Every finding on record at Paramount Community Living and Rehab Inc

The facility reported a census of 91 residents, with one main kitchen and eight kitchenettes. Based on observation, interviews and record review, the facility failed to prepare and serve food in accordance with food safety requirements regarding adequate temperatures and sanitary food storage. Findings included:-Observations in the [NAME] House kitchenettes revealed the following: [NAME] House 1212: On 02/16/26 at 08:39 AM a mustard bottle and two jars of cocktail sauce were opened and undated. [NAME] House 1215: On 02/17/26 at 08:19 AM, Certified Nurse Aide (CNA) HH brought pureed sausage and gravy to the resident. Upon request, CNA HH checked the temperature which measured was 65 degrees Fahrenheit (F). CNA HH took the plate of food and placed it in the microwave. Recheck of the temperature measured 165 degrees F. CNA HH served the resident and told the resident to be careful with her plate because it was hot. The resident stirred her food and stated it was too hot for her to eat. [NAME] House 1202: On 02/17/26 at 11:19 AM, kitchen staff delivered the lunch meal in foil-covered pans. One large pan with smaller foil-covered pans inside was placed on counter. Certified Medication Aide (CMA) S drained a pot of spaghetti noodles, and at 11:42 AM, served the residents plates of spaghetti with sauce, steamed vegetables and a breadstick without measuring temperatures on the cooked food items prior to serving. On 02/17/26 at 12:02 PM, observation in a dry storage panty revealed an undated plastic zipper bag of dry, ground oatmeal labeled pureed, an opened and undated canister of oats and an open and undated bag of potato chips. On 02/17/26 at 11:57 AM, observation revealed one plated pureed meal on the counter, uncovered and unattended while staff ate with the residents. On 02/18/26 at 11:11 AM, kitchen staff arrived with the delivery of a pureed entree for one resident, and a large clear bag of uncut vegetables. The entree was chicken pot pie entree with garden salad and pumpkin spice blondie for dessert. CNA II prepped the salad by cutting the vegetables, then rechecked the entree temperatures. CNA II attempted to measure the temperature of the chicken pot pie but was dissatisfied with amount of time to obtain the measurement, so CNA II attempted to recalibrate the thermometer by placing it in a plastic cup of water with one ice cube. She then removed the entree from the oven and used the thermometer to check the internal temperature.The temperature measured 130 degrees F. so she placed the entree back into the oven at 11:51 AM. Using the same thermometer, CNA II then assessed the temperature of the pureed entree (chicken pot pie) which measured 100 degrees F. Without sanitizing the thermometer, CNA II placed it under running hot water then wiped it off with a kitchen towel that was previously used to wipe spots on the counter and a serving spoon. CNA II then returned to preparing the salad. On 02/18/26 at 12:27 PM, CNA II rechecked the temperature on the non-pureed entree which measured 165 degrees. Observation of the pureed entree revealed the food item was dry, crusty and dark on top with a temperature of 161 degrees F. CNA II placed it back in the oven and resumed serving other residents. Review of the temperature and sanitation logs for one kitchenette (1215) revealed the following: Temperature logs lacked evidence the evening meal temperatures were assessed and documented on 02/01/26-02/02/26, 02/04/26-02/07/26, 02/09/26, 02/11/26-02/13/26. No temperatures were documented in the temperature logbook for breakfast or lunch meals on 02/06/26. No temperatures documented for refrigerator/freezer, on first shift, 02/06/26, 02/09/26 and 02/11/26. No temperatures documented for refrigerator/freezer, on second shift, 02/01/26-02/02/26, 02/04/26-02/07/26, 02/09/26, 02/11/26-02/13/26. On 02/06/26-02/09/26, the sanitation checks were documented as not working. Sanitizer bucket tests were not completed/documented, for the same dates. During an interview on 02/17/26 at 08:19 AM, CNA HH stated she put cold milk in the pureed biscuits and gravy and that was why it was cold. She said she would need to heat up the food before serving it to the resident. During an interview on 02/16/26 at 08:45, CNA JJ stated the food should be dated when opened, and all food and refrigerator and freezer temperatures should be documented each shift. She stated she does not know why the temperature checks were not completed on second shift but said she does it when she works. On 02/17/26 at 12:00 PM, CMA S stated the resident who received the pureed plate which had sat on the counter was fed after the other residents who were able to come to the dining table themselves. On 02/17/26 at 10:55 AM, Dietary BB stated she expected temperature logs to be completed on each shift by the CNA or CMA who was working in each kitchen. On 02/18/26 at 12:10 PM, CNA II stated she would start plating the food for the residents once the temperatures of the chicken entrees reached 165 degrees. On 02/18/26 at 12:30 PM, CNA II stated she was aware the temperature of the entree needed to be 165 degrees F or higher and acknowledged that after using several