be in place when a wound developed and R3 should have had a treatment in place when she returned from the hospital on 11/10/20. Furthermore, he reported that barrier cream was not an appropriate treatment for stage three pressure ulcers, and according to the algorithm an air mattress should have been put in to place after she returned to the facility from the hospital on 11/10/20. The transfer form should have had the skin conditions documented. The care plan should have been updated with current interventions and confirmed it lacked current interventions for R3. On 12/02/20 at 01:53 PM, Physician GG revealed he was not aware of her pressure ulcers, the nurse practitioner from the wound center took care of any ulcers when she made rounds in the facility. After review of the discharge summary from the hospital she transferred from, there was not any notification of pressure ulcers present. R3 should have had a treatment in place to her stage three areas upon return and should be on a low air loss mattress as she did not move around much and was not always cooperative. On 12/02/20 at 02:00 PM, Physician Extender HH revealed that she saw R3 up until COVID (Coronavirus disease-a highly contagious respiratory disease) hit back in March for her wounds then the facility stopped the visits. The facility policy Skin Integrity, Pressure Injuries Nursing Protocol, last revised 11/2017, included that the resident with pressure injuries will receive necessary treatment and services, consistent with professional standards of practice, to promote healing prevent infection, and prevent new ulcer form developing. If a pressure ulcer is present, provide treatment to heal it and prevent development of additional pressure injuries. Contact the physician for alternative treatment if no evidence of progress toward healing in two to four weeks. The facility failed to provide timely treatment for two facility acquired stage two pressure ulcers at the time of development, failed to ensure preventative devices placed in the resident's bed, failed to notify the facility transferred to of the pressure ulcers, and failed to provide timely treatment to the pressure ulcers when R(3) readmitted to the facility. The resident developed two Stage two pressure ulcers that worsened to Stage three.

The facility reported a census of 33 residents with 3 reviewed for falls. Based on observation, interview and record review, the facility failed to ensure 1 sampled resident (#1) received adequate supervision and assistive devices to prevent repeated falls when staff failed to ensure all staff were aware of the use of a PBA (personal body alarm), a planned intervention to prevent falls. The staff failed to apply a PBA, as planned and the resident experienced a subdural hematoma (collection of blood on the surface of the brain), as a result of a fall. Furthermore, the facility failed to ensure staff implemented interventions as planned to prevent further falls for resident #2. Findings included: - Resident #1's admission Minimum Data Set, dated dated [DATE], included a Brief Interview for Mental Status of 11/15, indicating moderately impaired cognition. The assessment identified the resident exhibited trouble with sleep and appetite, and needed extensive assistance for transfers, limited assistance for locomotion, and used a wheelchair for mobility. The assessment reflected the resident with balance problems. The assessment evidenced a fall history with a fracture prior to the resident's admission. The staff assessed the resident without falls since admission. The Care Area Assessment for falls, dated 5/16/17, included the resident with the potential for injury due to falling and a fall at home, which resulted in a left hip fracture. The facility identified the resident as a resident at risk for falls with the most recent, 5/21/17, Fall Risk Assessment score of 10. A score of 10 or greater indicated the resident at high risk for falls. A care plan, dated 4/22/17, for falls included the following interventions: Assess and assure the wheelchair is the appropriate size, with footrests, anti-lock brakes and anti-tippers. Bed in lowest position. Call light and/or personal items available, in easy reach. Footwear to prevent slipping. Gait Belt for transfers. Grab bar in the bathroom. Environment well lighted and clutter free. Observe for side effects of medications. Orientation to new room and roommate. Therapy referral. Neurochecks per protocol, added 5/16/17. Weight bearing, as tolerated. Front wheeled walker and assistance of 1 staff. Remind resident to use the call light for assist. PBA (personal body alarm) in bed until UA (urine analysis) results received, and then reassess, added 5/16/17 and revised 5/26/17. Apply ice to head, added 5/26/17. Request order for UA due to urine turbidity, concentration and complaints of lower abdominal cramping, in addition to recent confusion and hallucinations, added 5/26/17. Review of the kardex and the communication book, revealed the lack of evidence staff added the information regarding the use of the PBA to either of these records to alert direct care staff of changes to the resident's care. A nursing note, dated 5/21/17, noted at 6:30 PM, revealed the resident was found on the floor by nursing staff. The staff alerted the charge nurse who completed an assessment, including initial vital signs of: 97.7 temperature-68 pulse-18 respirations-122/68 blood pressure-95%RA (room air) oxygen saturation level on room air. The staff found the resident lying flat on his/her back on the bedroom floor, with a pillow under the resident's head. The resident was alert and oriented to self and the situation. The resident expressed clear speech and responded appropriately. The resident complained of tenderness to the back of his/her head and exhibited a walnut sized hematoma, red/purple in color. Staff applied an ice pack to the area. The resident requested staff to transfer him/her to bed, and the direct care staff assisted the resident to bed with the use of a gait belt. Staff elevated the resident's HOB (head of bed) to approximately 45 degrees. The nurse continued with neurological assessments with vital signs remaining stable and within normal limits. The clinical record lacked further nursing notes until at 2:20 AM, the nurse and direct care staff heard an abnormal coughing sound coming from the resident's room. Staff found the resident with light brown fluid from the resident's mouth and staff noted a gastric odor. The resident's respirations were regular depth, without accessory muscles utilized, skin color pink, and warm to touch. Oxygen saturations measured at 93-94%, on room air. The resident's bilateral upper lobes sounded diminished and the upper airway exhibited abnormal exhalation sounds. Vital signs obtained were: 97.7 Temperature-88 Pulse-158/88 Blood pressure-93 Respirations-and 94% oxygen saturation on room air. The resident's eyes remained closed throughout the assessment, and the resident lacked responses to verbal, tactile or painful stimuli. The licensed nurse reported to the primary care physician of the resident's condition and received an order for [REDACTED]. The staff attempted to call the emergency contact #1 and received a disconnected message. Staff contacted emergency contact #2 who reported he/she would contact #1 emergency contact, and gave permission to send the resident to the hospital. At 3:00 AM, EMS arrived and transferred the resident to the hospital. The physician's orders [REDACTED]. Review identified staff documented neurological checks and vital signs on 5/21/17, starting at 6:30 PM and documented these until 1:15 AM, with the next set due at 5:15 AM. The document noted the resident transferred to the hospital at 3:00 AM. Review of this documentation identified the resident's vital signs and neuro checks remained WNL (within normal limits) and without significant changes prior to the change in condition at 2:20 AM. A Clinical Assessment, dated 5/21/17 at 6:30 PM, included the resident alert, with a history of falls; chair bound, and required assistance with elimination. The resident exhibited poor vision, with a problem with balance, received polymedications, and with predisposing conditions for falls. The skin assessment identified the resident had a walnut sized hematoma to back of his/her head, red/purple in color and a healing bruise to the left knee, light green in color. A hospital radiology report, dated 5/22/17, indicated the resident had a very large left cerebral subdural hematoma with considerable mass effect with increased pressure causing the brain to squeeze within the skull. Review of the history and physical report, dated 5/22/17, from the second hospital, identified the resident admitted intubated, with the right pupil at 4mm (millimeters) and unresponsive; the left pupil at 2mm and minimally responsive. The staff reported a Glasgow Coma Score of 4T with unequal pupils which are minimally responsive. This revealed a 22mm acute subdural hematoma with 19mm shifting noted. The neurosurgeon reported the resident was not a candidate for surgery. The hospital staff notified the family of the resident's condition with a decision made for comfort care. On 6/2/17 at 8:45 AM, licensed nursing staff D, reported the first thing to do when a resident falls included to ensure the resident's safety, get help, complete an assessment, and then, if able to, move the resident off the floor. If the resident hit his/her head or it was not witnessed, the nurse should also initiate neurological checks. The staff member should then make notifications to the physician and the family. On 6/2/17 at 10:00 AM, licensed nursing staff E reported the resident ate supper in the dining room, and the staff passed medications to the resident at suppertime. Staff reported the resident was often in the wheelchair, and staff usually assisted him/her to bed first. The resident was in bed, when the resident's roommate was heard to yell out for help. When staff E arrived in the resident's room, the resident was lying flat on the floor, approximately 2 feet from the roommate's bed, on his/her back. The roommate, reported to the staff, the resident walked towards his/her bed and fell backwards. The staff reported the resident was making normal conversation, when staff E checked on the resident several times before going off shift at 10:00 PM, as well as observing the nurse going in to check on the resident. On 6/2/17 at 11:30 AM, direct care staff G reported he/she assisted the resident with getting ready for bed on 5/21/17, between 6 and 6:30 PM. Staff reported the resident wanted to toilet, so