Every finding on record at Norris Square

Based on observation, interview, and document review the facility failed to appropriately assess past trauma and implement person centered care plan interventions utilizing a trauma-informed approach for 1 of 1 resident (R1) reviewed who had a history of past traumatic experiences.Findings include:R1's quarterly Minimum Data Set (MDS) assessment, dated 7/8/25, indicated R1 had mild cognitive impairment, requires a wheelchair for mobility, dependent on staff for hygiene, bathing, dressing, and positioning. R1's active diagnosis included: post-traumatic stress disorder (PTSD), major depressive disorder, anxiety disorder, bipolar disorder, and mild cognitive impairment. R1's care plan lacked individualized trauma-informed approaches or interventions and lacked identification of triggers to avoid potential re-traumatization. R1's Electronic Health Record (EHR) lacked evidence the facility assessed R1 for trauma. During observation on 12/9/25 at 10:07 a.m., R1 was observed calling out for staff assistance, asking staff to sit with him; staff sat with him briefly and left room. During observation on 12/9/25 at 10:34 a.m., R1 was observed calling out for staff to come sit with him; staff sat with him briefly and left room again. During observation on 12/9/25 at 10:47 a.m., R1 was yelling help me, help me, staff entered room to assist R1. R1 stated he wanted staff to sit with him again to assist him with eating breakfast; R1 resumed eating breakfast without assistance. During interview on 12/9/25 at 10:03 a.m., nursing assistant (NA)-C stated she did not think R1 had a diagnosis of PTSD; if he did, she does not know what his trauma was nor what his triggers were. NA-C stated it would be important to know because you don't' want to re-traumatize someone. NA-C stated the care plan would be where she would look to find out more about a residents' PTSD. NA-C reviewed the care plan and task list for R1; neither care plan nor associated task list contained information about R1's PTSD. During interview on 12/9/25 at 10:37 a.m., registered nurse (RN)-A stated R1 does not have a care plan for PTSD. RN-A stated he was unsure what R1's PTSD was related to and what his potential triggers were. RN-A stated it is important to know the traumatizing event and the triggers so you could avoid re-traumatizing the resident. RN-A stated usually the PTSD assessment is completed at admission or if the diagnosis is made after admission. RN-A stated R1 does have behaviors of calling out or emotional outbursts; unsure if this behavior could be related to a PTSD diagnosis. During an interview on 12/09/2025 at 11:04 a.m., director of nursing (DON), registered nurse (RN)-B, and administrator confirmed R1 had an active diagnosis of PTSD. The DON confirmed R1 lacked an individualized trauma-informed care plan. The administrator stated at the time of diagnosis (6/13/24), R1 had experienced the unexpected loss of his brother due to suicide. Further, R1 gets quite sad and upset still; more so, when his family hasn't visited him recently. Administrator stated the trauma assessment was not completed until 12/4/25, but was not follow up. Administrator stated it was important to complete the trauma assessment and care plan, so staff were aware of event and triggers. This would allow staff to provide the best possible care without re-traumatizing the resident. A trauma informed care policy was requested and not received.

Based on observation and interview, the facility failed to ensure proper cleaning of wheelchairs for 1 of 1 resident (R38) reviewed for safe, clean, and homelike environment.Findings include:R38's quarterly Minimum Data Set (MDS) assessment, dated 11/21/25, included R38 was cognitively intact with no behaviors. R38 used a wheelchair for mobility, required partial to moderate assistance with upper body dressing, required substantial to maximal assistance for lower body dressing.During observation and interview on 12/8/25at 2:57 p.m., R38 stated his wheelchair foot plate has left over food on it; he doesn't like it but doesn't know who is supposed to clean it. R38 stated he doesn't remember anyone ever cleaning the foot plate; wishes they would though.During observation on 12/9/2025 8:42 a.m., crusted food, dried liquid, and dirt remained on R38's wheelchair foot plate.During observation on 12/10/25 at 11:33 a.m., crusted food, dried liquid, and dirt remained on R38's wheelchair foot plate.During an interview on 12/10/2025 11:37 a.m., nursing assistant (NA)-D stated resident wheelchairs are cleaned on the resident's designated laundry day. The wheelchair cleaning schedule is posted at the nursing station. NA-D confirmed R38's wheelchair cleaning day was Thursdays; with a special note to put the wheelchair back in his room when clean. NA-D stated if she saw a foot plate with food or beverages dropped on it; everyone is responsible for cleaning immediately, even if it isn't his cleaning day. NA-D stated there is not a place to chart that wheelchair cleaning was completed; just assume someone is getting it done. During an interview on 12/10/2025 at 12:31 p.m., administrator stated wheelchairs are cleaned on the same day the resident's laundry is assigned to be done. Administrator confirmed R38 was supposed to have his wheelchair cleaned on Thursdays. The wheelchair cleaning schedule is posted at the nursing stations. Administrator stated the facility did not currently chart anywhere that wheelchair cleaning is being done. Administrator stated the process to clean wheelchairs is evening NA's place the wheelchair outside resident room to be deep cleaned on laundry day. Night NA's use shower room to deep clean wheelchair and place back outside room when dry. Administrator can not verify the last day confirmed she could not definitely say if R38's wheelchair had been cleaned recently. A policy for wheelchair cleaning was requested and not received.

Based on observation, interview, and document review, the facility failed to develop interventions to ensure residents call lights were answered in a timely manner for 3 of 3 residents (R5, R21, R37) who filed grievances related to long call light times.Finding include: R5 R5's quarterly Minimum Data Set (MDS) assessment, dated 11/21/25 indicated R5 was cognitively intact with no behaviors. R5 had no upper or lower body range of motion impairment and requires substantial assist for toileting hygiene and transfers. R5's diagnoses list included generalized muscle weakness and abnormal gait/mobility. R5's care plan included 1 assist for activities of daily living, bed mobility, and 1 assist with stand (mechanical) lift for transferring. R5 was also at risk for falls with interventions to, place call light withing reach and answer call light promptly. R5's frequently incontinent of bladder and bowel. A toileting schedule indicated offer toileting upon rising and before/after meals and before going to sleep. R5 also uses an incontinence product. During an interview on 12/8/25 at 5:41 p.m., R5 stated she often waits a long time for staff to answer her call light which is very upsetting to her. R5 stated she waited 45 minutes this morning to get ready for the day. The facility call light system includes a light outside the room and at each end of the halls. In addition, staff carry walkie talkies to which notifies them when a room light comes on. During continuous observation on 12/9/25 beginning at 9:29 a.m., a light was illuminated outside R5's door and at the end of the hall. In addition, R5's room number was heard from a nearby staff member's walkie talkie. An unidentified staff member walked past R5's room and enter a different room. At 9:31 a.m., the light outside R5's room remained on. An unidentified staff member entered the room next door that did not have an illuminated call light. At 9:38 a.m., a nurse is heard around the corner dispensing medications. R5's call light remains on. At 9:44 a.m., a staff member entered a room at the end of the hall. R5's and two other call lights are illuminated in the hall. At 9:48 a.m., nursing assistant (NA)-A entered the neighboring resident's room whose call light was not illuminated. R5's call light remained on. At 10:01 a.m., an unidentified staff member entered R5's room. The staff member was heard saying Do you have to go to the bathroom? The staff member left R5's room. The call light was still on. During an observation and interview at 10:05 a.m., R5 was sitting in the wheelchair in their room. R5 stated she placed her call light on at 9:30 a.m., to go to the bathroom and thought she had to have a bowel movement. NA-A was seen taking the neighboring resident out of their room and to the common area. R5's call light remained on. At 10:13 a.m., NA-A walked towards R5's room, turned, and started walking away. The staff turned back to R5's room and answered the call light. R5 was taken to the bathroom [ROOM NUMBER] minutes after the beginning of the observation. During interview on 12/9/25 at 10:23 a.m., NA-B stated R5 always goes to the bathroom after breakfast. During follow up interview on 12/9/25 at 11:48 a.m., R5 stated she is not incontinent and always knows when she has to go to the bathroom. R5 stated she gets up for the day at 6:30 a.m. and toilets again at 9:30 a.m., after breakfast. She will toilet again at 11:30 a.m. and then not again until 3:30 p.m. At 6:30 p.m., she goes to the bathroom again prior to going to bed. R5 stated she has not had any accidents in a long time but will sometimes urinate in her incontinence product because she can't hold it. During interview on 12/09/25 at 12:02 p.m., NA-A stated R5 will use her call light when needing to toilet however is incontinent most of the time. NA-A stated was incontinent of bowel during last toileting. During interview on 12/10/2025 at 11:50 a.m., NA-C stated, feels there are enough staff to answer call lights timely and provide for residents' needs. Review of call light logs from 12/3/25-12/10/25 indicated R5 had 21 call lights ranging from 16-55 minutes. Twenty of the 21 call lights coincided with R5's toileting schedule of 6:30 a.m., 9:30 a.m., 11:30 a.m., and 3:30 p.m. R21 During an interview on 12/10/25 at 10:30 a.m., R 21 stated she has reported to administration several times about long call light times. R21 stated each time she was told we are short-staffed. R21 stated the long call light times bother her because when she must use the bathroom in the morning upon waking, it is urgent, and she can't hold it very long. R21 stated she is anxious in the morning and has had accidents in the morning because it has taken them over an hour to assist her. R21's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R21 was cognitively intact with no behaviors. A grievance form dated 9/18/25 indicated R21 reported she waited 45-60 minutes for someone to help her get out of bed in the morning. Follow up by Administrator confirmed the long wait time, with an explanation of short-staffed. A grievance form dated 10/14/25 indicated R21 reported chronic problem with long call light times. Follow up by Administrator confirmed the long wait time, and staff would benefit from knowing wake up times. Review of call lights from 9/18/25 from 6am to 9am ranged from 20 minutes to 76 minutes. R37 R37's comprehensive Minimum Data Set (MDS) assessment, dated 11/28/25 indicated R37 had moderate cognitive impairment with no behaviors. A grievance form dated 11/25/25 indicated R37's wife reported long waits for call light response. Initial investigation response re-educated staff on timeliness of answering call lights. Review of call lights from 11/25/25 showed call light ranges of 18 minutes to 44 minutes. A random audit of call light logs from 12/3/225 to 12/10/25 indicated R6, R13, R17, R30, R32, and R38 had a total of 30 call lights ranging from 20-304 minutes. During an interview on 12/10/25 at 12:01 p.m., administrator stated all grievances are reviewed and investigated and she follows up with the resident once grievance investigation is completed. Administrator confirmed she was aware of the long call light grievances from September and October. Administrator verified call light audit report reviewed during survey had long call light times. Administrator stated they strive to have call lights answered within 10 minutes. Administrator confirmed long call lights times remain a problem.

Based on observation, interview, and document review, the facility failed to ensure oxygen therapy was administered as ordered and maintained appropriately for 1 of 1 resident (R16) reviewed for respiratory services. Findings include: R16's admission Minimum Data Set (MDS) dated [DATE], indicated R16 had moderately impaired cognition and required assistance with many activities of daily living (ADLs). The MDS indicated R16 required oxygen therapy and had diagnoses including respiratory failure, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), dementia, and anxiety. R16's care plan dated 9/19/24, indicated R4 had an alteration in respiratory status related to COPD, respiratory failure, and CHF and required the use of oxygen. The care plan instructed staff to ensure R16 had a full portable oxygen tank prior to leaving his room for meals and activities and to ensure oxygen was delivered via nasal cannula as ordered. R16's provider order dated 10/16/24 indicated, oxygen 4lits [liters] continuous. Can increase to 6lits [liters] PRN [as needed] to keep sats [blood oxygen saturation level] above 90%. R16's October 2024 treatment administration record (TAR) indicated, Fill and check portable liquid and O2 [oxygen] tank supply sufficiency every shift and as frequently as needed depending on liter flow rate .Tubing and canula in plastic bag and hang appropriately when not in use. R16's care sheet dated 10/22/24, instructed staff to Fill portable O2 tank before leaving room for meals and to help with O2 tubing. During observation and interview on 10/21/24 at 2:38 p.m., R16 was in his room sitting in the recliner but still receiving oxygen via nasal cannula through the portable tank hanging on the back of his wheelchair. The level of O2 in the portable tank was on the lowest edge of green indicating very low or almost empty. R16's oxygen concentrator was off and sitting next to the recliner. The tubing connected to the concentrator was undated and laying on the floor between the recliner and the bathroom. R16 stated he did not know when the staff last checked or filled the portable tank or changed the O2 tubing. During observation on 10/22/24 at 9:49 a.m., R16 was sitting in common area with several other residents waiting for an exercise activity to begin. R16 had O2 on through nasal cannula connected to a portable tank. The level in the tank was again at the lowest limit of the green indicator, appearing very low. During observation on 10/22/24 at 11:56 a.m., R16 was in his room sitting in the recliner. He was receiving oxygen via nasal cannula connected to the portable tank hanging on his wheelchair. The O2 level indicator now in the red indicating the tank was almost empty or empty. The concentrator was next to him, turned off and tubing lying on the floor. During observation on 10/22/24 at 12:04 p.m., R16 self-propelled out into the hallway. Nursing assistant (NA)-A walked by and told R16 he would assist him to lunch in a minute and would fix his oxygen. At 12:06 p.m., NA-A adjusted R16's nasal cannula and wheeled R16 to the dining room. NA-A did not check the level of oxygen in the portable O2 tank. During observation on 10/22/24 t a12:59 p.m., licensed practical nurse (LPN)-A pushed R16's wheelchair out of the dining room into the hallway and encouraged R16 to self-propel back to his room. LPN-A did not check the portable tank. Director of nursing (DON) approached R16 and offered to assist him back to his room. R16 declined. DON did not check R16's portable tank. R16 self-propelled approximately 60 feet to his room. During observation and interview on 10/22/24 at 1:38 p.m., unidentified hospice music therapist left R16's room after 30 minutes of music therapy. R16 was sitting in his room in his wheelchair and was not wearing his nasal cannula which was hanging off the arm of the wheelchair. R16 stated he thought the tank was empty and checked the nasal cannula confirming no O2 flow. R16 stated he could not remember the last time staff checked or filled the portable tank. During observation on 10/22/24 at 1:45 p.m., R16 was standing in the hallway inquiring about the upcoming activities. NA-B identified R16 standing unassisted and escorted him back into his room and into his wheelchair. NA-B asked if R16 needed anything from her, he declined, and she left the room. NA-B did not address R16's oxygen and did not place R16 back on the nasal cannula. During observation and interview on 10/22/24 at 1:50 p.m., LPN-A stated nurses were responsible for oxygen therapy maintenance. LPN-A stated her practice was to round at the start of the shift to ensure O2 was on as ordered and tubing was maintained appropriately. LPN-A further stated portable tanks were supposed to be checked by any staff prior to placing a resident on the tank and prior to leaving the room. LPN-A entered R16's room and identified R16 without his nasal cannula in place. LPN-A immediately placed R16 on O2 via the concentrator. LPN-A stated R16 should be on his concentrator when in his room and that all staff were responsible for ensuring he was wearing the nasal cannula and on the concentrator when in his room. LPN-A confirmed the portable tank was empty and also that the concentrator tubing should not be lying on the floor. LPN-A replaced the portable tank with a full one, refilled the water on the concentrator humidifier, and replaced the concentrator tubing with new tubing. During interview on 10/23/24 at 8:15 a.m., registered nurse (RN)-A stated staff should always check the portable O2 tanks when the resident was placed on the tank and each time prior to leaving the room. RN-A stated the resident should be on the concentrator when they were in their room rather than the portable to conserve the oxygen in the portable tank. RN-A stated R16 was on 4 liters of O2 and could go through a portable tank pretty quickly and checking his tank prior to leaving the room was very important. RN-A further stated O2 tubing should not be lying on the floor when not in use. During interview on 10/23/24 at 12:01 p.m., DON stated it was the nurse's responsibility to ensure oxygen therapy was maintained per provider orders. DON stated residents should be on the O2 concentrator when in their room and that the portable tank should be checked and full when the resident leaves their room and the expectation for any staff to check the portable tank prior to the resident leaving his room. DON further stated O2 tubing should not be lying on the floor when not in use for infection control. Facility policy Oxygen Administration dated February 2017, indicated nurses should check each shift, or more frequently as appropriate, the O2 tank to ensure appropriate flow and sufficient O2 is present in tank. The policy further indicated, Tubing, humidifier and nasal cannula, mask or other apparatuses to administer oxygen should be placed in a plastic bag when not in use. Facility policy Oxygen Equipment Care and Maintenance dated October 2011, indicated, Tubing is not to touch the floor .Curl tubing and place, with mask/cannula, in a plastic bag and hang appropriately .On each shift the nurse should monitor liter flow of oxygen.