thermometers, the temperature of the entree was still not at the appropriate temperature even after several different interventions. During an interview on 02/19/26 at 03:25 PM, Dietary BB stated food opened in the kitchen or kitchenettes should be placed in a ziplocked bag and dated with open and calculated expiration date. She said things like chips would have a 3-day expiration written on the bag, as well as the date it was opened. Dietary BB stated all lunch and supper menu items were prepared the day before and delivered in the mornings on the day they were to be heated and served. She stated the CNA or CMA who heated the hot food entree referred to the temperature guide which was hanging in each kitchen on the refrigerator. Dietary BB clarified all pureed entrees arrived to the kitchenettes hot after an initial temperature of 165 degrees F was achieved because pureed food was considered leftover. She said the temperature was verified as safe in the main kitchen prior to delivering it to the kitchenette, and the food had a holding temperature of 135 degrees F, which was to be rechecked by staff prior to serving. She said food should not be served if the temperature goes below 135 degrees F. The facility's policy Food Safety Requirements, last revised 01/2024, documented it was the policy of this facility to provide safe and sanitary storage, handling, and consumption of all foods including those brought to residents by family and other visitors. The objective and intent of the requirement was to ensure the facility follows proper sanitation and food handling practices to prevent the outbreak of foodborne illness. Safe food handling for the prevention of foodborne illnesses begins when food is received from the vendor and continues throughout the facility's food handling processes.

The facility identified a census of 91 residents. The sample included 19 residents with five residents sampled for unnecessary medications. Based on observation, interview, and record review, the facility failed to inform R59 or the resident's representative about the risk and benefits of taking a psychotropic (alters mood or thoughts) medication. Findings included:- R59's Electronic Medical Record (EMR) revealed the following diagnoses: dementia (a progressive mental disorder characterized by failing memory and confusion) with behavioral disturbances, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). R59's 11/13/25 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of four, indicating severely impaired cognition. The MDS documented R59 took antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), antidepressant (a class of medications used to treat mood disorders), and antianxiety (a class of medications that calm and relax people) medications. R59's Psychotropic Drug Use CAA documented R59 took routine antipsychotic, antianxiety, and antidepressant medication. Risks include decreased mental alertness, fatigue, drowsiness, dizziness, changes in appetite, and weight gain. R59's 02/10/26 Quarterly MDS documented R59 could not participate in the BIMS assessment. R59 had memory problems and severely impaired decision-making skills. R59 took antipsychotic and antidepressant medications. R59's Physician's Orders documented hydroxyzine (antihistamine used for its psychotropic qualities) 25mg; take one tablet by mouth every six hours as needed for restlessness related to anxiety disorder, end date 02/21/26; ordered on 01/21/26. R59's Physician's Orders documented hydroxyzine 25mg; take one tablet by mouth in the afternoon for anxiety; ordered on 12/12/25. R59's Physician's Orders documented Seroquel (antipsychotic) 50 mg; take one tablet by mouth every morning and at bedtime for agitation related to dementia with behavioral disturbances; ordered on 12/17/25. R59's Physician's Orders documented trazodone (antidepressant) 50mg; take one half a tablet at bedtime for insomnia; ordered on 01/09/26. R59's EMR documented an informed consent for Seroquel and hydroxyzine, but lacked evidence of informed consent regarding the trazodone. On 02/16/26 at 01:38 PM, R59 sat at the dining room table yelling, Help, help! There were handwritten notes from her daughter on the table in front of her, directing her not to yell for help. The notes encouraged her to ask the staff for what she wants. Staff occasionally responded to her and asked her what she needed. On 02/18/26 at 10:12 AM, Licensed Nurse (LN) I stated when a resident got an order for an antipsychotic medication, the nurse told the Director of Nursing (DON) before starting it. LN I stated that staff talked to the family, and they signed a consent form prior to starting the new medications. LN I was unsure if this was the case for new antidepressant medications, but after asking the DON, stated the facility did have a consent form for antidepressant medications. On 02/18/26 at 02:23 PM, Administrative Nurse D stated the facility should get consent for all psychotropic medications prior to starting the medications. Administrative Nurse D verified that the facility had previously only obtained consent for antipsychotic medications but had started including all psychotropic medications. The facility did not provide a policy for psychotropic consents.