the staff assisted the resident to the bathroom, and then with changed his/her clothing. Staff then assisted the resident into the bed and covered the resident up with the covers. Staff G reported they noted the PBA on the resident's bed, but since he/she didn't know the resident used an alarm he/she did not attach the alarm. Approximately 30 minutes later, the roommate called out for help. Staff notified the nurse, and he/she came and checked the resident for injury. After the nurse completed the assessment another CNA (certified nurse aide) and staff G assisted in sitting the resident up in the wheelchair. The nurse again checked the resident over, and then the staff assisted the resident into bed, and attached the PBA to the resident. Staff G reported he/she observed the nurse go into the room several times during the remainder of the shift. Staff G reported when asked about how the staff are notified of changes in the resident's care needs, staff G reported, either reading the care plan, the communication book and/or the kiosk (a small computer used for inputting resident information) or report. The staff verified they failed to check the care plan book or the communication book, and so was unaware of the use of the PBA for the resident. On 6/2/17 at 12:46 PM, direct care staff H, reported when he/she came on duty (2:00 PM) the resident was in bed, and his/her PBA was in the bed, but was not attached. The staff attached the alarm, at that time. Another unknown CNA put the resident to bed, and staff H was told he/she didn't attach the alarm either. After supper, the resident's roommate yelled for help and the staff found the resident on the floor. Staff H notified the nurse and he/she came to assess the resident and then the staff assisted the resident into bed. Staff H checked on the resident often, at least hourly after the fall, until 10 PM, when staff H reported going off-duty. The resident seemed his/her normal self every time staff H checked on him/her. Staff H reported they check placement of all residents with a PBA when coming on duty, but was not aware of any policy stating that was a requirement. On 6/2/17 at 1:04 PM, direct care staff I reported the resident was in bed, prior to supper, and because he/she worked the other hallway, was not aware the resident had fallen until around 9 PM. Staff I reported checking on the resident at approximately 10:00 PM, and the resident seemed his/her normal confused self. Then at the midnight bed check the resident seemed to sleep soundly and when checked was clean and dry. The resident did not awaken during the bed check. At approximately 2 AM, choking/gurgling noises were heard and the nurse and staff I went to check on the resident. The nurse performed a sternal rub without much response, from the resident. The staff then checked and changed the resident, and the nurse called the physician for evaluation in the emergency room . Staff I reported the kardex in the kiosk contained the care plan information and the communication book, at the nursing desk, also contained all the changes to care plans in it. Staff I further indicated at shift change, report was given on changes in the residents and his/her care plans; Staff I reported he/she was not aware of the resident having a personal body alarm, prior to that evening, after the fall occurred. On 6/2/17 at 1:15 PM, administrative nursing staff C and B reported the communication book was not kept up to date on everything, but that care plans were current for all the residents. Staff C verified the staff added the PBA into the care plan, after the fall on 5/16/17. On 6/2/17 at 1:55 PM, direct care staff J reported the resident required toileting assistance, use of a gait belt with transfers and ambulation, and used a wheelchair for mobility. Additionally, staff J reported the resident had a low bed, wore non-skid socks and the staff usually placed the call light into the resident's hand, because of impaired vision. The staff reported he/she was not aware the resident required a PBA. Licensed nursing staff M reported, on 6/2/17 at 4:04 PM, the resident fell during the nurse to nurse report. The CNA staff called for the nurse who went to assess the resident and found the resident on his/her back, lying flat on his/her back. Staff M looked for obvious trauma/bleeding, completed range of motion and then completed a set of vital signs. During that time, the resident responded to questions and reported the area on the back of his/her head as tender. The staff reported they treated a walnut sized raised area on the back of his/her head with an ice pack after completing the assessment, and started neurochecks. The assessment identified only the raised area was a concern. The staff lifted the resident into the bed and the head of the bed was kept elevated. Staff M reported that because the resident seemed stable, having good awareness the staff continued with other resident cares and did not attempt to notify the physician until approximately 11:00 PM. At that time, the staff reported the physician did not answer the phone and the #1 emergency contact's number was not in service. When staff M completed the 1:15 AM assessment, the staff reported the resident seemed more lethargic and less responsive, but the resident did turn and grasp the turn bars during the checking and changing, and all the vitals and neuros were stable, and staff M reported he/she felt the resident was in a deeper sleep. However, around 2:20 AM, staff heard a gagging noise, and when checking on the resident, noted emesis around the resident's mouth, and the resident was not responsive to verbal or tactile stimuli. Additionally, the resident did not react to a sternal rub and staff M notifed the physician. The physician gave the order to send to ER, the staff attempted to call the DPOA and again had no answer. Contact #2 was then called and gave permission to send the resident to the ER. At 1:15 AM the resident was less responsive but still followed instructions and staff M reported he/she thought the resident was sleeping more soundly. Staff reported they notified EMS (Emergency Medical Services) and the EMT's (emergency medical technicians) arrived and transported the resident to the hospital. Interview with administrative nursing staff B and C, on 6/2/17 at 4:00 PM verified the staff failed to properly and timely notify the physician of the resident's fall and trauma to the head. Physician N reported, on 6/7/17 at 7:30 PM, the staff had not attempted to call the physician's cell phone at 11:00 PM, having checked his/her incoming calls, and since the physician was at home at 11:00 PM and would have heard the home phone ring, he/she did not believe the staff called either number. However, the physician reported, had the nurse called with information that the resident had fallen and hit his/her head, and the vital signs were stable, the neurochecks were within normal limits, likely the physician would not have had the resident sent to the ER, either at 6:30PM when the fall occurred or at 11:00PM when staff reported they called. When questioned about the sudden change in the residents condition from 1:15 AM (the last neurochecks documented) to the change in condition at 2:20 AM, the physician believed that probably had the staff assisted the resident up, onto the side of the bed and really awakened him/her that some changes would have been observed, but since the resident had been stable for over 6 hours, he/she did not believe the staff probably would have noted the slight changes in the resident. The physician verified that the rapid change probably was not that rapid but the changes were so subtle that the staff would not recognize them. The Falls Management Policy dated 4/15 included to obtain vital signs, blood pressure, pulse and respirations. Obtain neurological checks (neuro-checks) per policy for any unwitnessed fall or any fall with evidence of injury to the head. Contact the physician and family, documenting in the medical record, including time and the person spoken with. If transferred, document transferring agency/responders. The facility failed to provide the resident with adequate supervision and/or assistive devices to prevent a fall, when the facility failed to ensure all staff aware of the use of the PBA and staff failed to attach the PBA, as care planned. The fall resulted in a subdural hematoma. - Resident #2's Physician order [REDACTED]. The annual Minimum Data Set, dated dated [DATE], included a Brief Interview for Mental Status of 3/15, indicating severely impaired cognition and needed extensive assistance of staff for ADL's (activities of daily living) including transfers and mobility and lacked evidence of falls. The quarterly Minimum Data Set, dated dated [DATE], identified the resident was rarely understood, with long and short term memory impairment, and had inattention and verbal behaviors. The assessment identified the resident continued to require extensive assist of staff for ADL's and had no falls. The Care Area Assessment for falls, dated 2/2/17, included the resident with unsteady balance and received anti-depressant medication daily. The resident's fall risk assessment, dated 5/18/17 scored 11, which indicated high risk. The 5/23/17 fall risk assessment, scored 15, indicating high risk for falls. The care plan, dated 6/1/17, for falls included the following interventions: 5/22/16 Discontinued safety alarms and wander-guards due to no longer ambulatory. Assess for pain. Assess that wheelchair is of appropriate size, need for footrest, and safety needs. Ambulate to the dining room with gait belt and front wheeled walker, and seat the resident in a straight back chair for meals, revised 6/1/17. Be sure to allow me sufficient time to complete toileting needs, revised 6/1/17. Bed in low position. Transfers and locomotion with 1 or 2 staff at all times. Dycem mat between cushion in recliner to prevent sliding. Encourage use of proper footwear, i.e., non-skid, well-fitted shoes. Monitor the resident even when family is present. Gait belt used with all transfers. Keep recliner control from reach of resident while in recliner. Mat beside bed and recliner. Request that family inform charge nurse when they are leaving the building. Resident is to be toileted after each meal then offered to be placed in his/her recliner after each meal. Sensor mat at bedside and chairside. A physician order, dated 5/22/16, and noted on 5/23/17, identified the discontinuation of the resident's safety alarms and wander-guards as the resident was no longer ambulatory. Review of nursing notes, dated 5/18/17 at 7:45 PM, identified