Based on observation, interview, and document review, the facility failed to clean and maintain a resident's wheelchair for 1 of 1 resident (R4) reviewed for safe, clean, and homelike environment. Findings include: R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated R4 was cognitively intact, was dependent on staff for mobility in a manual wheelchair, required partial/moderate assistance with transfers and set up/clean up assistance with meals. The MDS indicated R4 would have a loss of liquids/solids from mouth when eating or drinking. R4's diagnoses included progressive supranuclear ophthalmoplegia (a condition affecting the movement of the eyes), dysphagia (a condition affecting one's speech), and anxiety. R4's care plan dated 9/6/24, indicated R4 had an activities of daily living (ADL) self-care performance deficit and instructed staff to assist as needed with dressing, grooming, eating, bathing, and mobility. The care plan instructed staff to place a clothing protector on shirt and lap during meals. R4's clinical nutrition assessment dated [DATE], indicated R4 required an extra clothing protector for lap protection from spills and that R4 had a loss of food/liquids from mouth. R4's nursing assistant care sheet (south unit) dated 10/22/24, indicated R4's bath day was Monday mornings and laundry was pulled from R4's room on Sunday evenings. The south unit laundry/wheelchair cleaning schedule dated 6/13/24, indicated R4's room number was listed on Sunday (wash sling) and Wednesday. During observation and interview on 10/21/24 at 2:24 p.m., R4's right side of her wheelchair seat and seat cushion had dried liquids, cereal ,and other unidentified dried food items. R4 stated did not like the chair being dirty and did not know last time it had been cleaned. During observation and interview on 10/22/24 at 1:18 p.m., nursing assistant (NA)-A confirmed R4's wheelchair was very dirty with dried cereal and other food items on and under the right side of the seat cushion. NA-A stated that there was a schedule for wheelchair cleaning and the overnight staff cleaned them per the schedule, however it was the responsibility of all staff to ensure the resident's wheelchairs were clean. NA-A stated that if a dirty wheelchair was identified by staff, that staff should clean it or ensure it was cleaned right away. During observation on 10/23/24 at 1:00 p.m., R4 was in the dining room eating lunch in her wheelchair. The right corner of the seat appeared dirty with dried food items. During observation on 10/23/24 at 1:58 p.m., R4's wheelchair was still extremely dirty with the same dried liquids, cereal, and other unidentified food items. During interview on 10/23/24 at 2:06 p.m., registered nurse (RN)-A stated wheelchairs were cleaned weekly on the resident's bath day per the schedule but should be cleaned on an as needed basis as well. RN-A stated staff were expected to clean the wheelchairs immediately when identified as dirty, and should not just wait for the weekly scheduled washing. RN-A stated R4's wheelchair could get pretty dirty during meals due to the way she ate and leaned to the right side. During interview on 10/23/24 at 2:10 p.m., director of nursing (DON) stated wheelchairs were scheduled to be cleaned weekly on the resident's bath day, but the expectation was for staff to maintain a clean wheelchair throughout the week. DON further stated R4's wheelchair could get pretty dirty during meals and should probably be on a twice a week schedule for cleaning. Facility policy Infection Control Wheelchair Cleaning dated October 2015, indicated, Wheelchairs will be maintained in a clean, hygienic condition.