The facility identified a census of 91 residents. The sample included 19 residents with five reviewed for unnecessary medications. Based on interview and record review, the facility failed to ensure Resident (R) 8 was free from unnecessary psychotropic medications and/or chemical restraints when they failed to ensure both of R8's as needed (PRN) lorazepam (antianxiety medication) had a 14 day stop date or a specified duration with a supporting physician rationale. Findings included:-R8's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) and anxiety disorder. R8's Significant Change Minimum Data Set, dated 02/13/26, documented the resident had a Brief Interview for Mental Status (BIMS) score of two, which indicated severe cognitive impairment. The MDS noted R8 received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), antidepressant (medication used to treat depression), and an antianxiety medication. R8's Care Plan, dated 11/12/24, documented the resident had behaviors including verbal and physical aggression, yelling obscenities, and hitting. The plan directed staff the resident would see the provider for mental health medication management services. R8's EMR recorded the following physician's orders:Lorazepam 0.5 milligrams (mg), give one tablet by mouth at bedtime for anxiety, dated 12/29/25.Lorazepam 0.5 mg, give one tablet by mouth PRN every six hours for anxiety, dated 12/29/24. The order lacked a stop date or specified duration with a rationale.Ativan (lorazepam) give one 0.5 mg tablet by mouth every four hours PRN for restlessness/anxiety, dated 02/05/26. The order lacked a stop date or specified duration with a rationale. In an interview on 02/18/26 at 12:20 PM, Administrative Nurse D stated R8 had two orders for PRN lorazepam due to the recent addition of hospice orders to his existing orders. Administrative Nurse D verified that neither order had the required 14-day stop date or a specific duration and said the recent pharmacy review Performance Improvement Plan (PIP) will help the facility ensure PRN medications that require stop dates will be quickly identified. The facility policy did not provide a policy for PRN psychotropic medications.

The facility had a census of 91 residents. The sample included 19 residents with three in the sample reviewed for hospitalization. Based on observation, interview and record review the facility failed to provide a written bed hold policy at the time of transfer for Resident (R) 10. Findings included:- R10's Electronic Medical Record (EMR) recorded a Significant Change Minimum Data Set (MDS) dated [DATE], which documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS noted R10 received an anticoagulant (blood-thinning medication) routinely. Nurse's Progress notes, dated 02/11/26 at 10:30 PM, documented the facility transferred R10 to the hospital for a critical lab value of potassium (an electrolyte in the blood). R10's EMR lacked evidence that a written bed hold policy was provided at the time of the transfer. On 02/18/26 at 10:45 AM, Concierge GG stated the facility did not provide the written bed hold policy on 02/11/26 because R10 returned to the facility within 24 hours. On 02/18/26 at 12:10 PM, Administrative Staff A stated that any time a resident transferred out of the facility to the hospital, a bed hold policy should be sent out with them. The facility's Bed Hold Prior to Transfer policy, dated 01/2024, indicated that prior to transferring a resident to the hospital or the resident goes on therapeutic leave, the facility will provide written information to the resident and/or the resident representative regarding bed hold. The duration of the state bed-hold, if any, during which the resident is permitted to return and resume residence in a nursing facility