the resident sustained [REDACTED]. The nurse found the resident lying face down with the wheelchair beside the resident and the pedals of the chair around the resident's hip area. The nurse assessed the resident for injury, completed vital signs and then assisted the resident up into the wheelchair. Staff initiated neurological checks were initiated with bruising noted to the top of the resident's scalp, with a small abrasion to both knees, and a reddened area noted under the right eye. The resident denied pain. Vital signs and neuro checks noted within normal limits for the resident. Notifications to the Physician, director of nursing and DPOA (durable power of attorney), were made. The licensed nurse re-educated the staff on the importance of ensuring alarms are in place, at all times. Observation of the resident, on 6/2/17 at 9:15 AM, identified the resident seated in his/her recliner with a fall mat and sensor mat on top of the fall mat in front of the wheelchair. Additionally, the staff had the call light placed on his/her lap, feet elevated on the foot rest with shoes on, and the recliner control out of reach. The resident responded to verbal stimuli, however, was not oriented. Noted the resident's walker in the room well away from the resident's seating area. The resident remained seated in the recliner until 12:00 PM when staff toileted the resident using a sit to stand lift with 2 staff assisting the resident. Staff allowed the resident time for toileting then completed the cares and transferred the resident into the wheelchair, and then pushed the resident's wheelchair to the dining room and seated the resident at the table in the dining room, in the wheelchair. On 6/2/17 at 1:30 PM the resident sat in the lobby area, in his/her wheelchair with other residents, without a PBA, and with shoes on his/her feet resting on foot pedals. The resident appeared to sleep while seated in the wheelchair. At 2:30 PM on 6/22/17 the resident sat in the recliner, asleep. The resident remained in the recliner sleeping when observed at 3:30 PM. On 6/2/17 at 12:10 PM, direct care staff O, reported the resident required a sit to stand lift or transfer with a gait belt, needed shoes and non-skid socks for safety, keeping the call light within reach, using a fall mat when in bed or the chair, with the PSA (pressure sensitive alarm) mat on top of it and keeping the recliner controls out of reach of the resident, for his/her safety. Direct care staff K reported, on 6/2/17 at 2:45 PM, the resident no longer ambulated, and when the resident was alert and awake, stood and pivoted with 2 staff with the use of a gait belt; otherwise the staff used the sit to stand lift for transfers. At bedtime the staff usually reported the resident was usually positioned to his/her right side, facing the wall, for less distractions, and less attempting to get up. Staff reported the resident had a floor pressure alarm, a low bed, and non-skid socks. The resident enjoys sitting in the recliner to watch television with his/her feet up. When asked about the staff being made aware of changes in the resident's care plans, staff K reported that the communication book, should be reviewed daily when reporting to work to determine those changes. The facility policy on falls, dated 4/15, included to communicate interventions to the care giving team and the resident's fall will be noted on the 24 hour report for 3 days for post fall monitoring, including full vital signs every 8 hours. The facility failed to ensure this resident received interventions as planned to prevent falls.

The facility reported a census of 43 residents. The sample of 24 residents included 7 residents reviewed for elopement and lack of adequate supervision or assistive devices to prevent accidents. Based on observation, record review and interview, the facility failed to effectively monitor 1 (#50) resident from leaving the facility without staff knowledge. Staff found resident #50 on a residential street approximately 1 ½ blocks from the facility which placed the resident in immediate jeopardy. Furthermore, the facility failed to provide appropriate assistive devices and/or supervision for 3 (#44 and #38, #59) of the sampled residents. Resident #38 experienced repeated falls without adequate interventions and sustained a hip fracture. Findings included: - The signed physician orders, dated 6/3/15, revealed resident #50 admitted to the facility on [DATE], with the following [DIAGNOSES REDACTED]. The admission MDS (minimum data set), dated 11/21/14, revealed the resident had a BIMS (brief interview for mental status) of 4, indicating severely impaired cognition. The resident had a behavior of wandering, which occurred daily. The resident required supervision for locomotion and ambulation, with balance steady at all times, and without impairment in functional range of motion. The CAA (care area assessment), dated 12/1/14, for cognition documented the resident admitted to the facility following a hospital stay at a senior behavioral unit. The resident had previously been living with a family member at home, but had become increasingly agitated, paranoid (a thought process believed to be heavily influenced by anxiety or fear to the point of irrational thinking), violent, was wandering and had increased memory and dementia symptoms. The CAA for behavioral symptoms documented the resident triggered due to wandering. The resident would wander at times throughout the facility, and would at times go to the facility doors. The resident's family reported the resident had been wandering at home and had made attempts to elope from the home prior to the admission to the senior behavioral unit. The resident used a wanderguard bracelet. The quarterly MDS, dated [DATE], revealed the only change from the admission assessment was the resident without wandering, however, the resident had rejection of care, and behavior of this type occurred 1-3 days. The resident risk for elopement assessment, updated and reviewed on 4/20/15, documented the resident was physically able to leave the building on his/her own, was cognitively impaired, had impaired decision making skills, had a history of [REDACTED]. The care plan, reviewed on 5/28/15, documented the resident was at risk for elopement related to attempts to leave the facility and go home. Interventions included: --Assess for risk of elopement per the facility policy --Redirect the residents from doors of the facility. --Take a picture of the resident upon admission for identification and for updating the elopement book. --A wanderguard bracelet to be in place. Monitor for placement and function of the wanderguard every shift and as needed. The care plan, identified the resident was mostly independent and required assistance as needed with ADLs (activities of daily living). The physician ordered on [DATE], for the staff to monitor the wanderguard every shift. The nurse notes, dated 6/10/15 at 2:43 AM, documented the resident eloped from the facility this evening (6/9/15 at approximately 7:00 PM to 8:00 PM). The resident went out of the facility with the pizza delivery person. The wanderguard alarm did not sound when the resident went out the door. A resident notified staff of the resident leaving the facility. The resident was past the facility parking lot when observed. The nurses aid went after the resident and brought resident #50 back to the facility. Review of the weather on 6/9/15, from Wunderground.com recorded the temperature at 6:52 PM was 91.0 degrees Fahrenheit, with a heat index of 95.2 degrees Fahrenheit. Review of the nurses notes and residents vital sign record lacked documentation the residents vital signs were taken after the elopement. On 6/18/15 at 2:05 PM, observation revealed the facility located on a busy residential/business street, which the resident crossed after leaving the facility grounds. A large manufacturing plant was across from the facility. The resident also crossed another intersecting street, which allowed traffic to enter the facilities residential/business street both ways, was located approximately 1/2 block from the facility. The resident was found across the street from the city swimming pool, a city office complex, and a gas station on the opposite corner from the pool. The speed limit on the street in front of the facility was 25 miles per hour. On 6/18/15 at 2:25 PM, direct care staff F stated around 7:45 PM or 8:00 PM, on 6/9/15, a resident informed him/her and licensed nursing staff KK, that another resident had left the building from the front door with the pizza delivery person. Staff F identified the area, where the resident was found and stated Staff KK and Staff F went outside to look for the resident and did not see the resident until he/she was to about the middle of the parking lot when he/she saw the resident approximately a block away from the facility. The resident was across from the facility and walking in the street. By the time staff F caught up to the resident, he/she was another half a block away. The resident stated he/she was tired, and was looking for his/her car. Staff F was able to get the resident to walk back toward the facility. Staff F got the resident in the facility and the resident stated he/she was hot. The resident then was given some water. The resident wore a sweater, shirt, and slacks. Staff F stated the evening was warm and humid. The wanderguard alarm sounded at the back door upon entering with the resident's return. Furthermore, staff F was unsure if he/she received information regarding elopement during orientation. Staff F stated the resident did wander at times, and had a wanderguard bracelet. On 6/18/15 at 4:05 PM, licensed nursing staff V stated he/she was passing medications when the pizza delivery person came to the facility. Staff V stated he/she saw the pizza delivery person leave by the front door and continued passing medications for approximately 3-4 residents. The wanderguard alarm for the front door was sounding and he/she waited for someone else to turn off the alarm. When no one else came to turn off the alarm, staff V turned off the front door alarm. He/she noticed the pizza delivery person getting into his/her car, and staff V saw 2 other cars in the front parking lot. He/she did not see anyone else in the parking lot. Staff V stated he/she should not have just thought the alarm was sounding because a resident was too close to the door, he/she should have checked outside. He/she did not realize the resident was gone for 5-10 minutes until licensed nursing staff KK told staff V he/she was taking the facility van to go look for a resident. The