Based on observation, interview, and document review, the facility failed to perform timely comprehensive skin assessments, and implement interventions to promote healing and reduce the risk for further pressure ulcer development for 1 of 2 resident (R22) who was admitted to the facility without pressure ulcers. This resulted in harm for R22 when the facility failed to develop interventions to promote healing and prevention resulting in R22 developing three pressure ulcers. Findings include: A stage one pressure injury is intact skin with a localized area of redness that is non-blanchable (does not turn white when pressed). A stage two pressure ulcer is partial thickness loss of the skin with exposed dermis, presenting as a shallow open ulcer. A stage three pressure ulcer is full thickness loss of the skin in which subcutaneous fat may be visible. Additionally, slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture) or eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like) may be visible but does not obscure the depth of the tissue loss. R22's Face Sheet form indicated the following diagnoses: unspecified protein calorie malnutrition, pressure ulcer of unspecified buttock stage three, major depressive disorder, and type two diabetes. R22's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition, did not reject care, required partial to moderate assistance with toileting, showering, was occasionally incontinent of bladder, was five feet tall and 105 pounds, was at risk of developing pressure ulcers and did not have one or more unhealed pressure ulcers at a stage one or higher. Under the section Skin and Ulcer Treatments R22 had a check mark next to applications of ointments and medications other than to feet. R22's significant change in status (MDS) dated [DATE], indicated R22 had moderate cognitive impairment, did not reject care, was occasionally incontinent of bladder, and frequently incontinent of bowel, was 104 pounds, was at risk for pressure ulcers and had one stage three pressure ulcer and under the section, Skin and Ulcer Treatments had a check mark next to pressure relieving device for R22's chair and bed, had nutrition or hydration intervention to manage skin problems, pressure ulcer care, and applications of ointments and medications other than to feet. R22's significant change in status (MDS) dated [DATE], indicated moderate cognitive impairment, did not exhibit behaviors, and did not reject care. Required substantial maximal assistance for toileting hygiene, partial moderate assist for moving from sitting to lying, and chair to bed to chair, and toileting transfers required supervision or touching assistance, was occasionally incontinent of urine and always continent of bowels. R22's weight was 101 pounds, was at risk of developing pressure ulcers and had two stage three pressure ulcers, and under the section, Skin and Ulcer Treatments had a check mark next to pressure reducing device for chair, bed, pressure ulcer care, applications of ointments and medications other than to feet. R22's care plan dated 7/7/23, indicated an activity in daily living (ADL) self care performance deficit and required staff assistance due to limited mobility, impaired balance and an intervention included to observe skin for redness, open areas, scratches, cuts, bruises and report changes. R22's care plan dated 7/7/23, indicated R22 had limited physical mobility and required staff assistance due to limited mobility and impaired balance. The care plan was later updated on 11/2/23, to include an intervention identifying R22 required assist of one to reposition in bed and assist of two to boost up in bed. This intervention further indicated R22 had an air pressure reduction mattress on the bed, and R22 preferred to sleep in the recliner and had an air pressure cushion. Prior to 11/2/23, the bed mobility intervention was last revised on 9/13/23, to include R22 required assist of 1 to reposition self in bed and encourage off loading in bed and chair. R22's care plan dated 10/9/23, indicated an altered nutritional status due to weight loss and impaired skin integrity. Interventions indicated providing a diet as ordered, monitor intake, obtain weights, monitor lab work, honor food preferences and requests. R22's care plan dated 10/13/23, indicated R22 was at risk for impaired skin integrity due to limited mobility, medication side effects, bladder incontinence, malnutrition and had two stage three pressure ulcers on the left buttock and coccyx. R22's goal indicated the current pressure ulcers would show signs of improvement by the next review date as evidenced by a decrease in size or a resolved status. Interventions indicated following facility protocols and policies for prevention of skin breakdown, a pressure reducing mattress, able to request assistance for toileting and repositioning, observe for signs and symptoms of breakdown and update the nurse promptly if noted. The most recent intervention on the care plan was dated 8/4/23, and indicated R22 required a pressure reducing wheelchair cushion. No new interventions were added following the development of new pressure ulcers. R22's care sheet dated 10/11/23, indicated R22 required assist of one with a transfer belt for transfers and ambulating short distances. Additionally, R22 required assist of one when going to the bathroom, and with dressing, grooming, and bathing and required a body audit completed on Thursdays, further, R22 required frequent repositioning and offloading while in the bed and wheelchair. The care sheet had a yellow highlighted instruction dated 8/4/23, to remind R22 to reposition off bottom for a few minutes every two to three hours due to having a pressure ulcer. The care sheet lacked any information or instruction resident had a cushion for the reclining chair. R22's Amount Eaten Task form dated 10/3/23, to 10/31/23, indicated variable appetite, however mostly ate 76-100% of meals. R22's nursing progress notes dated 6/21/23 at 12:25 p.m., indicated R22's skin was clean, dry, and intact. R22's nutritional summary note dated 6/22/23 at 11:21 a.m., indicated R22 admitted to the facility with a wedge compression fracture, malnutrition, type two diabetes and consumed 76 to 100% at meals since admission. Additionally, the note indicated skin was clean dry and intact, and had a history of a pressure injury to R22's sacrum. An oral nutritional supplement (ONS) was discontinued due to refusals and a p.m. snack was added to promote intake. R22's nursing progress note dated 7/16/23 at 4:30 p.m., indicated R22 required an assist of one to transfer and usually self transferred and refused to be assisted and stayed in her recliner most of the time. R22 was checked changed and repositioned every two to three hours and as needed. R22's nutrition risk assessment dated [DATE], indicated R22 consumed 76 to 100% at most meals and received a p.m. snack every day with good acceptance and at times was sleeping and skipped the snack. Additionally, R22's weight on 7/19/23, was 110.2 pounds and was trending upwards which was desired due to malnutrition, but weight could fluctuate due to taking a diuretic medication. R22's nursing progress note dated 8/1/23 at 6:45 p.m., indicated a 1 inch stage two to three pressure ulcer on the right buttocks. The note indicated the coccyx, buttocks was macerated and erythematous and tender to touch and R22 was educated about frequent repositioning and sleeping in R22's bed versus the chair. The note indicated to continue to monitor and the next registered nurse was updated. R22's nursing progress note dated 8/4/23 at 8:21 a.m., indicated a late entry wound assessment and R22's daughter was notified of a stage two wound on buttocks and the practitioner, dietician, and therapy were notified. R22's nursing progress note dated 8/15/23 at 10:32 a.m., indicated R22 had a change in condition and was sent to the emergency room . At 5:58 p.m., nursing progress notes indicated R22 was admitted to the hospital and the hospital stated R22 had multiple sores on her bottom. R22's nursing progress note dated 8/16/23, indicated R22 came back to the facility, was fatigued and had a triad hydrophilic wound dressing. (A paste that maintains an optimal wound healing environment and facilitates a natural debridement.) Documentation lacked information a wound assessment was completed upon return from the hospital and a wound assessment was not completed until 8/25/23. R22's culinary progress note dated 8/22/23 at 8:16 p.m., indicated R22 had a weight gain and was 112.6 pounds. R22's weight continued to increase as a result of a good appetite and would be appropriate to discontinue from high risk monitoring however the dietician noted a wound assessment from 8/4/23, indicating a pressure area to R22's coccyx and body audits indicated the wound remained present, however a more recent wound assessment was not available. R22's nursing progress note dated 9/26/23 at 3:46 p.m., indicated R22 had two pressure ulcers; one on the coccyx (tailbone), and one on the left gluteal fold (the horizontal skin crease that forms below the buttocks). An additional progress note on 9/26/23, indicated R22 had a new pressure ulcer on her coccyx. R22's Order Summary Report form indicated the following orders: - 8/4/23 Boudreauxs butt paste external ointment 40% zinc oxide topical. Apply to buttock topically three times a day for pressure ulcer educate about not applying Vaseline to area; may use house supply of zinc oxide cream - 9/26/23 treatment for both open areas on buttocks (left gluteal fold, and below the coccyx area) to be done Monday, Wednesday, Friday, and as needed. Cleanse both buttocks open areas with normal saline, pat dry with gauze, use skin prep around both areas avoiding going into the wound, apply Manuka hd dressing directly in the wound and cover each area with a barrier film dressing every 1 hours as needed and replace dressing when soiled or if it falls off. During the month of 6/12/23 through 10/19/23, R22's completed body audit form indicated the following: - On 6/21/23, which indicated R22 had a trace of a healed pressure ulcer on her sacrum, with a small area of discoloration and required frequent reposition/offloading to avoid recurrence. - On 6/29/23, no skin concerns - On 7/2/23, skin was clean dry and intact clean, dry and intact (CDI) - On 7/6/23, skin was CDI. - On 7/13/23, R22 had blanchable redness to buttocks and skin was intact. - On 7/20/23, R22 had blanchable redness on gluteal folds, some parts were minimally excoriated and butt paste was applied and the rest of R22's skin was CDI. - On 7/27/23, R22 had blanchable redness to buttocks and butt paste was applied. - On 8/3/23, R22 had blanchable redness on gluteal folds and noted excoriation on the left gluteal fold and Boudreauxs Butt Paste was applied and the rest of the skin was CDI. - On 8/10/23, R22 had blanchable redness to buttocks and excoriation on left gluteal fold and butt paste was applied. - On 8/16/23, under comments indicated pressure on left gluteal fold and surrounding areas were excoriated and wound treatment was in place. - On 8/24/23, body audit indicated R22 had a stage two pressure injury to the left gluteal buttock and treatment and monitoring was in place. - On 8/31/23, body audit indicated R22 had pressure on the left gluteal fold and blanchable redness on surrounding areas and wound treatment was in place. - On 9/7/23, the body audit form indicated a stage two pressure ulcer to the left gluteal fold and a hydrocolloid was applied after R22's shower. - On 9/14/23, R22 continued with the left gluteal fold pressure ulcer with blanchable redness on the surrounding areas. - On 9/21/23, The body audit form indicated the pressure injury to the left gluteal fold and no increase in size. - On 9/28/23, the body audit form indicated R22 had pressure ulcers on the coccyx and the left gluteal fold. - On 10/5/23, the body audit indicated two pressure ulcers to left buttock coccyx region. - On 10/12/23, the body audit indicated a pressure injury on both the coccyx and left gluteal fold were still present. - On10/19/23,the body audit indicated a pressure injury on the coccyx and left gluteal fold. - On 10/26/23, the body audit indicated no new skin issues were observed and had a pressure injury on both the coccyx and left gluteal fold. The body audits lacked any kind of assessment of the wounds. R22's Bowel Bladder and Skin Risk assessment dated [DATE], indicated R22 stayed in her recliner most of the time. Additionally, R22's Bowel Bladder and Skin Risk assessment dated [DATE], indicated R22 self transferred to the bathroom and spent most of each shift in her recliner. The assessment indicated R22 self transferred and was occasionally incontinent of bowels and was checked, changed, and repositioned every 2-3 hours and as needed. R22's Skin and Wound Evaluation Assessment form indicated a skin and wound evaluation was completed on the following dates in the electronic medical record (EMR): - 8/4/23, a new stage two in-house acquired pressure ulcer to the coccyx measuring 0.6 centimeters (cm) long by 0.4 cm wide and was documented as not applicable for the depth, no tunneling (a passageway of tissue destruction under the skin) or undermining (destruction of skin tissue extending under the skin edges. The goal of care for the wound was documented as healable - 8/25/23, the coccyx pressure ulcer measured 0.7 cm long by 0.8 cm wide and had a depth of 0.5 cm and 10% of the wound contained slough. - 9/1/23, the coccyx pressure ulcer measured 0.7 cm long by 0.6 cm wide and the depth was not applicable and 10% of the wound contained slough. - 9/18/23, the coccyx pressure ulcer now identified as a stage three ulcer measuring 0.8 cm long by 0.8 cm wide with a depth of 0.5 cm and 10% of the wound contained slough. Under the section labeled, Additional Care which included check boxes of various interventions such as cushion, air flow pad, or mattress with a pump, none was indicated. - 9/26/23, contained two wound assessments: At 8:29 a.m., a stage three coccyx pressure ulcer that measured 0.8 cm long by 0.8 cm wide by 0.5 cm deep. At 8:33 a.m., a stage three pressure area to the coccyx documented as New as of 9/26/23 and measured 1.1 cm long by 0.7 cm wide with a depth of 0.5 cm and 50% of the wound contained slough with 4 cm of redness to the surrounding tissue. A cushion, turning and repositioning program was indicated in the check boxes under the section, Additional Care. - 10/2/23, at 1:47 p.m., indicated a stage three pressure ulcer to the coccyx that measured 1 cm long by 0.9 cm wide by 0.5 cm deep and contained 10% slough. - 10/10/23, at 1:24 p.m., indicated a stage three pressure ulcer to the coccyx that measured 0.8 cm long by 1.1 cm wide by 0.5 cm deep. At 1:23 p.m., a stage three pressure ulcer to the coccyx that measured 1.1 cm long by 0.9 cm wide and 0.5 cm deep and 10% of the wound contained slough. - 10/26/23, at 9:25 a.m., indicated a stage three pressure ulcer to the coccyx that measured 1.1 cm long by 11.1 cm wide by 0.3 cm deep. - 10/31/23, indicated a stage three pressure ulcer that measured 1.2 cm long by 1.0 cm wide and no depth. An additional form indicated 0.8 cm long by 0.8 cm wide by 0.5 cm deep. The Skin and Wound Evaluation Assessment form identified each wound was located on the coccyx. A record request form was provided to the facility requesting all assessments related to skin and wounds since admission including picture assessments that identified each wound and their measurements, however the requested information was not entirely received. During interview and observation on 10/30/23 between 5:48 p.m., and 5:50 p.m., R22 stated she had irritation on her bottom that was hard to heal and stated they provided a pillow to use, and had not spoken with her about staying off her bottom. R22 had a circular cushion in another chair but did not have a cushion in the recliner R22 was in. R22 had a cushion in the wheel chair and additionally had an air mattress on her bed. R22's care sheet updated on 10/11/23, lacked interventions for a cushion in the recliner. During observation on 11/1/23 at 6:56 a.m., R22 was in her room in her reclining chair and her head was bent forward. During interview at 11/1/23 at 7:19 a.m., registered nurse (RN)-B stated R22 slept in her recliner 90% of the time and refused to sleep in the bed despite encouragement and added it was R22's choice. RN-B stated R22 was supposed to have a cushion in the chair she slept in. During interview and observation on 11/1/23 at 7:25 a.m., R22 was in the bathroom with staff and had a circular type cushion in her arm chair, but was not in R22's recliner chair where she slept. nursing assistant (NA)-B stated she had worked at the facility for two years and stated R22 slept in her chair. NA-B verified the circular cushion was not in R22's recliner chair she slept in this morning when R22 got up and verified R22 did not have any type of cushion in her recliner when she assisted her to get up. NA-B stated they toileted and repositioned R22 and stated R22 was continent. NA-B offered to apply the circular cushion to R22's recliner chair and R22 accepted. NA-B stated as the day goes on, R22 got weaker and needed assist and stated R22 could shift positions in her chair and added they tried to push for R22 to sleep in the bed as much as possible. During interview on 11/1/23 at 10:19 a.m., NA-C stated R22 could not get out of the recliner by herself and when R22 stood, she pushes off, but cannot get up on her own and just rocks in her chair and needed assist. During interview on 11/1/23 at 12:54 p.m., licensed practical nurse (LPN)-B stated wounds were measured once a week and stated R22 had two pressure ulcers and one was near the coccyx and the other on the left gluteal fold. LPN-B clarified R22's left buttocks was deteriorating and stated it looked like it was deeper and like the wounds were not improving. LPN further stated the pressure ulcers were hard to heal because R22 did not get off her bottom and wasn't eating well. LPN-B stated R22 could get up to go to the bathroom by herself and added R22 slept in her recliner chair. During interview on 11/1/23 at 1:07 p.m., nurse manager (NM)-G stated she asked hospice about an offloading cushion for R22 at the care conference on 10/13/23, and added R22 received an air mattress for her bed, and a gel cushion for R22's wheel chair. NM-G verified the care conference note lacked information regarding a cushion for the recliner chair. NM-G further stated R22 wished to only sleep in her chair and when asked about a circular cushion observed in R22's room, NM-G stated the cushion could have come from hospice and hoped the family brought in the cushion because hospice should notify the facility if they bring items in. NM-G further stated she had not followed up to see if interventions were effective and did not follow up to verify if a cushion was in place. During interview on 11/1/23 at 1:14 p.m., LPN-B verified no wound assessments were completed after 8/4/23, until 8/25/23. LPN-B stated from 10/10/23, to 10/26/23, they were missing a week of assessments. LPN-B further stated the problem with putting the cushion in the chair when they had therapy look at it, was the manufacturer wouldn't approve a cushion in the recliner because they couldn't guarantee it wouldn't slide out and that was why they asked hospice to look into it. During interview on 11/1/23 at 2:20 p.m., the health unit coordinator (HUC)-H verified the hospice notes in the paper chart and in the electronic medical record (EMR) lacked any information regarding a cushion or follow up on a cushion for the reclining chair. During interview and observation on 11/1/23 at 3:38 p.m., R22 was in her reclining chair with a pillow behind her back, but there was no cushion on the seat of the recliner chair. RN-F measured the wound on R22's left buttocks and was 1.6 cm long by 0.9 cm wide and 0.3 cm deep. RN-F measured the wound to R22's coccyx and was 1 cm long by 1 cm wide that included tunneling in the corner right inside corner that measured 0.4 cm at 1 O'clock. RN-F also stated R22 had a new stage one pressure injury to R22's right inner buttocks that measured 0.7 cm long by 0.9 cm wide. RN-F stated R22 did not want the cushion her daughter gave her and stated R22 didn't always use it and stated R22 was on a repositioning schedule and occupational therapy got R22 a special cushion she thought was the circular cushion. RN-F stated since R22 had a new wound they may have to do something different and verified that wound assessments were supposed to be done weekly and used to be completed on Wednesdays, but stated there had been some changes and verified wound assessments were documented in the chart and were missed. RN-F further stated if wounds are not monitored they are going to get worse because you cannot evaluate a wound if you are not assessing them and expected there to be interventions in place regarding R22's recliner chair. During interview on 11/2/23 at 8:11 a.m., the director of nursing (DON) stated she found a wound assessment in a file and provided four of five pages of a hand written note on a Body Audit form dated 10/16/23. The form indicated R22's left gluteal fold measured 0.8 cm long by 0.76 cm wide by 0.5 cm deep and the coccyx measured 0.57 cm long by 0.66 cm wide by 0.5 cm deep. During interview on 11/2/23 at 8:25 a.m., LPN-B stated she had the mobile application for documenting the wound assessment on her phone and it was deleted so the assessment dated [DATE], did not pull over and stated the assessment was completed on 10/16/23, and stated they were 100% paperless and verified prior to 10/16/23, R22 was missing several wound assessments. During interview on 11/2/23 at 10:52 a.m., the hospice RN stated, she just met R22 on 10/27/23, and was hopeful R22's wounds would heal and was dependent on her nutrition status. Hospice RN stated she just forwarded an email from the house hold coordinator (HHC)-C to check on the status of a wound cushion. During interview on 11/2/23 at 11:02 a.m., hospice RN stated she was not notified of a new wound and was not aware R22 was not sleeping in her bed and stated it would be important if R22 was in her chair to have an intervention for her recliner chair and further stated wound assessments were important to complete to make sure new interventions were put in place if the wound was not healing according to the plan. During interview on 11/2/23 at 12:34 p.m., hospice RN stated HHC-C sent her an email on 11/1/23, regarding a cushion and stated it was the first time she had heard about a cushion and further stated she ordered a standard cushion and the nursing facilities wound care team was taking care of the wounds and updating her on the wound measurements. During interview on 11/2/23 at 12:46 p.m., nurse practitioner (NP)-J stated R22's albumen level (an indicator of nutritional status) was completed on 8/15/23, and was 3.7 which was within normal limits. NP added R22 sitting in general like she preferred to do, put her at increased risk, but not having a cushion in addition to the reclining chair could have contributed to worsening pressure ulcers and additional ones as well and further stated she would have expected weekly skin assessments because even if there were no pressure ulcers, you want to see if there was one developing and once one was present, you want to make sure it doesn't worsen and if you have one pressure ulcer, you are at additional risk of getting another one. During interview on 11/2/23 at 1:27 p.m., DON stated wound assessments should be completed according to their policy of every seven days at a minimum and would have expected staff to document wound assessments and additional interventions in place knowing R22 did not want to lie in bed. During interview on 11/3/23 at 11:40 a.m., DON stated assessments were not getting completed and they were looking to adjust staff loads to include trained medication aides. A policy, Skin Integrity Management Policy dated October 2022, indicated it was the facility policy to properly identify, assess, and monitor residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers/injuries; to implement preventative measures; and to provide appropriate treatment modalities for pressure ulcers/injuries according to industry standards of care. A Braden scale was completed on admission and weekly to determine level of risk and regardless of the resident's total risk score, each risk factor and potential causes should be reviewed individually, addressed in the analysis and interventions implemented. Based upon findings of the clinical assessment in partnership with the resident and or family input, a care plan will be developed or modified to reflect alterations in interventions and implementation of new interventions specific to the resident. When a non surgical wound is discovered a new Wound Assessment is documented in point click care that includes the onset of the skin condition, type of wound, location, date, stage, length, width and depth; wound base description, surrounding skin description and if present drainage, odor, undermining, tunneling, and or pain. Documentation on the wound using the wound assessment with a structured progress note generating from the assessment should be done at least weekly, or more frequently depending on the wound characteristics or type dressing used. Implement appropriate interventions and update care plan and nursing assistant assignment sheets. An avoidable pressure ulcer/injury means the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate.

Based on interview and document review, the facility failed to follow their grievance process to ensure a voiced grievance concerning activities was resolved to satisfaction for 1 of 2 residents (R29) reviewed for grievances. Findings include: R29's significant change Minimum Data Set (MDS) dated [DATE], indicated it was very important R29's family or close friend was involved in discussions about care, was very important to have books, newspapers, and magazines to read, listen to music, do things with groups of people, do favorite activities, and participate in religious services or practices. R29's quarterly MDS dated [DATE], indicated R29 had a memory problem, was dependent on staff for most activities of daily living (ADLs), had minimal difficulty hearing and wore a hearing aid. R29's Medical Diagnosis form (undated), indicated the following diagnoses: unspecified severe dementia with other behavioral disturbance, delusional disorders, major depressive disorder, and difficulty in walking. R29's care plan dated 9/25/23, indicated R29 was dependent on staff for activities due to dementia and would attend activities of choice. An intervention dated 10/31/23, indicated R29 had an electric keyboard to use at the table. Other interventions included R29 required one to one visits if R29 was unable to attend group activities, assistance to attend activity functions, invite to scheduled activities including church, special music, bingo, exercise, socials, outdoor activities, and coloring, take to any and all religious services and take to communion, when R29 chose not to participate in organized activities to provide independent activities in common areas to include cards, and activity blankets. R29's Quality Concern form dated 10/18/23, completed by house hold coordinator (HHC)-C indicated family member (FM)-B was concerned the common area television was not set to a TV program channel, but was set to music and wanted more at R29's table to keep busy. Additionally, HHC-C contacted R29's family to provide ideas on items to keep R29 busy and followed up with staff by posting a small reminder sign on the TV for the appropriate volume level and generation appropriate shows to enjoy. Under section four of the form, the administrator spoke with life enrichment about giving R29 more options on 10/19/23, however the form was undocumented under the sections, Person that completed this form contacted and updated on this date along with Name of person making the follow up contact. During observation 10/30/23 at 6:01 p.m., R29 was in her room in bed. During observation on 10/31/23 at 9:39 a.m., R29 was out in a day room with the television on and had a stuffed cat next to her. During interview on 10/31/23 at 10:11 a.m., FM-B stated R29 had no social interaction and added R29 used to be a director of a program and went to nursing facilities every day to entertain residents and was now spending her life alone. FM-B further stated R29 was an extremely social person. FM-B stated staff turned on the music channel, but stated it was so quiet, FM-B could not hear the television. FM-B stated they have expressed concerns for the past couple of years, and the answer they received was they were working on it, but nothing ever changed. During observation on 10/31/23 at 1:40 p.m., R29 was in bed and the door to the room had been closed and R29's shades were drawn and the room was dark. R29 had mouth movements. During interview on 10/31/23 at 1:48 p.m., nursing assistant (NA)-A stated R29 required total assist for cares and staff lay R29 down after lunch. During interview and observation on 10/31/23 at 2:20 p.m., R29 was brought out to the day room and was given a key board, activity coordinator (AC)-A turned on a black and white movie and left resident by herself. AC-A stated they documented who attended activities. During interview on 11/2/23 at 9:09 a.m., registered nurse (RN)-A stated R29 had severe dementia and could not effectively communicate her needs to staff. When R29 saw staff she called for their attention and most of the time wanted to hold your hand and stated staff should pay attention and talk with R29 and offer a keyboard. RN-A stated R29 wanted to be involved in activities and exercises, especially music. During interview on 11/2/23 at 12:22 p.m., administrator (A)-D stated he documented responses such as following up with culinary on the Quality Concern form and stated he hoped to follow up with the resident or family to see if they were satisfied. During interview on 11/2/23 at 3:28 p.m., A-D stated he expected grievances to be taken care of immediately because he did not want someone to get the courage to submit a grievance and then not hear about if for a couple of days. A policy, Quality Concern/Grievance Process undated, indicated if the concern or grievance was being filed orally, the staff member receiving the information should write a brief description of the concern, if the staff member receiving the concern can immediately address the issue this will be noted in section three and the form will be signed and dated with a copy routed to the administrator. The concern or grievance will be addressed minimally within five working days and action items will be communicated to the individual filing the grievance unless indicated as anonymous.