The facility reported a census of 91 residents; 19 residents were selected for review. Based on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set to reflect the condition for Resident (R) 59's falls. Findings included:- R59's Electronic Medical Record (EMR) revealed the following diagnoses: dementia (a progressive mental disorder characterized by failing memory and confusion) with behavioral disturbances, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). R59's 11/13/25 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of four, indicating severely impaired cognition. The MDS documented R59 had one fall. R59's 11/13/25 Falls Care Area Assessment (CAA) documented R59 had a history of falls. R59's 02/10/26 Quarterly MDS documented R59 could not participate in the BIMS assessment. R59 had memory problems and severely impaired decision-making skills. The assessment inaccurately documented that R59 had two or more non-injury falls, no falls with major injury, and no falls with injury (except major) Review of the Resident Assessment Instrument (RAI- a comprehensive, standardized tool used in long-term care facilities to assess residents, guide care planning, and monitor quality of care.) documented falls with major injury, which included, but is not limited to, traumatic bone fractures, joint dislocations/ subluxations, internal organ injuries, amputations, spinal cord injuries, head injuries, and crush injuries. The RAI documented non-major injury includes, but is not limited to, skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains; or any fall-related injury that causes the resident to complain of pain.) R59's Event Note, dated 11/17/25 at 06:30 AM, documented a fall. R59 received a laceration to her left eyebrow and had complaints of pain in her left hand and wrist. An X-ray was ordered of the left shoulder, left hand, and wrist due to pain and weakness. R59's Fall note, dated 12/09/25 at 02:23 PM, documented a fall with no injuries. R59's Fall note, dated 12/22/25 at 09:11 PM, documented a fall with no injuries. R59's Nursing Note, dated 12/23/25 at 05:06 AM, documented R59 did not sleep the night and yelled out the entire shift. R59's Nursing Note, dated 12/23/25 at 07:09 PM, documented that the X-ray results showed a nondisplaced fracture of the right fourth and fifth rib. R59'3 Physician/Practitioner Progress Notes, dated 12/24/25 at 06:45 AM, documented a fall on 12/22/25 where an x-ray was obtained due to pain in the right ribs. X-ray showed a fracture to the right fourth and fifth rib. R59's Fall note, dated 02/05/26 at 07:00 AM, documented a fall with no injuries. R59's Nursing note, dated 02/05/26 at 03:30 PM, documented R59 was complaining of shoulder pain and had decreased range of motion. Staff received a new order for a shoulder x-ray. R59's Nursing note, dated 02/06/26 at 03:07, documented that the X-ray results showed no fractures. R59's Fall note dated 02/10/26 at 06:45 PM documented a fall with no injuries. On 02/16/26 at 01:38 PM, R59 sat at the dining room table yelling, Help, help! There were handwritten notes from her daughter on the table in front of her, directing her not to yell for help. The notes encouraged her to ask the staff for what she wants. Staff occasionally responded to her and asked her what she needed. On 02/18/26 at 12:27 PM, Administrative Nurse E stated she sees that the MDS was coded incorrectly, and she will complete a modification of the MDS. It is important that the MDS accurately represents the residents. On 02/18/26 at 02:23 PM, Administrative Nurse D stated she expected the MDS to be completed in a timely and accurate manner. The facility did not provide a policy.