last he/she saw the resident was about 15 minutes before the resident left. On 6/18/15 at 3:15 PM, direct care staff W stated the resident was an elopement risk. Direct staff stated W stated the resident tried to elope again by following a family member outside 2 days later, he/she saw it happen. The wanderguards, and the care plans are how he/she would know if someone was an elopement risk. The only thing he/she was told was to not shut off an alarm, and let the nurse know the alarm was sounding. The resident was forgetful, and had to be redirected at times from the doors. On 6/18/15 at 3:21 PM, direct care staff LL stated he/she was down the hall in a residents room and when he/she came out the licensed nursing staff KK came into the facility and stated a resident was out of the building. He/she did not hear the front door alarm sounding. The only reason the staff knew a resident left the building was because another resident saw him/her leave. Staff LL did not remember receiving orientation regarding elopement. Staff LL stated he/she knew a resident was an elopement risk if the resident had a wanderguard bracelet on. The facility with a elopement book at the nurses station. On 6/18/15 at 3:40 PM, licensed nursing staff KK stated he/she did not hear the alarm sound when the resident eloped. However, the alarm worked when the resident came in the facility through the back door. As soon as staff KK and direct care staff F went out the front door and to the middle of the parking lot they saw the resident. The resident was approximately a half a block of away from the facility. Direct care staff F brought the resident back to the facility. Staff KK stated he/she checked the residents wanderguard and the door alarm with the decoder and both functioned. The resident was wearing a gray sweater, a sweatshirt, slacks and shoes and socks when he/she left the building. The facility did have an elopement book, with the residents names, pictures, policies and procedures in the book. He/she stated the resident was an elopement risk, and required redirection from the doors at times. The nurses check the residents wanderguard bracelet every shift. On 6/18/15 at 3:50 PM, licensed nursing staff J stated he/she would check the wanderguard bracelets on his/her shift, and the other nurses would check the wander guard bracelets on their shift to ensure they worked appropriately. Staff J then documented on the TAR (treatment administration record). Review of the residents TAR revealed initials and a check mark for each shift. The initials and the check mark meant the alarms were checked and working. Check of the front door wanderguard system at this time revealed the alarm functioned. On 6/18/15 at 2:10 PM, administrative nursing staff B stated there are 8 residents at risk for elopement. The staff are educated regarding elopement during orientation and throughout the year. A list of the residents and pictures are kept at the nurses station. At 5:00 PM, administrative nursing staff B further explained the nurses check the wanderguard alarms on the doors every shift, and on each resident who would have a wanderguard bracelet. The CNAs also are to let the nurses know of any alarm that sounded, then wait for the nurse to announce all clear. On 6/18/15 at 2:20 PM, the resident stood in the front lobby area, looking around for a few minutes, then proceeded to the dining area for an activity. On 6/18/15 at 3:15 PM, the resident ambulated in the hallway with a friend toward his/her room, with a steady gait, and alert and oriented to self. The resident wore a wanderguard bracelet to his/her right wrist. The resident was not exit seeking or exhibiting wandering behavior. The facility undated policy for response to door alarms/wanderguards, documented the facility utilized the wanderguard system and regular coded door alarms, and both the alarms were auditory. There was an alarm indicator in the front lobby; which would designate which door the alarm sounded. If it is the wanderguard (lower unit) which sounded, staff were to do a visual check to assure a resident had not stepped out of the door, and then notify the charge nurse. The staff must immediately account for the residents at risk . The charge nurse would initiate action per the elopement policy. All malfunctions (alarm sounding without reason) must be immediately recorded and reported to the executive director and Maintenance director. We are currently maintaining a log at our front door to record any alarm soundings. It required a date, time, rather it was a resident, staff or visitor and your initials. Do not reset the alarm until you can verify why the alarm was sounding. The facility elopement guideline revised in 2013, documented for a missing resident event: the charge nurse would initiate a search of the unit upon which the resident resided, with all employees assigned to the unit. The facility would establish a process to alert staff of the missing resident. Once a search of all respective areas was conducted, all available employees would continue to participate in searching all areas of the facility and the external premises. The facility failed to ensure safety for this congnitively impaired resident, who left the facility without staff knowledge, when staf shut off the wanderguard alarm on the front door. The resident was found walking in the street approximately 1 1/2 blocks from the faiclity, on a day when the temperature was 91 degrees Fahrenheit, placing this resident in immediate jeopardy. The facility abated the immediate jeopardy, on June 24, 2015 at 4:20 PM by initiating the following: the facility developed and implemented a facility wide system to assure correction and continued compliance with the regulations. All residents at risk wanderguards and all exit doors alarms were checked for functioning properly. Signs were placed at all exit doors educating all who exited to check with a staff member before letting any resident exit the building. All staff were in-serviced on the proper elopement procedures, the alert code, and immediate action steps when an elopement occured. This immediate jeopardy was abated, on June 24, 2015 at 4:20 PM: however, the deficiency remained at a scope and severity of a G. - The signed physician orders, dated 5/8/15 of resident #38, documented the resident admitted to the facility on [DATE], with the following [DIAGNOSES REDACTED]. The admission MDS (minimum data set), dated 3/25/15, revealed the resident sometimes understands others, and a BIMS (brief interview for mental status) score of 2, indicating severely impaired cognition. The resident required extensive staff assistance for transfers, locomotion and toileting. The residents balance was not steady moving from a seated to standing position, moving on and off the toilet, and surface-to-surface transfers. The resident had a functional impairment in range of motion to the lower extremity on one side, and his/her mobility was per wheelchair. The resident was frequently incontinent of bladder and always incontinent of bowel. The resident sustained [REDACTED]. The CAAS (care area assessment), dated 4/6/15 for cognition documented the resident recently admitted to the facility from an assisted living facility, and sustained a fall and hip fracture. The resident had surgical repair of the hip and then was readmitted to the facility for rehabilitation and long term care. The resident triggered for Cognitive Loss due to a BIMS score of 2, physical behaviors, and rejections of care. The resident had a [DIAGNOSES REDACTED]. The resident was having falls at the facility he/she came from. The resident was unsteady and needed staff assistance of 1-2 with transfers. The resident was currently with hip precautions and worked with therapy. The 30 day MDS, dated [DATE], documented the following changes: the resident with short and long term memory problem, and moderately impaired decision making. The resident had rejection of care, behavior of this type occurred 1-3 days. The resident required extensive assistance for ambulation; balance not steady walking or turning around, and facing the opposite direction while walking; functional limitation in range of motion to lower extremity on one side; and mobility per walker and wheelchair. The resident was without falls since admission. The Immediate Plan of care for this resident dated 3/10/15, documented the resident fell in the past 31-81 days, and instructed staff: --Encourage rest periods daily to avoid overtiring. --4/20/15: Monitor for changes in abilities in ambulation. --4/20/15: Wear gripper socks. The care plan, reviewed on 4/30/15, documented a fall in the past 30 days: --Bed in low position. --Call light or personal items available and in easy reach. --Footwear to prevent slipping. --Gait belt with transfers. --Grab Bars. --Gripper socks when not wearing shoes. --Keep environment well lit and free of clutter. --Monitor for changes in ability to ambulate. --The resident required staff assistance for transfers and mobility. Update to the care plan, dated 5/30/15, for a fall, documented the resident's personal body alarm (PBA) pulled off, and was changed to a pressure pad chair alarm. However, the PBA had sounded according to the 5/30/15 nurses notes. The plan lacked any further intervention initiated. Update to the care plan, dated 6/3/15, for a fall, documented the staff to ensure the alarm in place when the resident was in bed. The Resident Cardex Information direction sheet, dated 5/4/15, for the CNA's (certified nurses aides), directed staff to answer the sensor alarm immediately, assistance of 2 staff with gait belt and walker, left hip precaution, walk to dine, and to use a sit to stand lift if refused, bed in low position, sensor alarm in bed and in wheelchair, incontinent of bowel and bladder, toilet upon rising, after meal, and at bedtime, check and change every 2 hours during the night, make sure to reposition every 2 hours. The nurses progress notes, dated 4/20/15 at 8:30 AM, documented the resident observed sliding off the edge of the right side of the bed and was unable to get to the resident fast enough to prevent the resident from sliding to the floor. The resident was without apparent injuries. Will use dysom under the alarm pad to hold the pad in place. The nurses progress notes, dated 4/29/15 at 6:55 AM documented: the resident was found on the floor at 4:15 AM, lying on his/her right side between the bed and the recliner with the personal body alarm sounding. The resident was still wrapped in blankets with some blankets on the bed. The resident without bruising or skin tears. The resident moved