Based on interview and document review, the facility failed to ensure effective collaboration between the facility and a contracted hospice organization for 1 of 2 resident (R22) reviewed for hospice services. Findings include: See also F686 R22's Face Sheet form indicated the following diagnoses: unspecified protein calorie malnutrition, pressure ulcer of unspecified buttock stage three, major depressive disorder, and type two diabetes. R22's hospice election benefit indicated R22 enrolled in hospice on 10/4/23. R22's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition, did not reject care, required partial to moderate assistance with toileting, showering, was occasionally incontinent of bladder, was five feet tall and 105 pounds, was at risk of developing pressure ulcers and did not have one or more unhealed pressure ulcers at a stage one or higher. Under the section Skin and Ulcer Treatments R22 had a check mark next to applications of ointments and medications other than to feet. R22's significant change in status (MDS) dated [DATE], indicated R22 had moderate cognitive impairment, did not reject care, was occasionally incontinent of bladder, and frequently incontinent of bowel, was 104 pounds, was at risk for pressure ulcers and had one stage three pressure ulcer and under the section, Skin and Ulcer Treatments had a check mark next to pressure relieving device for R22's chair and bed, had nutrition or hydration intervention to manage skin problems, pressure ulcer care, and applications of ointments and medications other than to feet. R22's significant change in status (MDS) dated [DATE], indicated moderate cognitive impairment, did not exhibit behaviors, and did not reject care. Required substantial maximal assistance for toileting hygiene, partial moderate assist for moving from sitting to lying, and chair to bed to chair, and toileting transfers required supervision or touching assistance, was occasionally incontinent of urine and always continent of bowels. R22's weight was 101 pounds, was at risk of developing pressure ulcers and had two stage three pressure ulcers, and under the section, Skin and Ulcer Treatments had a check mark next to pressure reducing device for chair, bed, pressure ulcer care, applications of ointments and medications other than to feet. R22's care plan dated 10/6/23, indicated R22 received hospice services. R22's care plan dated 7/7/23, indicated an activity in daily living (ADL) self care performance deficit and required staff assistance due to limited mobility, impaired balance and an intervention included to observe skin for redness, open areas, scratches, cuts, bruises and report changes. R22's care plan dated 7/7/23, indicated R22 had limited physical mobility and required staff assistance due to limited mobility and impaired balance. The care plan was later updated on 11/2/23, to include an intervention identifying R22 required assist of one to reposition in bed and assist of two to boost up in bed. This intervention further indicated R22 had an air pressure reduction mattress on the bed, and R22 preferred to sleep in the recliner and had an air pressure cushion. Prior to 11/2/23, the bed mobility intervention was last revised on 9/13/23, to include R22 required assist of one to reposition self in bed and encourage off loading in bed and chair. R22's care plan dated 10/9/23, indicated an altered nutritional status due to weight loss and impaired skin integrity. Interventions indicated providing a diet as ordered, monitor intake, obtain weights, monitor lab work, honor food preferences and requests. R22's care plan dated 10/13/23, indicated R22 was at risk for impaired skin integrity due to limited mobility, medication side effects, bladder incontinence, malnutrition and had two stage three pressure ulcers on the left buttock and coccyx. R22's goal indicated the current pressure ulcers would show signs of improvement by the next review date as evidenced by a decrease in size or a resolved status. Interventions indicated following facility protocols and policies for prevention of skin breakdown, a pressure reducing mattress, able to request assistance for toileting and repositioning, observe for signs and symptoms of breakdown and update the nurse promptly if noted. The most recent intervention on the care plan was dated 8/4/23, and indicated R22 required a pressure reducing wheelchair cushion. No new interventions were added following the development of new pressure ulcers. R22's care sheet dated 10/11/23, indicated R22 required assist of one with a transfer belt for transfers and ambulating short distances. Additionally, R22 required assist of one when going to the bathroom, and with dressing, grooming, and bathing and required a body audit completed on Thursdays, further, R22 required frequent repositioning and offloading while in the bed and wheelchair. The care sheet had a yellow highlighted instruction dated 8/4/23, to remind R22 to reposition off bottom for a few minutes every two to three hours due to having a pressure ulcer. The care sheet lacked any information or instruction resident had a cushion for the reclining chair. During interview and observation on 10/30/23 between 5:48 p.m., and 5:50 p.m., R22 stated she had irritation on her bottom that was hard to heal and stated they provided a pillow to use, and had not spoken with her about staying off her bottom. R22 had a circular cushion in another chair but did not have a cushion in the recliner R22 was in. R22 had a cushion in the wheel chair and additionally had an air mattress on her bed. R22's care sheet updated on 10/11/23, lacked interventions for a cushion in the recliner. During observation on 11/1/23 at 6:56 a.m., R22 was in her room in her reclining chair and her head was bent forward. During interview at 11/1/23 at 7:19 a.m., registered nurse (RN)-B stated R22 slept in her recliner 90% of the time and refused to sleep in the bed despite encouragement and added it was R22's choice. RN-B stated R22 was supposed to have a cushion in the chair she slept in. During interview and observation on 11/1/23 at 7:25 a.m., R22 was in the bathroom with staff and had a circular type cushion in her arm chair, but was not in R22's recliner chair where she slept. Nursing assistant (NA)-B stated she had worked at the facility for two years and stated R22 slept in her recliner chair. NA-B verified the circular cushion was not in R22's recliner chair she slept in this morning when R22 got up and verified R22 did not have any type of cushion in her recliner when she assisted her to get up. NA-B stated they toileted and repositioned R22 and stated R22 was continent. NA-B offered to apply the circular cushion to R22's recliner chair and R22 accepted. NA-B stated as the day goes on, R22 got weaker and needed assist and stated R22 could shift positions in her chair and added they tried to push for R22 to sleep in the bed as much as possible. During interview on 11/1/23 at 10:19 a.m., NA-C stated R22 could not get out of the recliner by herself and when R22 stood, she pushes off the chair, but cannot get up on her own and just rocks in her chair and needed assist. During interview on 11/1/23 at 12:54 p.m., licensed practical nurse (LPN)-B stated wounds were measured once a week and stated R22 had two pressure ulcers and one was near the coccyx and the other on the left gluteal fold. LPN-B clarified R22's left buttocks was deteriorating and stated it looked like it was deeper and like the wound was not improving. LPN further stated the pressure ulcers were hard to heal because R22 did not get off her bottom and wasn't eating well. LPN-B stated R22 could get up to go to the bathroom by herself and added R22 slept in her recliner chair. During interview on 11/1/23 at 1:07 p.m., nurse manager (NM)-G stated she asked hospice about an offloading cushion for R22 at the care conference on 10/13/23, and added R22 received an air mattress for her bed, and a gel cushion for R22's wheel chair. NM-G verified the care conference note lacked information regarding a cushion for the recliner chair. NM-G further stated R22 wished to only sleep in her chair and when asked about a circular cushion observed in R22's room, NM-G stated the cushion could have come from hospice and hoped the family brought in the cushion because hospice should notify the facility if they bring items in. NM-G further stated she had not followed up to see if interventions were effective and did not follow up to verify if a cushion was in place. During interview on 11/1/23 at 1:14 p.m., LPN-B verified no wound assessments were completed after 8/4/23, until 8/25/23. LPN-B stated from 10/10/23, to 10/26/23, they were missing a week of assessments. LPN-B further stated the problem with putting the cushion in the chair when they had therapy look at it, was the manufacturer wouldn't approve a cushion in the recliner because they couldn't guarantee it wouldn't slide out and that was why they asked hospice to look into it. During interview on 11/1/23 at 2:20 p.m., the health unit coordinator (HUC)-H verified the hospice notes in the paper chart and in the electronic medical record (EMR) lacked any information regarding a cushion or follow up on a cushion for the reclining chair. During interview and observation on 11/1/23 at 3:38 p.m., R22 was in her reclining chair with a pillow behind her back, but there was no cushion on the seat of the recliner chair. RN-F measured the wound on R22's left buttocks and was 1.6 cm long by 0.9 cm wide and 0.3 cm deep. RN-F measured the wound to R22's coccyx and was 1 cm long by 1 cm wide that included tunneling in the right inside corner that measured 0.4 cm at 1 O'clock. RN-F also stated R22 had a new stage one pressure injury to R22's right inner buttocks that measured 0.7 cm long by 0.9 cm wide. RN-F stated R22 did not want the cushion her daughter gave her and stated R22 didn't always use it and stated R22 was on a repositioning schedule and occupational therapy got R22 a special cushion she thought was the circular cushion. RN-F stated since R22 had a new wound they may have to do something different and verified that wound assessments were supposed to be done weekly and used to be completed on Wednesdays, but stated there had been some changes and verified wound assessments were documented in the chart and were missed. RN-F further stated if wounds are not monitored they are going to get worse because you cannot evaluate a wound if you are not assessing them and expected there to be interventions in place regarding R22's recliner chair. During interview on 11/2/23 at 10:52 a.m., the hospice RN stated, she just met R22 on 10/27/23, and was hopeful R22's wounds would heal and was dependent on her nutrition status. Hospice RN stated she just forwarded an email from the house hold coordinator (HHC)-C to check on the status of a wound cushion. During interview on 11/2/23 at 11:02 a.m., hospice RN stated she was not notified of a new wound and was not aware R22 was not sleeping in her bed and stated it would be important if R22 was in her chair to have an intervention for her recliner chair and further stated wound assessments were important to complete to make sure new interventions were put in place if the wound was not healing according to the plan. During interview on 11/2/23 at 12:34 p.m., hospice RN stated HHC-C sent her an email on 11/1/23, regarding a cushion and stated it was the first time she had heard about a cushion and further stated she ordered a standard cushion and the nursing facilities wound care team was taking care of the wounds and updating her on the wound measurements. During interview on 11/3/23 between 11:38 a.m., and 11:40 a.m., the director of nursing (DON) stated they talked about getting a cushion and hospice was going to provide it and they received the cushion on 11/2/23. DON further stated hospice was aware R22 was not sleeping in bed. A policy, Hospice Care Coordination dated November 2017, indicated the purpose of the policy was to provide guidance and clarity for facility staff to ensure coordination of care when a resident chooses to enroll in a Medicare or Medicaid approved hospice benefit program. The facility will continue to maintain 24 hour accountability for the resident when a resident chooses the hospice benefit. This includes but is not limited to continue to meet the resident's personal and medical needs. The facility's services must be consistent with the coordinated plan of care developed with the hospice provider and the facility must continue to offer the same services to the resident who chooses the hospice benefit as they do to those who have not chosen the hospice benefit. The hospice provider maintains responsibility for provision of the hospice care and services based on the residents assessment and individualized needs including but not limited to: nursing to support the resident's ongoing care, provision of medical supplies and DME (durable medical equipment) and drugs necessary for palliation of pain and symptoms associated with the terminal illness. A communication process will be maintained 24 hours a day to ensure resident care.