The facility had a census of 91 residents; the sample included 19 residents. Based on observation, interview and record review, the facility failed to provide consistent activities for Resident (R) 7. Findings included:- The Electronic Health Records (EHR) for R7 included diagnoses of cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), paralysis of vocal cords and larynx (a disorder where one or both vocal cords cannot move properly due to interrupted nerve impulses, causes hoarseness, breathing difficulties, and swallowing issues), tracheostomy status (opening through the neck into the trachea through which an indwelling tube may be inserted), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). R7's Annual Minimum Data Set (MDS), dated for 0130/26, documented a Brief Interview for Mental Status (BIMS) score of 13, which indicated cognitively intact. The assessment documented that R7 used a wheelchair for mobility and was dependent on staff for all activities of daily living (ADL). The Functional Abilities (Self-care and Mobility) Care Area Assessment (CAA), dated 01/30/26, documented R7 was totally dependent on staff for all ADLs. R7's Care Plan, dated 11/06/25, documented R7 preferred independent activities in her room, and her preferred activities included bingo, being around animals, baking, being around family, and watching TV. R7's EHR, including Progress Notes, lacked documentation that activities were offered to R7 or R7 had participated in any activities. Observed on 02/17/26 at 11:00 AM, R7 was in her room watching TV. She reported she had not been offered any activities that day. Observed on 02/18/26 at 01:37 PM, R7 remained in her room watching TV. She reported she had not been offered any activities to participate in that day. On 02/16/26 at 11:36 AM, R7 reported staff did not offer her activities. She said she stayed in her room and had to determine her own activities. On 02/17/26 at 03:07 PM, Certified Nurse Aide (CNA) M stated residents who stayed in their rooms were not offered activities to do in their room, but they were offered the opportunity to get up and participate in group activities. On 02/17/26 at 03:30 PM, Licensed Nurse (LN) H stated she would offer some type of activity to the residents who remained in their rooms, if time permitted. On 02/18/26 at 10:10 AM, Activity Z stated activities were always offered to those residents who remained in their rooms and their activity preference was charted quarterly but not charted any other time. Activity Z also said R7 frequently refused activities and preferred her own individual activities, but it was not charted anywhere whether an activity was offered or refused. The facility policy Life Enhancement and Activity Programming, dated 01/2024, documented the facility would provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident.

The facility reported a census of 91 residents with 19 residents selected for review. Based on observation, interview, and record review, the facility failed to follow fall prevention interventions to prevent falls for Resident (R) 59. Findings included:- R59's Electronic Medical Record (EMR) revealed the following diagnoses: dementia (a progressive mental disorder characterized by failing memory and confusion) with behavioral disturbances, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). R59's 11/13/25 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of four, indicating severely impaired cognition. The MDS documented R59 had one fall. R59's 11/13/25 Falls Care Area Assessment (CAA) documented R59 had a history of falls. R59's 02/10/26 Quarterly MDS documented R59 could not participate in the BIMS assessment. R59 had memory problems and severely impaired decision-making skills. The assessment inaccurately documented R59 had two or more non-injury falls and no falls in major injury (includes, but is not limited to, traumatic bone fractures, joint dislocations/ subluxations, internal organ injuries, amputations, spinal cord injuries, head injuries, and crush injuries) and no falls with injury that is not major (includes, but is not limited to, skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains; or any fall-related injury that causes the resident to complain of pain). R59's Care Plan, dated 07/31/25, documented R59 was at risk for falls related to weakness and poor safety awareness due to dementia. Interventions included Dycem (a non-slip mat used for stabilization and gripping to prevent slipping) in the recliner, initiated on 02/11/26. Also, an intervention for staff to offer a weighted blanket when R59 appears anxious or restless was initiated on 12/10/25. On 02/16/26 at 01:38 PM, R59 sat at the dining room table yelling, Help, help! There were handwritten notes from her daughter on the table in front of her, directing her not to yell for help. The notes encouraged her to ask the staff for what she wants. Staff occasionally responded to her and asked her what she needed. On 02/17/26 at 8:08 AM, R59 was seated at the table. Certified Nurse Aide (CNA) HH was pureeing food in the blender. R59 was agitated and hollering at the sound of the blender On 02/17/26 at 08:16 AM, R59 was hollering she was cold, and staff got her a non-weighted blanket. On 02/17/26 at 11:10 AM, R59 continued to be in the dining room at the table covered up, and yelling out. On 02/17/26 at 01:57 PM, R59 sat in the common area with the same non-weighted blanket over her. On 02/17/26 at 02:54 PM, CMA T and CNA HH assisted R59 out of the recliner to the wheelchair. There was no Dycem in the recliner or in her wheelchair as care planned. On 02/17/26 at 01:57 PM, CMA T stated R59 does not have a weighted blanket, and the houses do not have weighted blankets; they only have them in the main building, and that is why she couldn't get her one. On 02/18/26 at 09:24 AM, CNA O stated staff tried to distract R59 when she got restless; staff tried to keep her calm. CNA O was not aware of specific fall interventions for R59 but said they can look at the tablet to know how to care for a resident. On 02/18/26 at 10:12 AM, Licensed Nurse (LN) I stated she did not know what the interventions were, but she could find out. She went to the care plan and brought up the interventions. LN I stated she expected staff to follow the care planned interventions. On 02/18/26 at 02:23 PM, Administrative Nurse D stated she expected the staff to follow all interventions as they are in the care plans. Administrative Nurse D said she would look into why the interventions were not followed and have the appropriate interventions available for the staff to use. Administrative Nurse D stated the daughter might have removed the weighted blanket from her room. The facility's Falls Management policy, dated 01/2024, documented the interdisciplinary team will implement interventions based on individual needs, communicate the interventions to the care-giving teams, and provide training as needed.