extremities well without signs and symptoms of pain or discomfort, and without rotation noted. The resident was assisted back to bed with 2 staff. The Verification of investigation, dated 4/29/15, documented an intervention to reposition the resident with pillows. However, staff failed to write this intervention into the care plan. The nurses progress notes, dated 5/30/15 at 12:32 PM, documented the resident was found on the floor beside his/her wheelchair in the day room, with the alarm sounding. The wheelchair brakes were locked. The resident was moving all extremities without signs and symptoms of pain, and the resident was without injury. The resident's fall was on a carpeted surface. Review of Verification of Investigation: dated 5/30/15 lacked documentation of specific recommendations/interventions taken to prevent reoccurrence of falls. The nurses progress notes, dated 6/3/15 (Wednesday) at 1:15 AM, documented the resident found on the floor beside the bed, with the alarm sounding, and the bed lowered to the floor. The resident moved all extremities, and without signs and symptoms of pain or discomfort. Review of Verification of Investigation, dated 6/2/15, with time of occurrence as 9:45 PM, lacked recommendations/interventions to prevent reoccurrence of fall. Furthermore, documentation of witnesses identified direct care staff W stated he/she had put the resident to bed and the alarm was on and the bed lowered. The gown was still in the bed, and the resident was on the floor beside the bed. The clinical record lacked evidence the pillows were in place in the bed prior to the fall. The nurses progress notes dated 6/4/15 (Thursday) at 2:50 PM, documented the resident with 1+ edema to the right lower extremity; and with signs and symptoms of pain with movement of the right lower extremity. The resident was not bearing any weight to the right lower extremity during therapy today. A fax was sent to the primary care physician regarding the assessment. Review of the facility Fax to the physician, dated 6/4/15 (Thursday), regarding the resident, documented urgent, and to please reply to the following information: Therapy notified nursing that the resident was showing signs and symptoms of pain to right lower extremity, and unable to determine if it was the knee or hip (or in between). The resident had fallen twice in the past week, and without signs and symptoms of injury at that time. Requested an order for [REDACTED]. The reply from the physician, dated 6/4/15, documented please X-ray right knee and right hip and pelvis. The order was noted on 6/5/15 (Friday). The nurses progress notes, dated 6/5/15 (Friday) at 12:19 PM, documented receipt of an order for [REDACTED]. On 6/5/15 at 3:00 PM, the resident left per the facility van to obtain X-rays at the hospital. At 4:45 PM, the resident returned to the facility. The nurses progress notes, dated 6/8/15 (Monday) at 12:26 PM, documented receipt of the results of the residents' X-rays. The findings suggested a right femoral neck fracture. Faxed X-ray results to the physician and left a message about x-ray results with the physicians nurse. Waiting on return phone call from the physician. The physician order, dated 6/8/15 instructed staff to transfer the resident to the hospital due to a fracture of the right hip. On 6/10/15 at 2:21 PM, licensed nursing staff L stated if a resident would have a non injury fall, staff would continue to monitor the resident for bruising, and notify the family and the physician. There should have been a Verification of investigation and a new intervention to prevent future falls placed on the investigation and the care plan. The resident did not act like he/she was in pain. Staff L stated he/she questioned whether placing pillows in the residents bed was an appropriate intervention. The nurses would put the interventions on the care plan and the nurses would let the aides know. On 6/10/15 at 3:30 PM, administrative staff A stated he/she did not have the investigation for the fall on 4/20/15 and 6/3/15. Furthermore, staff A verified the nurses are to complete this form with each fall. On 6/10/15 at 3:53 PM, administrative nursing staff C stated he/she tried to educate the staff to not use educate the resident as an intervention. Try to teach the staff to go through the 5 why's. The nurse was to put an intervention on the care plan for a fall. When the team reviewed a fall investigation, and the team decided the intervention put in place was not good, the team would put another intervention in place, and then tell the charge nurse and the aides of the new intervention. The staff were to move the chair alarm to the bed, and should check the alarm on every shift. The CNAs (certified nurses aide), do not document if and when the body or bed alarm was checked to see if the alarm was operating. On 6/10/15 at 4:29 PM, direct care staff E stated the night the resident fell (6/2/15), he/she had been placed in bed facing a different direction, toward his/her right side. Staff E stated he/she usually positioned the resident facing toward the door. The resident always liked to lay on his/her left side and face the radio. The bed was in a low position and the personal alarm was in place when he/she left. Direct care staff E stated he/she did not know if the resident was trying to turn over or what in bed, but the aide who put the resident to bed was just helping out and he/she had not worked with the resident. Staff E did not know the resident was to have pillows in place. On 6/11/15 at 9:06 AM, licensed nursing staff M stated when the resident was first admitted , he/she was transferring independent, and ambulated on his/her own, even though his/her gait was not really steady, the gait was somewhat staggering. The day he/she sent a fax to the physician requesting X-rays, was the day therapy came and said the resident was having some pain. The resident was bouncing his/ her right leg, but when staff M touched the resident's knee, he/she was having pain. With the residents cognition you had to monitor the residents facial features for pain. Nursing administration tells the nurses to just send the physician a fax, and not call them. The fax machine was out of toner that week and the week before. Nursing staff called the doctors to use the facilities other fax machine, but staff M remembered Friday, June, 5 2015, when he/she was looking at some faxed orders dated Wednesday, which had been noted on Friday, June, 5, 2015. It can take up to 3 days to receive the results of an X-ray, but if it was important the hospital would call. With this particular hospital sometimes he/she would have to call because the hospital may have the results, but have just not transcribed the results, to send to you. On 6/11/15 at 9:48 AM, administrative nursing staff I verified the fax machine was out of toner on the week of 6/1/15 through 6/3/15. Furthermore, the order to obtain the X-rays was returned to the facility with a date of 6/4/14. On 6/11/15 at 10:40 AM, direct care staff D stated the resident required two staff to get up. Standing the resident was hard and staff D did not know why, and then found out the resident had a hip fracture, and direct care staff D stated he/she walked the resident back and forth to and from the bathroom, and required 2 staff assistance. However, the resident would not walk after the fall on 6/2/15. The resident had a pull tab alarm, which was then switched to a pressure pad alarm, because the resident was pulling it off and looking at it, which the resident did a lot of the time. The resident had a low bed, but staff D did not know that pillows were to be put in the bed. On 6/11/15 at 11:43 AM, therapy staff H stated he/she brought to the nurses attention the resident was having pain after he/she fell . The resident would not stand at the bars for exercises and when the resident was back in the wheelchair, staff H observed external rotation of the right leg and knew something was wrong. On 6/11/15 at 3:00 PM, administrative nursing staff C stated the interventions for pillows was from the 4/29/15 fall out of bed. On 6/11/15 at 3:09 PM, direct care staff E stated the resident was in bed with his/her gown on, the alarm was in place, had slipper socks on prior to the fall, and the bed was in a low position, when he/she saw the resident last, prior to the fall on 6/2/15. On 6/11/15 at 4:00 PM, administrative nursing staff B stated he/she did not know how long it took a fax to be returned from the doctor or the results of a X-ray from the hospital. The Intervention to place pillows around the resident for the 4/29/15 fall, were not placed on the care plan and staff were not aware of the intervention. There was not an appropriate intervention in place for this resident to prevent this resident from injuring self when he/she had a fall on 6/2/15. Review of the facility guideline for falls management, effective 1/22/15, documented, during the preadmission intake, determine if the resident has a history of falling or is unsteady in gait. Assure that the appropriate fall interventions are in place prior to the residents admission. Newly admitted /readmitted residents are assessed for fall risk by means of the clinical Health Status tool. The Immediate plan of Care At Risk-Falls Risk is initiated. At risk residents are identified through a fall alert communication system to care givers. Following a fall, appropriate interventions are implemented, and the care plan is updated. The facility failed to provide adequate supervision and/or assistive devices to prevent repeated falls for this resident with multiple falls. Furthermore, the facility failed to determine the causal factors of the falls and failed to put effective interventions in place to prevent further falls. This resident had a fall that resulted in a hip fracture. - The signed physician orders, dated 5/7/15 of resident #44, documented the resident admitted to the facility on [DATE], with the following [DIAGNOSES REDACTED]., uncertainty and irrational fear), and vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain). The 14 day MDS, dated [DATE], revealed the resident had a BIMS (brief interview for mental status) of 7, indicating severely impaired cognition. The resident required limited staff assistance for bed mobility, transfers, and locomotion; extensive staff assistance for toilet use; and supervision for walking in room. The residents balance was not steady, but able to stabilize without staff assistance, no impairment in functional range of motion, and mobility per wheelchair and walker. The resident was without falls, and the resident was occasionally incontinent