Based on observation, interview, and record review the facility failed to ensure residents received medications according to physician's orders for 1 of 1 resident (R2) reviewed for medications. Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated severely impaired cognition and diagnoses of dementia (severe) without behavioral distrubance, alzheimer's disease, anxiety disorder, and major depressive disorder. It further indicated R2 was totally dependent on staff for transfers and required extensive assistance with all other activities of daily living (ADL). R2's physician's orders (last revised on 10/27/23), included Rivastigmine patch 24 hour 9.5 milligrams (Mg)/24 hour (hr). Apply 1 patch transdermally one time a day for dementia, date and initial with black sharpie and remove per schedule. R2's care plan dated 7/31/23, indicated R2 was not able to self administer medications with an intervention for staff to set them up and admnister them per physician's orders. R2's medication variance report dated 8/19/23 indicated during a body audit registered nurse (RN)-C found 4 Rivistigmine patches (dated 8/16/23, 8/17/23, 8/18/23, 8/19/23) on R2's back. R2's medication variance report dated 8/26/23, indicated during a body audit RN-D found 2 Rivastigmine patches (one dated 8/26/23 and the second one was undated) on R2's back. R2's medication variance report dated 10/27/23, indicated family member (FM)-A discovered 2 Rivastigmine patches on R2's back. R2's progress note dated 8/19/2023 (Late Entry) indicated during weekly body audit, writer found 4 Rivastigmine patches on residents shoulders and neck. Vital signs stable (VSS), there was no adverse effect, medication variance report completed, power of attorney (POA), DON, clinical coordinator (CC), on-call nurse practioner (NP) notified. R2's progress note dated 8/26/2023 indicated R2 had a second patch of Rivastigmine found on the right middle part of her back during the body audit. Writer assessed the left part of the body starting at the residents head and found it to be clear except for a new patch on the upper left side of R2's back signed and dated for today (8/26/23). When writer turned R2 to assess the right side, another patch was found on the middle part of her back . Writer could not determine the date and signature on the patch but it was labeled with the medication name (Rivastigmine). During an interview on 11/1/23 at 2:25 p.m. registered nurse (RN)-C stated he observed 4 Rivastigmine patches on R2's back. During an interview on 11/01/23 at 11:39 a.m., registered nurse (RN)-B verified on 8/27/23 she administered a Rivastigmine patch and failed to remove the patch from the previous day stating she assumed the night nurse had removed the patch already. RN-B further stated I knew I had to remove the other patch, I just assumed it had already been removed. During an interview on 11/01/23 at 12:40 p.m., licensed practical nurse (LPN)-A verified she was involved in the medication errors discovered on 8/19/23 regarding R2's Rivastigmine patches. LPN-A stated she had placed a new patch without removing the old one for two days in a row. LPN-A further stated the next day was R2's shower day and was helping the evening shift get R2 ready and noticed three patches on her back. During an interview on 11/01/23 at 1:40 p.m., RN-E verified making a medication error (8/19/23) regarding R2's Rivastigmine patches stating she had applied a new patch without removing the old one and had assumed the aides were removing them. During an interview on 11/2/23 at 11:45 a.m., the pharmacist stated Rivastigmine patches were used to help patients with dementia retain memories and help with attention. He further stated Rivastigmine can stay in a person's system for up to 30 hours and the adverse effects of having too much Rivastigmine could result in seizures, falls, and complete delirium. The Pharmacist stated he completed a review of R2's medications as a result of these errors and was unable to recall what the maximum dose per day was but that it was included on the report. R2's consultant pharmacist report dated 10/30/23, indicated R2 was receiving Rivastigmine patch 24 hour 9.5 mg/24 hours every day. It further indicated staff had not removed the old patch before placing a new patch and measures to prevent the error had failed multiple times. It also indicated a maximum daily doseage of 12 mg per day. During an interview on 10/31/23 at 10:56 a.m. the director of nursing (DON) verified there were three medication errors regarding R2's Rivastigmine patches since August (8/19/23, 8/26/23, 10/27/23). She stated upon investigating the errors they identified the problem and put interventions in place but the errors continue to occur and it doesn't appear to be a one staff issue. During an interview on 11/3/23 at 10:35 a.m., the administrator stated on 10/27/23, he observed two medication patches on R2's back. He further stated they have a system in place (to prevent these errors from occuring) and it seems like the system should work but it's not. We keep adding things to fix the problem but it doesn't work. The administrator also stated he expected the nurses to follow the plan set in place and medication errors should not be occurring. The facility's medication administration policy modified on 5/21, indicated the facility will ensure safe, effective and timely drug therapy and provide an accurate and concise documentation system. It further indicated RN's, and LPN's will administer medications as ordered by the attending physician and/or nurse practioner.

Based on interview and record review the facility failed to follow up on pharmacy recommendations for 1 of 5 residents (R34) reviewed for unnecessary medications. Findings include: R34's quarterly Minimum Data Set (MDS) dated [DATE], indicated moderately impaired cognition, inattention, disorganized thinking and diagnoses of alzheimer's disease and major depressive disorder. It further indicated R34 required substantial assistance with activities of daily living (ADL), mobility, and received an antidepressant 7/7 days in the lookback period without attempting a gradual dose reduction (GDR) and not noted to be clinically contraindicated. R34's care plan dated 10/17/23, indicated R34 used antidepressant medication for depression with an intervention to consult with pharmacy and my physician to consider dosage reduction when clinically appropriate. R34's physician's orders dated 4/5/23, indicated Lexapro oral tablet 20 milligrams (Escitalopram Oxalate). Give 20 milligrams by mouth in the morning for major depressive disorder. R34's pharmacy consultation report dated 6/14/23, indicated R34 receives Escitalopram 20 milligrams (mg) daily for major depressive disorder (MDD), a dose which exceeds the maximum recommended daily dose of 10 mg daily in those [AGE] years of age and older. The resident also receives Quetiapine 100 mg every day at hour of sleep (QHS) for psychosis. It further indicated a recommendation to re-evaluate Escitalopram for risk versus benefit of current dose, considering a decrease to 10 mg daily if warranted. The pharmacy constultation lacked a physician's response to the recommendation. During an interview on 11/02/23 at 4:11 p.m., the director of nursing (DON) verified they had not received a response from the physician/NP regarding R34's pharmacy recommendation on 6/14/23 and did not follow up on it stating they had changed pharmacies and it was a messy transition and some of the older recommendations had slipped through the cracks. A policy related to follow up on the consultant pharmacists recommendations was requested but not received.

Based on observation, interview, and document review, the facility failed to ensure grooming was offered and/or provided for 1 of 1 resident (R31) reviewed for shaving. Findings include: R31's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition, rejected cares four to six days, had moderate difficulty in hearing, required extensive assistance for bed mobility, transfers, ambulation in the room, dressing, toileting, and hygiene, and was frequently incontinent of bowel and bladder. R31's Admission Record form dated 11/2/23, indicated R31 had the following diagnoses: anxiety disorder, unspecified dementia, psychotic disturbance, mood disturbance, and anxiety, major depressive disorder, and senile degeneration of the brain. R31's care plan dated 3/9/23, indicated R31 had an activities of daily living (ADL) deficit related to depression, anxiety, and mild dementia and refused baths and was resistive with cares at times and required assist of one with dressing, grooming, and hygiene. Additionally R31 required an explanation of the reasoning for the care to be done as needed, what cares would be done prior to starting cares, and if R31 refused, was to be reapproached. Additionally, if R31 refused care or bathing, to report to the nurse. R31's nursing progress notes were reviewed 3/9/23 through 11/2/23, and on 3/18/23, had refused brief change despite explanation and a progress note dated 3/14/23, indicated R31 refused baths at times, was hard of hearing, used a pocket talker to communicate and staff were to use the pocket talker to help R31 communicate. Additionally on 9/15/23, R31 was incontinent of bowels and had initially refused to be changed, however allowed the staff to change after staff provided an explanation. R31's Weekly Body Audit form dated 10/19/23 and 10/26/23, indicated R31 received a shower. R31's care sheet dated 10/11/23, indicated R31 had a bath on Thursdays, could be resistive with cares, and would refuse baths at times, staff should avoid yes or no questions related to cares and showers but instead state it was time to do a certain task, and explain the task. The care sheet lacked information regarding providing shaving assistance. R31's Task Personal Hygiene form from 10/4/23 through 11/2/23, indicated how R31 maintained personal hygiene such as combing hair, brushing teeth, shaving, applying makeup, and washing and drying face and hands. The form indicated R31 refused the task four times on 10/14/23, 10/24/23, 10/25/23, and 10/29/23. The form identified, R31 required extensive assistance 29 times, limited assistance 16 times, supervision twice, and was independent three times on 10/13/23, 10/20/23, and 11/2/23. R31's Task Bathing form from10/3/23 through 10/31/23, indicated R31 did not refuse bathing. During observation on 10/30/23 at 2:03 p.m., R31 had hairs approximately one half an inch long on her chin. During observation 10/31/23 at 9:27 a.m., R31 was in her room and still had a thick patch of hairs on R31's chin. During observation on 11/1/23 at 8:50 a.m., nursing assistant (NA)-A assisted R31 in a.m., cares that included assisting in washing R31's face, under arms, peri cares, combing hair, doffing night clothing and dressing R31. NA-A did not offer to shave or provide any explanation on shaving R31. During interview on 11/1/23 at 9:07 a.m., R31 stated NA-A did not offer to shave R31's chin hairs and stated this would have been something she wanted done. During interview on 11/1/23 at 1:44 p.m., R31 stated she did not receive assistance with shaving and still had the long chin hairs. During interview on 11/1/23 at 1:44 p.m., NA-A stated they looked at the care sheet to know what cares a resident required, refusals were documented in the nurse aide documentation, R31 did not refuse any cares today and further stated if R31 refused cares, staff had to reapproach and then R31 would usually agree to cares. NA-A stated personal hygiene included washing hair, face, and shaving and stated R31 did not get shaved because she did not have any chin hairs and if R31 did have chin hairs, NA-A would have to check the care plan. NA-A verified shaving hygiene was not on the care sheet and later stated, he thought he had seen the chin hairs and was not sure how long they had been there, but there was nothing on the care sheet to indicate they needed to shave R31. During interview on 11/1/23 at 1:56 p.m., registered nurse (RN)-B stated the NA's had care sheets to know what kind of cares a resident required and stated personal hygiene consisted of brushing teeth, combing hair, washing face, and shaving. RN-B stated she had seen the chin hairs and staff should ask if R31 wanted to shave. RN-B further stated R31's chin hairs have been like that since mid September and expected female residents to not have chin hairs. During interview on 11/2/23 at 1:34 p.m., the director of nursing (DON) stated she expected cares to be completed as care planned. A policy, Bath, Partial dated December 2014, indicated the purpose was to clean, refresh, and sooth the resident, but lacked information on shaving the resident. A policy, Shaving the Resident dated December 2014, indicated the purpose was to remove facial hair and improve the resident's appearance and morale. The policy provided instruction on how shaving was to be completed, but lacked information regarding when shaving was to be completed.

Based on interview, observation, and document review, the facility failed to provide meaningful activities for 1 of 2 residents (R29) who was dependent on staff for activities. Findings include: R29's significant change Minimum Data Set (MDS) dated [DATE], indicated it was very important R29's family or close friend was involved in discussions about care, was very important to have books, newspapers, and magazines to read, listen to music, do things with groups of people, do favorite activities, and participate in religious services or practices. R29's quarterly MDS dated [DATE], indicated R29 had a memory problem, was dependent on staff for most activities of daily living (ADLs), had minimal difficulty hearing and wore a hearing aid, and did not reject care. R29's Medical Diagnosis form (undated), indicated the following diagnoses: unspecified severe dementia with other behavioral disturbance, delusional disorders, major depressive disorder, and difficulty in walking. R29's care plan dated 9/25/23, indicated R29 was dependent on staff for activities due to dementia and would attend activities of choice. An intervention dated 10/31/23, indicated R29 had an electric keyboard to use at the table. Other interventions included R29 required one to one visits if R29 was unable to attend group activities, assistance to attend activity functions, invite to scheduled activities including church, special music, bingo, exercise, socials, outdoor activities, and coloring, take to any and all religious services and take to communion. When R29 chose not to participate in organized activities to provide independent activities in common areas to include cards, and activity blankets. R29's Task Activity Participation form dated 10/4/23 through 11/2/23, indicated R29 did not refuse activities, was unavailable for activities 16 times after 1:00 p.m., including Wednesdays on 10/4/23, 10/11/23, 10/18/23, 10/25/23, and11/1/23. R29's Task Event dated 10/4/23 through 11/2/23, indicated R29 attended the following activities: Bingo one time Campus wide activity one time Exercise 25 times Games one time Guest or family visit two times Music 5 times Chaplain visit zero times Had zero 1:1 visits R29's activity calendar dated October 2023 and November 2023, indicated the following activities were offered during the time frame 10/4/23 through 11/2/23: Bingo was an activity 7 times Exercise 36 times Catholic Mass at 11:00 a.m., on Wednesdays 5 times, Chapel Service at 2:00 p.m., on Wednesdays 5 times, and, rosary at 11:00 a.m., on Thursdays 5 times Music 8 times R29's Quality Concern form dated 10/18/23, completed by house hold coordinator (HHC)-C indicated family member (FM)-B was concerned the common area television was not set to a TV program channel, but was set to music and wanted more at R29's table to keep busy. Additionally, HHC-C contacted R29's family to provide ideas on items to keep R29 busy and followed up with staff posting a small reminder sign on the TV for the appropriate volume level and generation appropriate shows to enjoy. Under section four of the form, the administrator spoke with life enrichment about giving R29 more options on 10/19/23, however the form was undocumented under the sections, Person that completed this form contacted and updated on this date along with Name of person making the follow up contact. During observation 10/30/23 at 6:01 p.m., R29 was in her room in bed. During observation on 10/31/23 at 9:39 a.m., R29 was out in a day room with the television on and had a stuffed cat next to her. During interview on 10/31/23 at 10:11 a.m., FM-B stated R29 had no social interaction and added R29 used to be a director of a program and went to nursing facilities every day to entertain residents and was now spending her life alone. FM-B further stated R29 was an extremely social person. FM-B stated staff turned on the music channel, but stated it was so quiet, FM-B could not hear the television. FM-B stated they have expressed concerns for the past couple of years, and the answer received was they were working on it, but nothing ever changed. During observation on 10/31/23 at 1:40 p.m., R29 was in bed and the door to the room had been closed. R29's shades were drawn and the room was dark. R29 had mouth movements. During interview on 10/31/23 at 1:48 p.m., nursing assistant (NA)-A stated R29 required total assist for cares and staff lay R29 down after lunch. During interview and observation on 10/31/23 at 2:20 p.m., R29 was brought out to the day room and was given a key board, activity coordinator (AC)-A turned on a black and white movie and left resident by herself. AC-A stated they documented who attended activities. During observation 11/1/23 at 6:57 a.m., R29 was in the day room and playing the keyboard with the television off. During observation on 11/1/23 at 9:24 a.m., R29 was in the day room and the TV was turned on. An activity calendar for 11/1/23, indicated catholic mass was at 11:00 a.m., chapel services were at 2:00 p.m., short stories started at 10:30 a.m., and morning exercises began at 10:00 a.m. During interview on 11/2/23 at 9:09 a.m., registered nurse (RN)-A stated R29 had severe dementia and could not effectively communicate her needs to staff, stated when R29 saw staff she called for their attention and most of the time wanted to hold your hand, staff should pay attention and talk with R29 and offer a keyboard. RN-A stated R29 wanted to be involved in activities and exercises, especially music. RN-A stated staff had care sheets or a care plan that summarized the care a resident required. During interview on 11/2/23 at 9:42 a.m., the life enrichment specialist (LES)-B stated she completed an MDS assessment about preferences, resident's attendance was tracked and reported at resident care conferences. LES-B stated she could go back months to review attendance. LES-B stated R29 attended music one time in the past 30 days, and added R29 hasn't attended church services because they were in the afternoon. LES-B further stated R29 did not receive one to one visits from the chaplain, but was something they could set up. Additionally, from 10/4/23 to 11/1/23, LES-B stated R29 attended bingo only once because that was held in the afternoon. LES further stated R29 went to church twice in the past month and church services were held every week on Wednesdays. LES-B stated it was very important for R29 to attend church, very important to have books and magazines, listen to music, be in groups of people. LES-B stated expected there to be care planning for R29 to take a nap around the times of scheduled activities so R29 could attend. LES-B added they spoke with nursing about staff changing nap times however, it was difficult to find a balance. LES-B expected the chaplain to visit if R29 could not attend church. During interview on 11/2/23 at 1:37 p.m., the director of nursing (DON) stated the purpose of a preferences assessment was to create an individualized care plan and meet the needs of the resident and expected the assessment to reflect what R29 was capable of or what was appropriate for R29. During interview on 11/2/23 at 4:32 p.m., LES-B stated after 1:00 p.m., activity participation indicated not available because R29 was put to bed in the afternoons. LES-B further stated, staff state, oh shoot, we just put her to bed, when asked about activities. Additionally, despite the October calendar for activities on 10/18/23 and 10/25/23, indicated chaplain, LES-B stated the chaplain had a function work group and was not at the facility on 10/18/23 and 10/25/23. A policy, Care Plan Policy and Procedure dated November 2022, indicated the person centered care plan will ensure the resident has the appropriate care required to maintain or attain the resident's highest practicable physical, mental, and psychosocial well-being. The team will continue to collect additional information and data including but not limited to the registered nursing assistant, licensed nurse, life enrichment representative and will develop a comprehensive care plan that contains both strengths and vulnerabilities and dependencies. The care plan is to be changed and updated as the care changes for the resident and as the resident changes occur it will be updated in the electronic medical record. It is to be current at all times.