The facility identified a census of 91 residents. The sample included 19 residents with two residents reviewed for dialysis (blood purifying treatment given when kidney function is not optimum). Based on observation, record review, and interviews, the facility failed to ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for Resident (R) 6 and R13. Findings included:1. R6's Electronic Medical Record (EMR) documented a diagnosis of chronic kidney disease, stage 5 (the final, most severe stage of chronic kidney disease where kidney function drops to less than 15%, indicating kidney failure) and dependence on renal (kidney) dialysis. R6's Annual Minimum Data Set (MDS), dated [DATE], documented R6 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented R6 had impairment to one side of her body, upper and lower extremities, and received dialysis services. R6's Care Plan, with an initiated date of 11/16/21, documented R6 had dialysis on Monday, Wednesday, and Friday. An intervention with an initiated date of 11/16/21 documented the facility was to establish a means of communication between the dialysis facility and themselves. R6's EMR under the Orders tab revealed physician orders: Dialysis on Monday, Wednesday, and Friday at 07:00 AM with a start date of 04/23/25. Complete Dialysis Post-Observation form (found in PCC under forms tab) upon return from dialysis, dated 04/23/25. Complete Dialysis Pre-Observation includes vital signs. Fill out the dialysis communication form to send with the resident, dated 04/23/25. R6's EMR under the Forms tab revealed the post-dialysis form was not completed on 02/13/26, and the pre-dialysis and post-dialysis forms were not completed on 02/16/26. Review of R6's dialysis binder revealed the post-dialysis observation form was not completed on 02/13/26 and 02/16/26. Observed on 02/17/26 at 12:16 AM, staff delivered R6 her lunch meal tray. 2. R13's EMR documented a diagnosis of end-stage renal disease (ESRD-a terminal disease of the kidneys) and dependence on renal dialysis. The Annual MDS, dated [DATE], documented R13 had a BIMS score of 15, which indicated intact cognition. The MDS documented R13 required some assistance with activities of daily living (ADL) and received dialysis services. The Nutritional Status Care Area Assessment (CAA) dated 09/15/25, documented R13 was on dialysis three times a week. R13's Care Plan with an initiated date of 03/27/24, documented R13 had ESRD with dialysis. An intervention with an initiated date of 03/03/23 documented R13 received dialysis every Monday, Wednesday, and Friday; staff was instructed to monitor for changes in mental status, dated 11/30/22. R13's EMR under the Orders tab revealed physician orders: Dialysis on Monday, Wednesday, and Friday with a start date of 04/21/25. Complete Dialysis Post-Observation form (found in PCC under form tab) upon return from dialysis. Review the Dialysis Communication form for any recommendations or new orders placed on 04/22/25. Post Dialysis Vital Signs every Monday, Wednesday, and Friday; ordered on 01/09/26. R13's Dialysis Post-Observation form did not show new vital signs, and the order for vital signs to be obtained after dialysis was not completed on 02/11/26 or 02/13/26. R13's Resident Specific Post-dialysis information (Completed by the facility upon return) information was not filled into the dialysis communication form on any day from 12/01/25 to 0218/26. Observed on 02/16/26 at 11:32 AM, R13 sat in his recliner in his room. R13 had recently returned from dialysis. R13 stated the facility checked his vital signs prior to dialysis, but they do not check them or do anything after dialysis. On 02/18/26 at 09:51 AM, Licensed Nurse (LN) G stated the post-dialysis form was not done on 02/13/26, and she confirmed the pre- and post-dialysis assessment was not in the EMR. On 02/18/26 at 12:12 PN, Administrative Nurse D stated the facility communicated with the dialysis treatment center by performing pre- and post-dialysis observation assessments on the dialysis residents with the form in the EMR and putting those forms in each resident's dialysis binder. Administrative Nurse D further stated that the pre- and post-dialysis observation assessment form was the key communication tool and must be completed. The facility policy Special Need-Dialysis Transportation, dated 01/2024, documented a dialysis documentation form would accompany the resident to all appointments and documentation would occur according to protocols.