of bladder. The significant change MDS (minimum data set), dated 5/7/15, revealed the resident a BIMS (brief interview for mental status) score of 5, indicating severely impaired cognition. The resident required extensive staff assistance for bed mobility, transfers, and toilet use; and limited assistance for locomotion. The residents balance was not steady, and only able to stabilize with staff assistance. The resident with limitation in range of motion to the lower extremity on both sides, used a wheelchair for mobility, and frequently incontinent of bladder. The resident had 2 or more falls, both non-injury, since the last assessment. The CAA (care area assessment), dated 5/24/15, for ADLs (activities of daily living), the resident required extensive assistance with some ADLs and instability with transitions. The resident was able to propel himself/herself in a wheelchair for mobility much of the time. The resident currently used the sit to stand lift for many transfers as this was much more comfortable. The resident's balance unsteady with transitions and needed staff assistance. For fall, the resident with a instability with transitions, a history of falls both in and out of the facility, and used a antianxiety medication. The resident was stiff and unstable with transitions and had pain with transfers. A sit to stand lift used at times for comfort although the resident may be transferred with assistance as able. Review of the Fall Risk Assessment, dated 2/16/15, contained a score of 10, a score of 10 or more, represented the resident a high risk for falls. The Immediate Plan of Care, dated 2/16/15, documented a history of falls, with instructions to staff: --Ensure balance in wheelchair. --Assistance in transfer with 1 staff. --Call light available. --Assistance with mobility as needed, assistance of 1 staff. --Encourage rest periods daily to avoid overtiring. --Gait belt. --Wheelchair/walker safety check

The facility reported a census of 42 residents. The 24 residents sampled included 3 reviewed for restorative services. Based on observation, interview and record review, the facility failed to ensure restorative services, for 1 of the 3 sampled residents, to prevent avoidable decline in ambulation for resident (#3). Findings included: - The Physician order [REDACTED].#3 admitted to the facility on [DATE]. The Admission MDS (minimum data set), dated 2/11/15, documented the resident with severely impaired cognition and required limited assist of 1 staff for ambulation, was not steady walking, only able to stabilize with staff assistance, and had no impairment in functional limitation of ROM (range of motion). The resident received speech, occupational and physical therapy for 5 out of 7 days, and received no restorative program. The Care Area Assessment, dated 2/11/15, documented the care area of ADLs (activities of daily living) did not trigger. The quarterly MDS, dated [DATE], documented the resident received no therapy or restorative services during the 7 day look back period (the resident discharged from therapy on 5/15/15) and revealed no other changes from the Admission MDS. The care plan, last updated 3/5/15, directed staff to assist with ADLs and mobility as needed and provide rehabilitation as ordered. The recommendations for restorative from the therapy department and used as the restorative care plan, revised 6/2/15, documented the resident discontinued from skilled therapy services and referred for the restorative program on 5/15/15. The update on 2/4/15, directed staff to have the resident ambulate to and from meals with front wheeled walker 3-5 times per week. The update on 5/15/15, directed staff to assist the resident to ambulate up to 75 feet using the walker, cues and a gait belt and to perform seated exercises, hip flexion, knee extension and abduction, and ankle ROM 3-7 times per week. review of the resident's medical record revealed [REDACTED]. On 6/3/15 at 9:28 AM, the resident sat in the wheel chair in the TV room. At 11:50 AM, the resident was propelled by staff in a wheel chair out of the activity room and placed by the aviary. At 12:52 PM, the resident was propelled back to the bedroom by staff, where the resident sat alone in the wheel chair. At 1:14 PM and 1:36 PM, there was no change in the resident's position. At 1:52 PM, the resident was assisted to the bathroom by Direct Care Staff G using a gait belt and walker. The resident's gait was very slow and unsteady. Staff G then propelled the resident to the activity room. On 6/3/15 at 9:44 AM, Direct Care Staff D reported the facility did not have a staff member specifically designated to restorative care. The facility did have a restorative aide (RA), but that person had surgery and has been gone over a month. Staff D stated the other CNAs (certified nurse aides) were supposed to do what they can, but all the CNAs had been trained to do is the walking of the residents. Staff D had never been trained to do any ROM exercises, and staff D stated he/she had no idea how to do them. Staff D stated he/she did not do any ROM on any residents at this time. Staff walk the resident to and from the bathroom, which may be 10-12 feet, and that is about it. Staff D was not aware of a specific distance the resident was supposed to ambulate daily and stated the resident received no restorative services. On 6/3/15 at 10:11 AM, Direct Care Staff E reported the facility did not have a restorative aide. The facility added new charting on the CNA's kiosk (computer system information) for restorative care on 5/27/15, and had a meeting about restorative charting that needed done on specific residents. Staff were told there would be some ROM, walk to dine, or weights needing done but it would depend on the resident. Staff are supposed to do 15 minutes of restorative on those residents for it to count, and staff were told to count from the time staff walk into the resident's room, get them dressed and do everything normally done for the resident, even if it is toileting them. Staff was told that whether it is the ROM exercises or walking that was ordered for the resident did not matter, because putting the resident's arms into clothing counted as ROM on the arms and toileting them counted as walking. Staff from the 6-2 shift is supposed to let the 2-10 shift know if any restorative charting was done or not. Staff is supposed to type in the amount of time they spend with the resident providing care, and when that amount of time matches the amount the resident is supposed to have, it will deactivate in the kiosk, showing the restorative has been done. Staff E reported he/she had walked the resident to and from the bathroom once in a while, but the resident does not get walked to meals. Staff E was not aware of a distance the resident was supposed to walk or of any ROM to be done with the resident. Staff E stated he/she had never done any ROM with the resident. On 6/3/15 at 11:56 AM, Administrative Nursing Staff B reported the facility currently did not have a restorative aide. The RA had been on medical leave for back surgery for [REDACTED]. In the absence of a RA, Administrative Nursing Staff B and C had held an in-service and trained the CNAs to do the restorative care. Staff B stated the guidance for the care is in the kiosk for the CNAs, and told the staff exactly what is to be done for each resident. On 6/3/15 at 1:56 PM, Direct Care Staff G reported he/she did not provide restorative care and the facility did not have a RA. Staff G, who worked the 2-10 shift, stated that staff were not told who needed restorative care at shift change, but Staff G had been told there was some place in the kiosk that restorative care could be charted. Staff G stated the resident would walk sometimes to the bathroom, about 10 feet, but staff G was not aware of a specific distance the resident was supposed to walk daily. When asked about the hip flexion, knee extension and abduction or ankle ROM exercises, Staff G stated he/she did not know what those were and had never done anything like that. Staff G stated he/she did not do any ROM exercises with the resident, and never had. On 6/3/15 at 2:18 PM, Direct Care Staff H reported there was a description box in the kiosk for each resident who was supposed to get restorative care. When asked if Staff H could demonstrate hip or knee flexion ROM, Staff H stated he/she did not know what that meant. Staff H stated the resident did not have a restorative plan. Staff H stated the resident would walk to the bathroom from the wheelchair, which may be about 5 feet, but that is about all the resident ever walked. On 6/3/15 at 3:55 PM, Therapy Staff I reported the facility had a restorative program that was used when a resident discharged from OT or PT. The therapy staff was responsible for the discharge plan, which included the restorative plan of care. Staff I stated the restorative person was on a leave of absence at this time, so the facility had tried to educate the CNAs, as possible, about the restorative plan of care for the residents as they were discharged from therapy. Staff I did not know if those restorative plans were being carried out or not, since the facility did not currently have a restorative aide. Staff I stated that the therapists were educating, any CNA who was working that day, at the time of a resident's discharge from therapy. Staff I stated therapy staff may need to simplify the verbiage when the CNAs were trained. Therapy staff had educated direct care staff as able and within reason, knowing that it would not include everybody. Staff I stated the therapy department could not be responsible for what the CNAs do or do not do on restorative after the resident had discharged from therapy. Staff I stated therapy staff take the time to write a proper and safe plan, train one direct care staff and hand it off to the facility. Staff I reported that therapy had voiced concern to the facility that since the RA has been gone, the restorative plans had not been followed through. Staff I stated that from the therapy department standpoint, therapy work with what we have, and in the absence of a RA, therapists have to give the information to who is available, which for now, was only regular CNAs and not a RA. Staff I reported the resident was on therapy several times this year, the last time from May to June 1, 2015. The resident had quit making progress in therapy so therapy recommended restorative care to maintain the resident's status. Staff I stated he/she was not surprised that the CNA's did not know what the care plan activities or exercises were for the resident. On 6/4/15 at 11:31 AM, Therapy