Based on observation, interview, and document review, the facility failed to ensure residents were free from physical restraints for 1 of 1 resident (R29). Findings include: R29's quarterly Minimum Data Set (MDS) dated [DATE], indicated R29 was dependent on all activities of daily living (ADLs), incontinent of bowel and bladder, had fallen, and did not use restraints. R29's Medical Diagnosis form (undated), indicated the following diagnoses: unspecified dementia, severe, with behavioral disturbance, delusional disorders, senile degeneration of the brain, disorientation, muscle weakness, and difficulty in walking. R29's clinical physician orders were reviewed and lacked orders for a restraint. R29's care plan dated 2/23/23, indicated R29 required one person assist to reposition and turn in bed. Additionally, R29 was at high risk for falling and should not lie down if she was not sleeping. R29's care plan dated 9/13/23, indicated R29 was at risk for falls due to a history of falling and had a perimeter mattress on the bed. During observation on 10/30/23 at 6:01 p.m., R29 was in bed lying on a perimeter mattress and resident had a pillow located on the outer right side of the bed and was not under R29. During observation on 10/31/23 at 1:40 p.m., R29 was in bed and had pillows located under R29's fitted bed sheet on the side of the bed facing R29's door. During interview and observation on 10/31/23 at 1:48 p.m., nursing assistant (NA)-A stated R29 required complete assistance with cares and was at risk for falling. NA-A stated in order to prevent falls, the bed is placed in the lower position and pillows were placed under the bed sheet to prevent R29 from jumping out of bed. During interview and observation on 10/31/23 at 2:04 p.m., registered nurse (RN)-A stated R29 should not have pillows under the bed sheet because it was a form of a restraint and removed the pillows and further stated R29 has tried to get out of bed in the past. During interview on 11/2/23 at 1:37 p.m., the director of nursing (DON) stated residents cannot be restrained. A policy, Physical Restraint Policy dated November 2022, indicated the facility had a stringent policy regarding the use of physical and chemical restraints. A physical restraint is defined as any manual method, physical or mechanical device, equipment or material that is attached or adjacent to the resident's body, cannot be removed easily by the resident, and restricts the resident's freedom of movement or normal access to their body.

Based on observation, interview and document review the facility failed to ensure a dignified dining experience for residents during meals in the dining room for 4 of 4 residents (R7, R12, R38, R41) reviewed for assistance meals. Findings include: R7's admission Minimum Data Set (MDS) dated [DATE], indicated R7 was cognitively intact, required supervision for eating . R7's care plan dated 9/7/21, nutritional problem related [CONDITION(S)] and dementia. Interventions included provide, serve diet as ordered. Monitor intake per facility policy. Staff were to offer additional fluids as ordered and assist with all feeding needs. R12's admission MDS dated [DATE], indicated R12 had severe cognitive impairment and required extensive assist with eating. R12's care plan dated 3/29/21, indicated interventions that included serve diet as ordered. Staff were to monitor intake per facility policy. R38's significant change MDS dated [DATE], indicated R38 had severe cognitive impairment and required extensive assistance with eating. R38's care plan dated 8/23/21, indicated nutritional problem with interventions that included assistance with all feeding needs. R41's significant change MDS dated [DATE], indicated R41 had severe cognitive impairment, and required extensive assist with eating. R41's care plan dated 5/5/21, indicated encourage and assist with oral intake as needed. During dining observation on 9/22/21, between 8:34 a.m. to 9:08 a.m. nursing assistant (NA)- A stood at the dining table and assisted residents R12, R38 and R41 with their meal. NA- A would move between the three residents (R12, R38, R41) during the breakfast meal as she stood and walked around the table from one resident to the next and assisted the residents to eat. During lunch observation on 9/22/21, between 12:11 p.m. to 12: 48 p.m. NA-A stood up in the dining room and moved from one resident (R7, R12, R41) to another resident and provided assistance to eat. NA-A walked around the table, moved from resident to resident and assisted the residents to eat. NA-A also discussed non resident related topics with a dietary staff as she walked around the dining room area from table to table and assisted the residents to eat. During interview on 9/22/21, at 1:17 p.m. nursing assistant (NA)-A stated she usually had to assist several residents who required assistance by herself during breakfast and lunch because the other nursing assistants were still getting other residents up and were assisting residents to get ready for meals. NA-A also stated there were two other nursing assistants that worked with her that shift, but she usually had to assist the residents by herself when she worked the morning shift. NA-A further stated no one had talked to her about standing up and moving around to assist residents during meals although she had no other alternative since she was the only person available to assist the residents during that shift's meals. During interview on 9/23/21, at 1:02 p.m. director of nursing (DON) stated the nursing assistants were trained to sit and could then assist two residents with the goal to be at the conversation level. The facility Dignity Policy dated 12/14, indicated residents were cared for in a manner and in an environment that promoted maintenance and/or enhancement of each resident's quality of life. Facility was committed to an atmosphere and humanized and individualized each resident and their experiences. The facility Dining Room Protocol Policy dated 1/13, indicated staff were to participate in the delivery of meal service and purpose included to provide a dignified, prompt meal service. After all residents were served, proceed to assigned tables to provide eating assistance, as indicated or as appropriate.

Based on observation, interview, and document review, the facility failed to ensure stock medication were discarded after expiration on 1 of 3 medication carts, potentially affecting 13 of 13 residents on that unit. In addition, the facility failed to ensure resident's personal medication was discarded after expiration for 1 of 13 residents (R28). Findings include: During the medication tour of the 2-south unit on 9/22/21, at 1:41 p.m. with registered nurse (RN)-A multiple expired medications were observed in the medication cart. The following concerns were identified: R28's acetaminophen suppositories 650 milligram (mg) with expiration date of 5/4/21. R28's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Stock medication [MEDICATION(S)] 600 mg with expiration of 1/2021 and [MEDICATION(S)] [MEDICATION(S)] with expiration 11/3/19. When interviewed on 9/22/21, at 1:41 p.m. RN-A stated the medications were expired and should not be given to residents. RN-A further stated the expiration date should be checked prior to administration but there was not a process of checking the medication cart on a regular basis for expired medications. When interviewed on 9/22/21, at 1:52 p.m. RN-B stated not being familiar with a specific process to check the medication carts. RN-B stated, The infection preventionist I think has done it before, but no schedule set to do it on a regular basis that I know of. RN-B further stated she would expect the nurses to check the medication expiration prior to administration. When interviewed on 9/22/21, at 2:05 p.m. RN-C stated there was no process for going through the medication carts on a regular basis to check for expired medications. When interviewed on 9/23/21, at 8:06 a.m. interim care center clinical coordinator stated the facility did not currently have a policy regarding a process for regularly checking medication carts for expired medications, however they were establishing a new task for nursing staff to check each cart for expired medications every Sunday night. When interviewed on 9/23/21, at 8:50 a.m. administrator stated the expectation was no expired medications in the medication carts. The facility provided Medication Storage Guidance dated March 2020, indicated Unless otherwise noted by the manufacturer, standards of practice, or facility policy (whichever is more stringent), all multi-dose container will be considered to be expired on the date on the actual container as indicated by the manufacturer unless there is suspected or obvious product contamination. of medication policy revised 04/2019 indicated Discontinue, outdated, or deteriorated drugs or biological's are returned to the dispensing pharmacy or destroyed.

Based on interview and record review the facility failed to ensure weights were monitored for 1 of 1 resident (R6) reviewed for weights. Findings Include: R6's Face Sheet dated 12/23/20, indicated R6 had unspecified dementia without behavioral disturbance, [CONDITION(S)] (a rare skin condition that usually starts with an itchy, raised rash, then develops into large blisters on the skin) and abnormal weight loss. R6's significant change Minimum Data Set (MDS) dated [DATE], indicated R6 had severe cognitive impairment, required extensive assist of two staff for bed mobility, transfers, toileting and personal hygiene. R6's care plan dated 1/7/21, R6 had significant weight lost with interventions that included obtain weight per policy or doctor or nurse practitioner's (NP) order. R6's careplan updated 7/30/21, indicated weight to be maintained greater than 150 lbs in three months. R6's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . For five pounds (lbs.) difference from previous weight notify doctor or NP. Wednesdays for weight monitoring. R6's treatment administration record (TAR) had an unreadable printed date indicated weekly weight. For five lbs. difference from previous weight notify doctor or NP. Only one weight was documented on the TAR for the month of 9/2021, at 153.7 lbs. R6's nutritional progress notes dated 9/20/21, indicated R6 had not been weighed in almost two months since he does not leave his bed. R6 had visually appeared to have stabilized. R6 continued to have many open areas on skin due to [CONDITION(S)]. R6's nutritional assessment dated [DATE], indicated R6 ideal body weight of 171.6 lbs. R6's weight and vitals summary printed 9/23/21, indicated weight documentation as follows: - 9/22/21, weight 153.7 lbs.(mechanical lift) - 9/21/21, weight 145 lbs. (wheel chair) with notation of technical error - 7/22/21, weight 154.9 lbs. (mechanical lift) - 4/7/21, weight 150.5 lbs. (mechanical lift) - 3/31/21, weight 152.9 lbs. (mechanical lift) - 3/3/21, weight 167.5 lbs (mechanical lift) - 2/24/21, weight 169.2 lbs. (mechanical lift) - 2/17/21, weight 166.6 lbs. (wheelchair) - 2/3/21, weight 176.4 lbs. (wheelchair) During interview on 9/22/21, at 1:42 p.m. nursing assistant (NA)-B stated, R6 had not been weighed recently although he was scheduled to be weighed every Wednesday. NA-B also stated if resident agreed to get out of bed he was weighed, however staff had not offered to weigh him in bed and use the mechanical lift. During interview on 9/22/21, at 1:52 p.m. registered nurse (RN)-E stated, R6 had not been weighed and had refused to be weighed on 9/21/21. RN-E also stated staff used the mechanical lift to weigh R6 on Wednesday mornings. RN-B further stated R6 was usually approached and encouraged to get out of bed and he would refuse. RN-B stated that R6 was not asked if staff could weigh him in bed with use of the mechanical lift to check his weight. RN-E was unable to provide documentation that R6 refused to be weighed in bed with use of mechanical lift. During interview on 9/23/21, at 9:27 a.m. director of nursing (DON), stated the best practice would have been for nursing staff to discuss with the NP so that an order was given to hold off weights for R6 due to skin/wound issues. DON also stated, could not find any documentation that R6's weights were not completed due to his refusals to be weighed. During interview on 9/23/21, at 12:08 p.m. registered dietician (RD)-E stated he had visually assessed R6 and R6 did not seem to have lost weight in the last 3 months, although he had not been weighed since 7/22/21, and then again on 9/22/21. RD-E also stated it was good practice for staff to monitor residents weights weekly per physician orders. The Facility Weight Policy modified 12/2015, indicated. significant weight changes will be documented in the resident's medical record and reported to the doctor/NP involved family member and registered dietitian by the nurse.

Based on observation, interview and document review the facility failed to ensure hand hygiene was performed by staff during assistance with meals in the dining room for 4 of 4 residents (R7, R12, R38, R41) reviewed for dining. Findings include: R7's admission Minimum Data Set (MDS) dated [DATE], indicated R7 was cognitively intact, required supervision for eating. R12's admission MDS dated [DATE], indicated R12 had severe cognitive impairment and required extensive assist with eating. R38's significant change MDS dated [DATE], indicated R38 had severe cognitive impairment and required extensive assistance with eating. R41's significant change MDS dated [DATE], indicated R41 had severe cognitive impairment, and required extensive assist with eating. During dining observation on 9/22/21, between 8:34 a.m. to 9:08 a.m. the following was observed: nursing assistant (NA)-A stood at the dining table and assisted residents R12, R38 and R41 with their meal. NA-A was the only nursing staff that helped the residents in the dining room. NA- A moved between the three residents (R12, R38, R41) during the breakfast meal and stood and walked around the table from one resident to the next to assist with the meal. NA-A was not observed to perform hand hygiene after she assisted one resident and then assisted another resident. During lunch observation on 9/22/21, between 12:11 p.m. to 12: 48 p.m. the following was observed: -NA-A stood in the dining room and moved from one resident (R7, R12, R41) to another resident and provided assistance to eat. NA-A was the only nursing staff in the dining room to assist the residents with their meal. -At 12:11 p.m. NA-A stood and assisted R12. NA-A touched R12's Broda chair after she assisted R12 with a drink of water. - At 12:15 p.m. NA-A sat near R12 while R12 coughed intermittently at dining table. NA-A wiped R12's running nose with napkin. NA-A did not perform hand hygiene. NA-A placed the dirty napkin on the dining table near R12's plate of food. NA-A then wiped R12's mouth after giving a bite of her meal with a cloth napkin. NA-A then stood up and reached across the dining table to R41's food area and touched R41's plate of food and stated to R41, put it right here and removed cup from near R41's plate mat. NA-A did not perform hand hygiene. -At 12:29 p.m. NA-A touched face mask to adjust while NA-A stood and assisted R12. No hand hygiene was observed. - At 12:30 p.m. NA-A touched R41's water cup and placed closer to R41. - At 12:31 p.m. when NA-A left R12's table no hand hygiene was noted. NA-A then went to R7's table, touched his Broda chair, and gave R7 several bites of food. At 12:33 p.m. NA-A then went back to assist R12 and offered R12 a drink. R12 coughed and when done, NA-A wiped R12's mouth. No hand hygiene was observed. NA-A then went to assist R41. - At 12:35 p.m. NA-A then went to assist R7. No hand hygiene was noted. NA-A was observed to provide hand hygiene once during the lunch observation. During interview on 9/22/21, at 1:17 p.m. NA-A stated there were two other nursing assistants that worked with her that shift, but she usually had to assist the residents by herself when she worked the morning shift. NA-A further stated she sometimes got busy with having to assist several residents and sometimes forgot to sanitize hands frequently. During interview on 9/23/21, at 1:02 p.m. director of nursing (DON) stated it was the requirement that hand hygiene was done between residents and was implemented by staff per facility policy. The facility Hand Washing Policy updated 5/2019, indicated to assure the safety of guests and visitor staff were expected to wash hands frequently to prevent bacteria and viruses from easily traveling from one person to another person or from people to food and food contact surfaces. Staff directed to always wash hands after coughing, sneezing, blowing nose or using tobacco.