The facility reported a census of 91 residents; the sample included two residents reviewed for bed rail safety. Based on interview, observation, and record review, the facility failed to obtain informed consent from the residents or the resident's legal representative for installation of bedrails for Resident (R) 53 and for R86. Findings included:1. The Electronic Health Records (EHR) for R53 included diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (severe functional limitations, including balance issues, reduced mobility, and possible communication difficulties, requiring a multidisciplinary rehabilitation approach), visuospatial deficit and spatial neglect following cerebral infarction (often disabling, cognitive impairment following stroke, characterized by a failure to detect, report, or orient to stimuli on the side opposite the brain injury). R53's Admit Minimum Data Set (MDS), dated 12/24/25, documented a Brief Interview for Mental Status (BIMS) score of four, which indicated severe cognitive impairment. The assessment documented R53 required partial to moderate assistance with activities of daily living (ADL). R53's Cognitive Loss/Dementia Care Area Assessment (CAA), dated 12/24/25, documented R53 had a BIMS score less than 13 and had a presence of inattention, disorganized thinking, and an altered level of consciousness. R53's Communication CAA, dated 12/24/25, documented R53 had an impaired ability to make herself understood through verbal and non-verbal expression; the assessment also documented R53 had an impaired ability to understand others through verbal content. R53's Care Plan, dated 12/25/25, documented R53 chose to use one to two quarter bed rails to complete bed mobility and repositioning. R53's EHR lacked evidence of an order for R53 to have bed rails and lacked a signed, informed consent for bed rails. Observed on 02/16/26 at 12:54 PM, R53 had upper side rails on each side of her bed. 2. The EHR for R86 included diagnosis of morbid (severe) obesity (a chronic, life-threatening disease defined by a Body Mass Index [BMI] of 40 or higher, or 35-39.9 with significant obesity-related health conditions), and unilateral primary osteoarthritis of the left knee (a degenerative, age-related joint disease causing cartilage breakdown in only the left knee, leading to pain, stiffness, and reduced mobility). R86's Significant Change MDS, dated 12/04/25, documented a BIMS score of 15, which indicated intact cognition. The assessment documented R86 had impairment in both lower extremities and that she used a wheelchair for mobility. R86 required set-up or clean-up assistance for personal and oral hygiene and was dependent on staff for toileting and lower body dressing. R86's Cognitive Loss/Dementia CAA, dated 12/04/25, documented she had the presence of behavioral symptoms (verbal, physical, or other), and that R86 had rejected care at least one day out of seven. R86's Functional Abilities (Self-Care and Mobility) CAA, dated 12/04/25, documented R86 required set-up or clean-up assistance for personal and oral hygiene and was dependent on staff for toileting and lower body dressing. R86's Care Plan, dated 12/15/26, documented R86 chose to use one to two quarter bed rails to complete bed mobility and repositioning. R86's EHR lacked evidence of an order for R86 to have bed rails and lacked a signed informed consent for bed rails. Observed on 02/16/26 at 12:41 PM, R86 had upper side rails on each side of her bed. On 02/17/26 at 01:36 PM, Licensed Nurse (LN) G stated a resident must be able to turn and assist themselves before getting any type of bed rail, but no formal consent is required. On 02/17/26 at 01:46 PM, Administrative Nurse D stated consents were not required for bed rails because the facility did not use bed rails; they were called mobility assist rails. Administrative Nurse D confirmed that there were no informed consents for bed rails. The facility policy Bed Rails/Mobility Assist Devices, dated 01/2024, documented that if a side rail or mobility assist device was used, the facility would ensure correct installation, correct use, and maintenance of side rails, and would review the risk and benefits of side rails with the resident or resident representative and obtain informed consent prior to installation.