Staff J reported he/she was the therapist in the facility who provided the day to day therapy and who wrote the restorative care plan recommendation when a resident discharged from therapy. That sheet was given to the DON (director of nursing), and from there, the facility was expected to implement the restorative plan for the resident by following the recommendations. Staff J reported he/she had not actively seen any restorative care happening in the building since the full time RA went on medical leave, about 2 months ago. Staff J stated that if restorative care is not provided as ordered, it takes no time at all for a resident to deteriorate. Staff J reported that when the resident's therapy ended around 5/15/15, the resident required minimal assist of 1 staff or stand by assist to ambulate and was able to ambulate 75 feet, and now can only ambulate 10 or 15 feet with maximum assistance of 1 to 2 staff. On 6/4/15 at 2:36 PM Administrative Nursing Staff C reported he/she had been the nurse in charge of the restorative care since February 2015. Staff C stated it appeared as though the CNAs were charting the restorative cares as being completed. Staff C had trained last week with some of the CNAs that they needed to pick up some of the restorative duties while the facility was without a RA. The RA had been gone for 2 months. Staff C stated that prior to last week, staff C could not tell if the CNAs were doing the restorative or not. Staff C had not ever observed any staff providing ROM for a resident, but had seen staff walking residents sometimes. Staff C reported that in the adjustment of changing the program from paper to electronic in the kiosk, Staff C had failed to assess the cares being done by the CNAs, but had focused more on whether charting was being done about the restorative care or not. Staff C stated that as a whole, the restorative program had needed help and had not been adequate for a while now. Staff had discussed the need to train a new RA and the need to provide education with the current staff about the terminology related to ADLs and ROM. Staff C stated the facility knew there was a problem with the restorative system. Staff C stated the resident was supposed to be on restorative and should be getting ROM and ambulation of 75 feet per day. Staff C confirmed that the resident cannot do that currently, but was able to when therapy ended in May. The facility provided policy for Restorative, last reviewed on 2/20/15, documented the facility provided a Restorative Nursing program with interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. The following elements are in place for the facility to demonstrate satisfactory compliance with the guide: staff are trained in carrying out the Nursing Restorative Program, documentation of treatment matches frequency and content as per plan of care, and a periodic evaluation of the resident's response to treatment. The facility failed to provide the planned restorative program to maintain this resident's ability to ambulate, who declined from 75 feet to 10 feet in the three weeks since therapy discontinued.

The facility reported a census of 42 residents with 3 residents sampled and reviewed for Range of Motion (ROM). Based on observation, interview and record review, the facility failed to provide restorative services, for one (#1) of the three residents sampled, to prevent decline in ROM of the legs. Findings included: - The June, 2015, Physicians Order Sheet, documented resident #1 admitted to the facility on [DATE]. The Admission MDS (minimum data set), dated 7/10/14, documented the resident with severely impaired cognition by staff assessment, required extensive assist of 2 staff for transfers, and ambulation did not occur. The resident had limitations in ROM with impairment on both sides of the upper and lower extremities, used a wheel chair for mobility, and rehabilitation potential had not been assessed. The resident received Occupational Therapy (OT) on 4 out of 7 days and Physical Therapy (PT) on 2 out of 7 days and with no restorative program noted. The Care Area Assessment, dated 7/10/14, documented ADLs (activities of daily living) did not trigger. The Quarterly MDS, dated [DATE], documented no change from the Admission MDS other than the resident had a history of [REDACTED]. The physician's orders [REDACTED]. which are weak, ineffective, deformed, or injured), short wave diathermy (a high-frequency electric current is delivered to generate deep heat to joints), hot moist packs and e-stem (an electrical current used to cause a single muscle or a group of muscles to contract to strengthen affected muscles) to decrease the risk for contracture development. The physician's orders [REDACTED]. The care plan, last updated 12/23/14, directed staff to monitor ADLs for assistance and provide care as needed. The recommendations for restorative from the therapy department, and used as the restorative care plan, documented the resident discontinued from skilled therapy services and referred for the restorative program on 5/27/15 and directed staff to provide passive range of motion in the bed, knee stretching and extension (straightening of a limb) to the left knee, flexion (bending of a limb) to the right knee and ankle, range of motion to bilateral upper extremities (both arms) 3-7 times per week. Staff were to provide positioning in the bed with the positioning device (a foam leg wedge) with leg separation and a flexed knee attachment to both legs. The PT progress note, dated 1/6/15, documented the long term goal as the resident would have a restorative program established for passive range of motion to the bilateral lower extremities (both legs) with techniques used to decrease tone to decrease risk of further contractures and skin breakdown. The clinical record lacked documentation facility staff developed a restorative program for this resident following the PT recommendation, dated 1/6/15 for a long term goal for the resident to have an established restorative program. The physical therapy progress and discharge summary, dated 3/30/15, documented after stretching, the resident was able to flex (bend) the right knee 90 degrees and able to position the left leg in neutral position with supine (lying on his/her back) positioning device on while lying in the bed. The summary documented the resident progressed with ROM for adaptation of right leg flexion (bending) and left knee extension (straighten) to keep the left leg from going into flexed (bent) position to decrease contractures. This improvement in function, as a result of therapy services provided, had allowed the resident increased positioning in bed. On 6/23/15 at 8:32 AM, Administrative Nursing Staff B confirmed the therapy progress and discharge summary, dated 3/30/15, was the last therapy evaluation completed before the resident discharged to the restorative program. On 6/3/15 at 9:28 AM, the resident was observed lying in bed on the left side with eyes closed. The residents left leg was in a bent position, drawn up toward the body and the right leg was extended and slightly bent at the knee. A leg wedge positioning device was lying in the recliner next to the bed and a sign posted on the wall by the bed stated the following: Positioning device: Do ROM prior to placement of the device each time it is put on. It is to be worn after each meal while the resident is lying in bed and do not leave on overnight. This is to be removed no later than 9 PM. On 6/3/15 at 11:50 AM, the resident was propelled by staff in a wheelchair from the room to the dining room. The resident's legs remained stiff and in the position they had been observed in bed earlier, and an extended foot rest was used for positioning of the legs out in front of the resident in the wheelchair with the left knee bent at approximately a 90 degree angle. At 1:15 PM, direct care staff D and E assisted the resident from the wheelchair into the bed, using the hoyer lift. While in the sling, and throughout the transfer from the wheelchair to the bed, the resident's legs remained in a fixed position, with the right leg extended but slightly bent at the knee and the left leg in a bent and drawn up position. Range of motion exercises were not performed on the resident and the leg wedge remained in the recliner next to the bed and was not applied between the resident's legs. Direct care staff D reported the resident's legs are so stiff they cannot be changed from the position they are currently in. Staff D stated it seemed terribly uncomfortable for the resident, but there was nothing staff D could do about it. Staff D stated that not too long ago, staff could manipulate the resident's legs more, so both legs were kind of straight, which made transfers a lot easier and more comfortable for the resident while up in the sling. But, over the past several weeks, the resident has just got more and more stiff, and now staff were not able to change the position of the resident's legs at all. On 6/3/15 at 9:44 AM, Direct Care Staff D reported the facility did not have a staff member specifically designated to provide restorative care. The facility did have a restorative aide (RA), but that person had been gone over a month. Staff D stated the other CNAs were supposed to do what they can, but all the CNAs had been trained to do is the walking of the residents. Staff D had never been trained to do any ROM exercises, and staff D stated he/she had no idea how to do them. Staff D stated he/she did not do any ROM on any residents at this time. Staff D reported that staff does not do any restorative with this resident. The resident had a leg wedge/positioner that staff was supposed to put on the resident, but staff did not always put it on the resident. On 6/3/15 at 10:11 AM, Direct Care Staff E reported the facility did not have a restorative aide. The facility added new charting on the CNA's kiosk (computerized information) for restorative care on 5/27/15, and had a meeting about restorative charting that needed done on specific residents. Staff were told there would be some ROM, walk to dine, or weights needing done but it would depend on the resident. Staff were supposed to do 15 minutes of restorative on those residents for it to count, and staff were told to count from the time staff walked into the resident's room, get them dressed and do everything normally done for the resident, even if it is toileting them. Staff was told that whether it is the ROM exercises or walking that was ordered for the resident did not matter, because putting the resident's arms into clothing counted as ROM on the arms and toileting them counted as