Based on interview and document review, the facility failed to ensure an allegation of abuse was reported to the State Agency (SA) immediately (within two hours) for 1 of 3 residents (R1) reviewed for allegations of abuse. Findings include: R1's Face Sheet indicated R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact and had no behavioral concerns. R1's care plan revised 4/20/20, indicated R1 was at risk for abuse and/or neglect due to functional limitations, and would remain free from abuse in accordance with the Vulnerable Adult policy. An email titled Resident Complaint was sent via email on 8/11/21, at 5:26 a.m. from registered nurse (RN)-A and indicated R1 had just reported a staff was sexually harassing her. The facilities Nursing Home Incident Report (NHIR) regarding this incident was submitted to the SA on 8/11/21, at 11:08 a.m. When interviewed on 8/17/21, at 8:51 a.m. R1 verified she was uncomfortable with maintenance staff (M)-A and reported inappropriate comments he had made to (RN)-A who informed R1 that she would need to report it. When interviewed during a return phone call on 8/24/21, at 2:50 p.m. RN-A stated she had immediately made the report to leadership via email and thought they would recieve the message before they came into work for the day. RN-A stated she was reeducated the following day by the director of nursing (DON) and understood that notifications must be verbal. When interviewed on 8/17/21, at 11:00 a.m. the DON stated she expected staff to follow the policy for reporting and allegations of abuse would be reported immediately via verbal communication to leadership. The DON stated RN-A received the verbal report of abuse from R1 at approximately 5:00 a.m. and reported this via email to the DON and the administrator at 5:26 a.m. The DON verified leadership was responsible to gather initial information and file the VA report within 2 hours. The facility policy Vulnerable Adult Abuse Prevention Plan revised 7/21, directed any person employed at Presbyterian Homes & Services, including contractors, and persons who are volunteering in the facility are responsible for reporting suspected or known cases of resident maltreatment to their immediate supervisor who will notify the administrator and/or appropriate designee and reporting to the administrator will be in person or via phone. Further, If the event that caused the allegation involves abuse or results in serious bodily injury the report must be made no later than 2 hours after the allegation is made.

Based on observation, interview, and document review, the facility failed to offer timely repositioning and provide a pressure relieving mattress for 1 of 3 residents (R1) who were at risk for pressure ulcer development. Findings include: R1's Face Sheet dated 7/20/21, indicated R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's 5 day prospective payment system Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment and required extensive assistance with bed mobility and transfers. R1's MDS also indicated R1 had a state one pressure ulcers with application of ointment/medications. R1's skin Care Area Assessment (CAA) dated 1/20/21, indicated R1 was at risk for pressure injury and had a reddened coccyx upon admission. R1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's care plan dated 7/9/21, indicated R1 had limited physical mobility and was at risk for pressure injury related to right sided [CONDITION(S)] and a severe cognitive impairment. R1 required assistance of two staff to reposition in bed. Further, R1 was not able to reliably request assistance and required a pressure reducing mattress/wheelchair cushion. R1 also was to be repositioned every two to three hours. R1's nursing assistant task sheet dated 7/20/21, indicated R1 had a stage one pressure sore on their coccyx and required repositioning every two to three hours. A progress note dated 7/5/21, at 6:35 p.m. indicated R1 was transferred back to the facility from the hospital. The progress note further indicated R1 needed an air mattress due to the coccyx wound. A skin assessment dated [DATE], indicated R1's coccyx had a stage one pressure injury and non-blanchable redness. On 7/19/21, during continuous observation from 9:30 to 1:23 p.m R1 was in his room, seated in a wheelchair, and watched television. R1's bed lacked a pressure relieving mattress. At 10:21 a.m. registered nurse (RN)-A entered R1's room with maintenance staff to assist with a bed issue. RN-A exited R1's room at 10:22 a.m. without offering R1 repositioning. At 11:30 a.m. R1 was in their room, still in the wheelchair when another resident visited. At 11:40 a.m. nursing assistant (NA)-A entered R1's room and assisted R1 with their shoes. NA-A exited the room without offering repositioning to R1. At 11:46 a.m. RN-A entered R1's room and obtained a blood glucose reading. R1 was then wheeled to the dining room for lunch by RN-A. At 12:40 p.m. when R1 finished their meal NA-A wheeled R1 back to their room and left without offering repositioning. At 1:00 p.m. R1's family arrived to visit. At 1:23 p.m. NA-A entered R1's room and assisted R1 to the bathroom using an EZ stand (mechanical lift). At this time, R1's skin was assessed by RN-A. A [MEDICATION(S)] dressing was noted on R1's coccyx. The skin under the [MEDICATION(S)] was noted to be intact with three centimeters of blanchable redness and wrinkle indentations. Three hours and 53 minutes had passed before R1 was repositioned. In an interview on 7/19/21, at 2:05 p.m. NA-A stated R1 was transferred to their wheelchair before breakfast. NA-A stated R1's repositioning frequency was identified on a nursing assistant task sheet and verified R1 required repositioning every two to three hours. In an interview on 7/19/21, at 2:10 p.m. RN-A stated R1 was up in his wheelchair for breakfast and in the dining room around 8:30 a.m. RN-A was not aware of repositioning being offered since that time. RN-A stated R1 had a pressure injury and skin prep and [MEDICATION(S)] was being used. RN-A stated R1 was repositioned by offloading with an EZ stand or transferring to bed. RN-A stated R1 needed to be repositioned every two to three hours and R1 had went too long without off-loading pressure. In an interview on 7/20/21, at 10:05 a.m. RN-B verified R1 did not have a pressure reducing mattress in-place and was unsure if R1 needed one. RN-B stated if the facility lacked an air mattress a supplier was to be notified for a rental. RN-B stated if clinical coordinator called the rental company a mattress would be delivered the same day. In an interview on 7/20/21, at 10:40 a.m. RN-C stated staff were expected to follow a resident's care plan and R1 needed to be repositioned every two to three hours. RN-C stated if staff were unable to reposition a resident a nurse needed to be notified. RN-C stated pressure reducing mattresses came from a medical equipment company and a provider order was not needed. RN-C stated a pressure reducing mattress would arrive within 12 hours when requested. RN-C stated any member of the nursing staff were able to order a pressure reducing mattress. At 11:39 a.m. RN-C verified R1's care plan identified a pressure relieving mattress but was unsure why. RN-C stated ordering the air mattress was likely missed. At 12:08 p.m. RN-C verified the medical supplier never received a request for a pressure reliving mattress for R1. In an interview on 7/20/21, the director of nursing (DON) stated staff were expected to follow a resident's care plan and nursing assistant task sheet. The DON stated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A facility policy titled Skin Integrity Management modified 6/2021, directed to implement preventative measures and to provide appropriate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review, the facility failed to ensure therapy services were provided to maintain Assisted Range of Motion (AROM) and prevent decline in mobility for 1 of 1 resident (R2). Findings include: R2's annual Minimum Data Set (MDS) assessment dated [DATE], indicated R2 had [DIAGNOSES REDACTED]. The MDS also indicated R2's brief interview for mental status (BIMS) score of 14 indicated intact cognition, needed extensive assist of one from sitting from bed or toilet chair to standing or transferring to wheelchair. The MDS further indicated R2's range of motion (ROM) has no impairment on 8/26/20 and 12/14/20. A document titled Maintenance Program (MP) signed by Physical Therapist (PT) and dated 10/22/20, indicated R2 should have AROM daily while she was in bed or recliner. The document also included instructions for staff how to perform AROM. The Clinical Director (CD) of the nursing unit received the form from PT on 10/22/20, signed and uploaded it into patient medical record. The order was effective on 10/22/20. R2's care plan revised on 10/23/20, and daily care sheet both included AROM exercises daily. During interview on 12/14/20, at 10:09 a.m. nursing assistant (NA)-A stated she had worked with R2 for a few months and she did not do any range of motion with R2 because PT worked with R2. NA-A was not sure how often PT worked with R2. During interview on 12/14/20, at 10:46 a.m. R2 confirmed that only PT helped her to exercise and nursing staff did not help her to do any range of motion. She did not know staff were to assist her with AROM daily. During interview on 12/14/20, at 10:51 a.m. registered nurse (RN)-A stated that he did not think there was any order for AROM for R2 and if there was an order, the nursing assistant would do the AROM. During interview on 12/14/20, at 11:09 a.m. NA-B stated that R2 saw PT and PT did the AROM with her and he did not need to do any AROM with R2 even though AROM was on the daily NA task sheet for R2. The task charting for NA's was reviewed, the AROM that was to be performed daily by NA's, was performed 4 days on October, 11 days in November and 4 days in December. During interview on 12/14/20, at 11:01 a.m. CD said she was the one put in the order for AROM. She confirmed that nursing staff needed to help R2 with AROM, especially NA staff and they were supposed to chart daily about AROM in R2's chart. During interview on 12/14/20, at 11:13 a.m. PT confirmed she gave CD the order on 10/22/20, and CD signed and upload in it patient medical record. The order was effective on the same day. PT expected nursing staff to assist R2 with AROM daily. PT stated that staff also needed to document in R2's chart. Her expectation was that she put in recommendation and nursing staff would help follow it and get it done. PT also stated that R2 was getting better since they took the cast out on her right foot and now she could bear weight and walk. During interview on 12/14/20, at 12:21 p.m. director of nursing (DON) stated that he expect nursing staff would do what PT recommended for R2 and they would chart when completed. He stated that per documentation, he did not know why nursing staff did not do AROM with R2 because the order was in her care plan, daily care sheet and in the NA's task. He also said even though PT worked with R2, the NA's still needed to do AROM with R2. He expected the nurse should follow up with NA to make sure the order was done and he admitted it did not happen with R2's situation. The policy titled Balance and Range of Motion Assessment Policy, revised April, 2016, indicated residents will receive restorative nursing care to maintain resident's ability to maintain current balance range of motion and/or prevent further decline in balance and range of motion. The policy further indicated residents participation in range of motion program will be documented on resident specific flow sheet and/or other resident specific form or tracking tool.