walking. Staff from the 6-2 shift were supposed to let the 2-10 shift know if any restorative charting was done or not. Staff are supposed to type in the amount of time they spend with the resident providing care, and when that amount of time matches the amount the resident is supposed to have, it will deactivate in the kiosk, showing the restorative had been done. Staff E reported the resident had one leg straight out and one that is bent up and both are totally stiff. Staff C stated that the resident is supposed to receive ROM, to bend and stretch the tendons in the legs daily, every time staff get the resident up and down. Then, when staff lay the resident down, a curved wedge is to be strapped to the resident's legs to try and bend the straight leg more and make the one that is bent to not be bent so high. Staff E stated he/she had performed ROM on the resident Monday (2 days ago). Staff E stated the resident did not get ROM daily because only 2 CNAs in the facility do any ROM with residents. Staff E stated the resident used to be able to move both legs quite a bit, but now they are so stiff they really do not move at all and are in a fixed position. On 6/3/15 at 11:56 AM, Administrative Nursing Staff B reported the facility currently did not have a restorative aide. The RA had been on medical leave for the last 2 months. In the absence of a RA, Administrative Nursing Staff B and C had held an in-service and trained the CNAs to do the restorative care. Staff B stated the guidance for the care is in the kiosk for the CNAs, and told the staff exactly what is to be done for each resident. On 6/3/15 at 1:56 PM, Direct Care Staff G reported he/she did not provide restorative care and the facility did not have a RA. Staff G, who worked the 2-10 shift, stated that staff were not told who needed restorative care at shift change, but Staff G had been told there was some place in the kiosk that restorative care could be charted. Staff G reported the resident gets repositioned in bed, but is always sore and stiff. Staff G stated that staff can barely get the resident up and into the chair because of it. It takes two staff to do transfers with the resident with the hoyer lift. Staff G did not use the wedge on the resident's legs, stating there is a wedge in the room, but none of the staff usually use it. Staff G reported he/she had seen it on the resident once in a while, but that is rare. On 6/3/15 at 2:18 PM, Direct Care Staff H reported there was a description box in the kiosk for each resident who was supposed to get restorative care. When asked if Staff H could demonstrate hip or knee flexion ROM, Staff H stated he/she did not know what that meant. Staff H reported when staff dress the resident, the arms get moved around a little bit, and when you sit the resident up into the chair, staff try to straighten the leg that is bent out a little bit so the resident looks more comfortable. Staff H stated that when the resident is in bed, staff prop the resident's feet up on a pillow, but do not use the leg wedge. On 6/3/15 at 3:55 PM, Therapy Staff I reported the facility had a restorative program that was used when a resident discharged from OT or PT. The therapy staff was responsible for the discharge plan, which included the restorative plan of care. Staff I stated the restorative person was on a leave of absence at this time, so the facility had tried to educate CNAs, as possible, about the restorative plan of care for the residents as they were discharged from therapy. Staff I did not know if those restorative plans were being carried out or not, since the facility did not currently have a restorative aide. Staff I stated that the therapists were educating, any CNA who was working that day, at the time of a resident's discharge from therapy. Staff I stated therapy staff may need to simplify the verbage when the CNAs were trained. Therapy staff had educated direct care staff as able and within reason, knowing that it would not include everybody. Staff I stated the therapy department could not be responsible for what the CNAs do or do not do on restorative after the resident had discharged from therapy. Staff I stated therapy staff take the time to write a proper and safe plan, train one direct care staff and hand it off to the facility. Staff I reported that therapy had voiced concern to the facility that since the RA has been gone, the restorative plans had not been followed through. Staff I stated that from the therapy department standpoint, therapy worked with what they had, and in the absence of a RA, therapists have to give the information to who is available, which for now, is only regular CNAs and not a RA. Staff I reported the resident ended PT on 3/30/15 and ended OT on 4/16/15, and was then referred to restorative. The residents ROM goals were met and positioning goals were resolved prior to the end of therapy. The resident did not have difficulty during therapy and made steady progress toward the goals. On 6/4/15 at 10:30 AM, Complainant J reported the resident had not received restorative care since the therapy ended, and at that time the resident could straighten the bent leg (left) and bend the straight leg (right) with assistance from the staff moving it passively. Now, Complainant J reported, both legs were so stiff in place that neither bends. The resident also had contractures of the arms, the left is worse than the right. The left arm is stuck across the midsection and does not move anymore. The resident's right hand is cupped and the resident would not hold things with it anymore. Complainant J reported that when the resident was working with therapy he/she could use the fat spoons eat independently and could pick up a handled cup to drink. Now, the resident cannot grip or hold anything and the motion in the resident's arms is completely gone. On 6/4/15 at 11:31 AM, Therapy Staff J reported he/she was the therapist in the facility who provided the day to day therapy and who wrote the restorative care plan recommendation when a resident discharged from therapy. That sheet was given to the DON (director of nursing), and from there, the facility is expected to implement the restorative plan for the resident by following the recommendations. Staff J reported he/she had not actively seen any restorative care happening in the building since the full time RA went on medical leave, about 2 months ago. Staff J stated that if restorative care was not provided as ordered, it takes no time at all for a resident to deteriorate. Staff J reported that he/she was the therapist that had worked specifically with the resident's lower extremities. Staff J stated the resident's left knee was definitely more drawn up now than it was when therapy ended. Therapy recommended the leg wedge be used daily to maintain the tone of the muscle and to maintain the more stretched position of the left leg. Staff J stated he/she did not think the staff used it daily like it was ordered to do. Staff J stated the wedge was the least restrictive method to offer a sustained stretch and was working really well for the resident during therapy, but for it to help and assist in maintaining the resident ' s tone, it had to be used daily whenever the resident was in bed. In general, Staff J felt like the resident had declined because the resident ' s knee was currently drawn up much higher than it was when therapy ended. On 6/4/15 at 2:00 PM Licensed Nursing Staff K reported there is nobody doing restorative care with the residents since the RA went on medical leave 2 months ago. Staff K reported the resident had therapy a few times since admission; the last time had been within the last 2 months. Staff K stated the resident was currently supposed to be receiving restorative care, but Staff K had not seen any done. Staff K reported the resident had contractures to the lower extremities and since therapy ended, has declined. Staff K reported the resident's left leg would not stretch out like it used to be able to and the resident is extremely stiff in the joints and muscles now. On 6/4/15 at 2:36 PM Administrative Nursing Staff C reported he/she had been the nurse in charge of the restorative care since February 2015. Staff C stated it appeared as though the CNAs were charting the restorative cares as being completed. Staff C had trained last week with some of the CNAs that they needed to pick up some of the restorative duties while the facility was without a RA. The RA had been gone for 2 months. Staff C stated that prior to last week, staff C could not tell if the CNAs were doing the restorative or not. Staff C had not ever observed any staff providing ROM for a resident, but had seen staff walking residents sometimes. Staff C reported that in the adjustment of changing the program from paper to electronic in the kiosk, Staff C had failed to assess the cares being done by the CNAs, but had focused more on whether charting was being done about the restorative care or not. Staff C stated that as a whole, the restorative program had needed help and had not been adequate for a while now. Staff had discussed the need to train a new RA and the need to provide education with the current staff about the terminology related to ADLs and ROM. Staff C stated the facility knew there was a problem with the restorative system. Staff C stated the resident had a muscle tone issue, and Staff C was concerned about contractures. Staff C reported that when the resident was in therapy in April 2015, staff were able to get movement out of the resident's legs using passive range of motion. Staff C stated the staff was supposed to use the positioning device for the resident's legs because therapy spent a lot of time finding the right device to use on the resident's legs that would work and be comfortable. Staff C stated that since the RA had been gone, and the other staff do not know how to properly do ROM, the resident may be worse than before. The facility provided policy for Restorative, last reviewed 2/20/15, documented the facility provides a Restorative Nursing program with interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. The following elements are in place for the facility to demonstrate satisfactory compliance with the guide: staff are trained in carrying out the Nursing Restorative Program, documentation of treatment matches frequency and content as per plan of care, and a periodic evaluation of the resident's response to treatment. The facility failed to provide the planned restorative program to maintain this resident's ROM who declined from having legs that could be flexed and extended to being stiff and in a fixed position.