Based on interview and document review, the facility failed to complete a psychosocial assessment, implement safety measures, and notify appropriate parties for 1 of 1 residents (R1) who stated she wanted to kill herself with scissors she had in her possession, then cut her wrists with a butter knife and was transported to the hospital. The lack of facility assessment and implementation of safety measure, placed R1 in immediate jeopardy. The immediate jeopardy began on 7/1/20, at 5:00 p.m. when the facility failed to assess R1's psychological needs, and implement immediate safety measures after R1 threatened to kill herself with a scissors. The administrator and director of nursing (DON) were notified of the immediate jeopardy (IJ) on 7/14/20 at 4:00 p.m. The IJ was removed on 7/15/20, at 11:38 a.m. but noncompliance remained at the lower scope and severity level of a D- isolated incident with no actual harm with potential for more than minimal harm. Findings include: R1's entry Minimum Data Set (MDS), dated [DATE], indicated an admission from the community on 7/1/20. R1's MDS, dated [DATE], included R1 had been discharged to a hospital on [DATE]. R1's care plan dated 7/1/20, included, I have an alteration in mood or behavioral expression. R1's goal was, I will demonstrate effective coping skills through the review date. R1's interventions directed staff, Encourage me to participate in activities of interest. Explain all procedures to me. Intervene as necessary to protect the rights of others. Approach/Speak in a calm manner. Divert attention. Remove me from the situation and take me to an alternate location as needed. The care plan listed [DIAGNOSES REDACTED]. R1's body audit, dated 7/1/20, indicated R1 did not have any scratches, cuts or skin tears. R1's Brief Interview for Mental Status, [MEDICAL CONDITION] and Communication assessment, dated 7/2/20, indicated R1 had moderately impaired cognition. R1's incident report dated 7/2/20, at 2:30 p.m. included, Resident Services Director entered residents room around 2:30 pm to do initial assessment. Resident admitted to this facility on 7/1/2020 at 10:00 AM. Resident was sitting in her chair listening to her radio with her lunch in front of her, untouched. Resident Services Director noticed resident was holding a butter knife from lunch. Writer kept an eye on it, and as writer started talking with resident, res (resident) turned over her right wrist and started cutting herself with the knife. There was already a red mark on her wrist and started cutting herself with the knife. Writer asked what she was doing, and resident started to cry. Writer asked if she could have the knife and resident handed it over right away. Resident then stated, 'I just want to die.' Resident service director stayed with resident and texted nursing staff for assistance. Resident Service Director informed by nursing to stay with resident on 1:1 (one on one) until a safe plan could be made. Resident assessed and had superficial abrasions to right wrist. NP (nurse practitioner), Family updated and 911 called. Resident transferred to United Hospital via EMT (emergency medical transport). Information provided to this facility prior to resident being admitted there was no indication of prior attempts of resident trying to harm self. After resident admitted to this facility she did not voice any concerns with self harm and there were no indications that resident would self harm. Internal investigation started and all parties notified. R1's progress note dated 7/2/20, at 1 :07 a.m. indicated R1 was agitated and restless early in the shift and wanted to go to the bathroom right away. The progress note further indicated R1 pretended to take her medications, but would hide medication in her pocket and was educated about the risk of not taking medications. However, the note failed to include any attempt to find out why R1 did not want to take the medication or source of her agitation. R1's progress note dated 7/2/20, at 8:09 a.m. included, Yelling out taking off her oxygen. Writer approached resident to see how she could be helped. Resident had her phone, her call light her oxygen and her radio all in her left hand with lines twisted. Resident had walking cane in right hand. As writer approached resident swung cane in direction of writer. Writer grabbed cane to stop cane from hitting writer. Resident stated that she didn't mean to hit writer and began to calm down. Writer untangled all the cords and organized room, placed 02 (oxygen) back on resident. Offered PRN (as needed) lorazapem for anxiety but resident refused. Attempted to give AM medications but resident stated that it was too early for that. Was then making statements like, 'Why are you guys so nice to me?' but then would say 'I know you're going to kill me.' Then asked writer to call family member (F-A). Writer called (F-A) and left resident alone, letting her know that writer would be back after breakfast for her morning medications. The note failed to include an assessment of R1's distress. R1's progress note dated 7/2/20, at 10:34 a.m. included, Continues to make statements thinking the staff are going to kill her. Reassured resident that staff was not going to kill her and that she was safe. The progress note failed to include any assessment of R1's distress. R1's progress note dated 7/2/20, at 2:42 p.m. included, Nurse manager states that resident is going to the hospital because she was seen trying to cut herself with a knife. No puncture noted to wrist. All sharp objects collected from room and placed in nurse managers office. R1's progress note written by social services director (SSD) on 7/2/20, 4:14 p.m. included, Writer entered room around 2:30 pm to do initial assessments. Resident was sitting in her chair listening to her radio with her lunch in front of her, untouched. Writer noticed resident was holding her knife from lunch. Writer kept an eye on it, and as writer started talking with resident, res (resident) turned over her right wrist and started cutting herself with the knife. There was already a red mark on her wrist, making it appear that she had been doing this prior to writer entering her room. Writer asked what she was doing, and resident started to cry. Writer asked If she could have the knife and resident handed it over right away. Resident then stated: 'I just want to die. My (family member) says that I lie. That I just sit here and make things up, but I don't. I don't do that. I'm blind. I can't do anything. I'm better off dead. (family member) blames me for everything.' Writer told resident that she was here to listen. Resident talked about how her (family member) has a lot on (family member's) plate as (family member) is responsible for a (another family member) as well. Resident stated, 'my (family member) takes everything out on me.' She stated that she broke her phone after the phone call with her (family member) earlier this afternoon. She said, 'I shouldn't have done that. Now I don't have a phone.' and was very tearful. Writer reassured resident that staff can get her a new phone. Resident also told writer that she is scared because she can't see, and she has anxiety. Resident stated she does not have a plan in place to kill herself, and that this is the first time she has done something like this. She asked writer not to say anything to anyone about her wrist. Writer explained that she has to tell the nursing staff so they can help her and that she will be going to the hospital, as 911 was already called. Writer sat with resident talking with her until ambulance arrived to take her to the hospital. She had significant changes in behavior during that time, from happy and talking about her (family member) and how she enjoyed sewing, to very tearful and upset talking about the conversation she had with her (family member) this afternoon. Resident was transported to United Hospital per (family member's) recommendation. R1's progress note, dated 7/7/20, at 3:58 p.m. included, On Wednesday July 1st at around 5:00 pm, I have got report that, the patient hid the Caesar (sic) in her shoe. Patient said I want to kill myself. I gave sometime to patient and asked if I can help her, patient asked me if I can call her (family member, F-A), I promised her to call her (F-A) and J (sic) asked her to give me the caesar (sic) and she gave to me. I put the Caesar (sic) away from patient and called her (F-A). after pt (patient) talked to her (F-A), pt was happy and not showed such behavior. Nurse told aid to watch the pt and report if any behavior repeated. R1's Investigation Summary, dated 7/8/20, included, R1 had a previous incident on 7/1/20, at 5:00 p.m., Resident had two pairs of scissors. Resident Assistant (RA) asked resident what she was doing with the scissors and resident stated she was going to kill herself with them. The RA notified a nurse and R1 repeated to the nurse she was going to kill herself. The nurse listened to R1 and R1 did hand the scissors to the nurse. The nurse placed the scissors in the resident's drawer which was still accessible to R1.After resident left facility in anticipation of residents return, a room sweep was performed to identify any objects that resident could self-harm with and they were removed including the scissors. The nurse on duty that found the scissors received written corrective action to be placed in personnel file and re-educated on Threats to Harm Self and Prevention Policy and expectations to follow the policy. All other staff to be re-educated on Threats to Harm Self and Prevention Policy. When interviewed on 7/13/20, at 1:30 p.m. licensed practical nurse (LPN)-A stated she had not heard about any incident with R1 and had not received any recent training on residents at risk for self-harm. She had worked with R1 on 7/1/20 and noted agitated behaviors. When interviewed on 7/13/20, at 1:45 p.m. NA-E stated he worked with R1 on the morning of 7/2/20. NA-E heard R1 screaming and yelling at 6:00 a.m. NA-E attempted to assist R1, but she struck him with her cane. NA-E reported R1's agitation to RN-H. When interviewed on 7/13/20, at 1:55 p.m. RN-D stated when he had arrived at work on 7/2/20, he found a pair of scissors on R1's dresser, but was not aware that R1 had threatened to harm herself with those scissors and did not remove them. R1 was then left alone in the room without being monitored. RN-H later removed the scissors from the dresser, but RN-D did not know what time this was. When interviewed on 7/13/20, at 3:13 p.m. the SSD had found R1 with the butter knife on 7/2/20, and stayed with R1 while awaiting transport to the hospital. SSD had not had any prior training at the facility on how to respond to residents with threats of self-harm, but had notified nursing and stayed with R1 as described in the incident report. The SSD stated she completed a Threats to Self Harm Assessment on 7/2/20, while waiting for the ambulance. R1's Threats to Self Harm assessment dated [DATE], included, Resident was using her knife from lunch to cut her right wrist during visit with writer this afternoon. Resident stated she just wanted to die and was very upset after a phone conversation with her daughter. Resident is on medication for anxiety and depression. She stated that she is scared because she cannot see and is in a new environment She also told writer she has never done anything like this to herself before. Writer stayed with resident until the ambulance arrived to transport her to the hospital. When interviewed on 7/13/20, at 3:29 p.m. nursing assistant (NA)-D stated he had worked with R1 on 7/1/20, and had answered her call light around 5:00 p.m. R1 had a scissors in her hand and reported she had another scissors up her sleeve. NA-D asked R1 for the scissors and R1 refused to give them to him. R1 stated she was going to kill herself with the scissors. NA-D reported this immediately to RN-I. R1 gave the scissors to RN-I. When interviewed on 7/13/20, at 4:08 p.m. RN-I stated on 7/1/20, around 5:00 p.m. NA-D notified her R1 had a pair of scissors and stated she was going to kill herself with them. RN-I was able to get the scissors from R1 and placed them on top of R1's dresser in her room. RN-I stated she did a body assessment to ensure R1 did not injure herself. RN-I left the room and when she returned R1 was on the phone with a family member. RN-I did not complete a comprehensive assessment of R1's suicide risk, did not notify the physician or family member and did not report this incident to a manager, director of nursing, or social services. RN-I also did not place any interventions to ensure R1 did not harm self, such as removing any sharp objects or cords, (including the scissors) from R1's access or place any other interventions to protect R1. RN-I had not documented the incident that occurred on 7/1/20, until directed to on 7/7/20. When interviewed on 7/13/20, at 4:24 p.m. family member (FM)-A stated, R1 was upset when they spoke on 7/1/20, and R1 stated, 'You don't know what they are trying to do - you don't know you don't know they are trying to hurt me.' FM-A indicated they had not been made aware R1 had scissors in her room, and the facility only called FM-A to tell them when R1 was on the way to the hospital. FM-A stated the facility told them R1 had a butter knife and tried to kill herself. FM-A stated if the facility had called and told them R1 had scissors and threatened to kill herself the day before, family would have come to calm her down and see what they could do to get her help and prevent self-harm. However, this information had never been relayed to them until R1 was on the way to the hospital after the second incident. When interviewed on 7/13/20, at 2:55 p.m. RN-A stated they had not worked with R1. RN-A had training via Relias, which is an online training, about challenging behaviors and communication with people with dementia when hired. However, no specific training on self-harm or suicidal ideation's in the past couple weeks. When interviewed on 7/13/20, at 3:13 p.m. NA-A stated they had not received any training in the past couple weeks on self-harm or suicidal ideation's. When interviewed on 7/13/20, at 3:34 p.m. NA-B indicated she did not have training on working with residents with self-harm concerns or suicidal ideation. When interviewed on 7/14/20, at 11:28 a.m. RN-H stated the morning of 7/2/20, R1 was yelling and hitting the walls with her cane and attempted to hit staff also. RN-H stated she asked R1 to stop doing that. She found scissors on top of R1's dresser and removed those and some pushpins from the cork board. RN-H stated she let the director of nursing (DON) know she had removed sharp objects from R1's room. She had removed them due to fear of R1 hurting staff with them, and was not aware at that time that R1 had threatened to kill herself with those scissors. On 7/14/20, at 11:44 a.m. housekeeper (H)-A reported she had not recently reviewed what to do if a resident threatened self harm. H-A reported she would probably tell the resident not to do it, take the object away from the resident and push the call light for a nurse. H-A reported there was not a system in which resident safety precautions were communicated to her. H-A stated she thought the nursing assistant might tell her if there were precautions. When interviewed on 7/14/20, at 12:11 p.m. NA-F stated she had just received some training today on how to manage self-harm behaviors, by reading some information and signing a form. When interviewed on 7/14/20, at 1:27 a.m. the DON stated, RN-H had reported on 7/2/20 that R1 was striking out at staff with her cane and had removed some sharp objects from her room. The DON had not been aware of the 7/1/20 incident with the scissors until after starting to investigate the 7/2/20, incident with the butter knife. The DON stated for the 7/1/20, incident RN-I should have assessed R1 for self harm, remove the two pairs of scissors, not leave alone, and notify the practitioner, all which were not done. RN-I had received disciplinary notice and training. When interviewed on 7/14/20, at 11:45 a.m. dietary aide (DA)-C stated they had worked the day R1 was sent to the hospital. DA-C was not aware of any concern about R1 having any sharp utensils. This was not relayed to dietary staff. If DA-C had been aware, they would have provided plastic utensils rather than a regular butter knife and would have known to cut up food for R1. DA-C stated if a resident should not have sharp objects such as knives or glassware, it should be noted on their dietary card. DA-C had never received any training from the facility on what to do if someone threatened suicide or self-harm. When interviewed on 7/14/20, at 11:20 a.m. DA-B stated that last week they were given a sheet to read on signs to watch for if someone was at risk of harming themselves, but had not received any training. They had to sign that they read the sheet. DA-B stated she doesn't know how dietary would be informed if someone wanted to harm themselves and wanted to ask, but didn't know who to ask follow up questions to. When interviewed on 7/14/20, at 11:22 a.m. DA-A indicated she did not have training on working with residents with self-harm concerns or suicidal ideation, but last week they had to read and sign sheet on what signs to watch for. DA-A indicated supervisory staff should let them know if a resident has any precautions related to self-harm or special dinging service needs. DA-A also stated she didn't think dietary staff could know about suicidal tendencies in a resident because that was a, HIPPA (Health Insurance Portability and Accountability Act) thing. DA-A indicated dietary staff were told not to enter R1's room because R1 had hit an aide with her cane. Dietary staff were not given any instruction to withhold items such as knives or sharp objects from R1's meal tray. When interviewed on 7/14/20, at 11:45 a.m. the director of dietary services (DDS) indicated there should be dining precautions in place for residents identified with risk for self-harm including only giving them plastics, and not giving glass or something that would break. The DDS also indicated that they would also give a lighter weight plastic silverware, and a plastic knife only if needed. The DDS indicated they did not know what happened in R1's case, and they would have to check with staff to verify the communication break down. DDS stated if we had known the issue, they would have only provided disposable plastic. When interviewed on 7/14/20, at 11:50 a.m. RN-G stated that when R1 was threatening to kill herself on 7/1/20, RN-I should have followed their procedure which was to notify the clinical coordinator and director of nursing (DON), call 911, and not leave the resident alone. Staff should have removed all objects residents could use to harm themselves and make sure the resident was safe. Dietary should have notified not to provide any objects that could be used to harm oneself if at risk. R1 should have been assessed for self-harm and immediate interventions should have been placed. RN-G stated since the facility is so new and self-harm or suicidal ideation's had never come up before, they had not done any specific training on this for staff. However, there was a Relias annual training on vulnerable adult requirements, observing and reporting. When interviewed on 7/14/20, at 12:28 p.m. NA-C indicated she did not receive on-site training on working with residents with self-harm concerns or suicidal ideation and stated, We do an annual Relias training but I did not receive any education here. I would definitely try to find a supervisor or a nurse, talk to the resident to determine what to do best, especially if felt the person was going to actively do it in the minutes that I was there, would not leave the person alone, would look for sharp objects, remove call clip or any kind of cord or anything they could harm themselves, get it totally out of the room. When interviewed on 7/14/20, at 12:35 p.m. RN-C indicated she did not receive training on working with residents with self-harm concerns or suicidal ideation in the last couple weeks. A facility education entitled Guidelines for Handling Suicide Threats Policy and Threats to Harm Self and Prevention Policy had a document to sign indicating staff had received training on this. Staff who had worked since the 7/2/20, incident with R1, but had as of 7/14/20, at 12:49 p.m. yet to receive the training included: RN-A, RN-B, RN-C, RN-E, RN-F, NA-A, NA-B, NA-C, NA-D, NA-F, PT-A, DA-C. This was verified by the administrator. The facilities Guidelines for Handling Suicide Threats Policy, reviewed 2/16, indicated: 1. All suicide threats will be taken seriously and evaluated based on what is known and observed/assessed regarding the resident/client and what the physician recommends. 2. If a resident/client threatens suicide, designate a staff person to stay with him or her while the nurse is notified. 3. The nurse will notify the social worker or designee to assist in assessment and include a psychologist or psychiatrist as available. 4. The nurse will notify the family and physician promptly a recommendation for psych services will be reviewed with the physician and family for consideration of either inpatient geri-psych services or in-house referral. 5. Remove as many potentially lethal instruments from the room as possible, including medications, razors, tableware, nail files, glass, neckties, and panty hose. 6. Obtain direction from physician regarding psychiatric consultation, transfer to hospital, medication. Note that if suicidal threats are made, medication alterations may take an extended amount of time to reach full effectiveness. Therefore, if an identified plan threat is known admission to an inpatient setting should be strongly considered. 7. If satisfying direction has not been received for the physician and/or if any subsequent unmanageable suicide threats are made, and/or if you feel that the resident/client's mental condition renders him/her dangerous to self, call 911. 8. Take time to talk to the resident/client. See questions to ask a potentially suicidal resident/client. 9. Assure that sufficient observation and assessment is scheduled around the clock to reduce the chance of self injury. See guidelines for assessing suicide risk to determine frequency of monitoring. 10. If after repetitive suicidal ideation's or the need for 1:1 supervision, it becomes evident that the facility cannot provide adequate supervision and safety of the resident or others, the interdisciplinary team in partnership with the physician and psych services should consider alternate placement. 11. In the event that the resident is determined to need continuous observation until a longer term plan is implemented or emergency personnel are summoned, 1:1 supervision or indirect supervision through video observation may be used as indicated and compliant with appropriate consents and HIPPA requirements. The immediate jeopardy that began on 7/1/20, was removed on 7/15/20, when the facility reviewed their policies/procedures and ensured all staff would be trained in how to manage residents who may be at risk of harming themselves, prior to beginning their next shift. However, the noncompliance remained at the lower scope and severity level of a D- isolated incident with no actual harm with potential for more than minimal harm.