The facility identified a census of 91 residents. The sample included 19 residents with three residents reviewed for respiratory care. Based on observation, interview, and record review, the facility failed to ensure emergency equipment was readily available in the event of an accidental extubation (removal of a medical tube) of Resident (R)7's tracheostomy (opening through the neck into the trachea through which an indwelling tube may be inserted) cannula. Findings included:- The Electronic Health Records (EHR) for R7 included diagnoses of cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), paralysis of vocal cords and larynx (a disorder where one or both vocal cords cannot move properly due to interrupted nerve impulses, causes hoarseness, breathing difficulties, and swallowing issues), tracheostomy status (opening through the neck into the trachea through which an indwelling tube may be inserted), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). R7's Annual Minimum Data Set (MDS), dated for 0130/26, documented a Brief Interview for Mental Status (BIMS) of 13, which indicated cognitively intact. The assessment documented R7 used a wheelchair for mobility and was dependent on staff for all activities of daily living (ADL). The assessment also documented R7 had shortness of breath or trouble breathing when lying flat. The Functional Abilities (Self-care and Mobility) Care Area Assessment (CAA), dated 01/30/26, documented R7 as totally dependent on staff for all ADLs. R7's Care Plan, dated 02/07/25, documented R7 had a tracheostomy and instructed staff to monitor and document R7's level of consciousness, mental status, and lethargy as needed. Staff were also instructed to monitor and document R7 for restlessness, agitation, confusion, increased heart rate, and bradycardia (low heart rate, less than 60 beats per minute). Observed on 02/16/26 at 11:51 AM, there was no emergency tracheostomy kit, including a replacement cannula or Ambu bag (a handheld, manual, self-inflating resuscitator used to deliver positive pressure ventilation to patients with inadequate or no breathing) visible in R7's room. Observed on 02/17/26 at 09:20 AM, there was no emergency tracheostomy kit or Ambu bag visible in R7's room. On 02/17/26 at 01:23 PM, Certified Nurse Aide (CNA) N stated she would immediately get the nurse if R7 had a respiratory distress situation or the tracheostomy tube came out. On 02/17/26 at 01:26 PM, Licensed Nurse (LN) G stated that the two things which should be readily available for a tracheostomy resident were suction and oxygen. LN G then said the Ambu bag was in the oxygen storage room, and there was no other tracheostomy tube available. R7's tracheostomy tube was a special, metal one, and only one was ordered. On 02/17/26 at 01:50 PM, Administrative Nurse D confirmed there was no Ambu bag in R7's room; she did find the emergency tracheostomy kit after several minutes of searching in a plastic shelving unit on the windowsill of R7's room. On 02/17/26 at 02:08 PM, Administrative Nurse D stated the emergency tracheostomy kit had been taped to the wall next to R7's bed and the Ambu bag had been placed in the room. The facility policy Special Needs, dated 01/2024, documented the facility would provide the necessary care and treatment, including medical and nursing care, consistent with professional standards of practice and in accordance with physician orders.

The facility reported a census of 92 residents with 22 included in the sample. Based on observation, interview, and record review, the facility failed to ensure infection control techniques for Resident (R)9, regarding oxygen (O2) tubing/cannula storage, for R60, related to urinary catheters and perineal care, R242, related to storage of soiled catheter collection device stored next to personal care items of toothbrush and toothpaste, and R78, related to incontinence cares, to prevent the spread of infections in the facility. Findings included: - R9's physician orders revealed the following diagnoses that included chronic obstructive pulmonary disease (COPD-progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Review of the Quarterly MDS dated [DATE], revealed a BIMS score of 15. R9 received oxygen (O2). The care plan dated 03/17/2023 revealed the resident had COPD and staff were to give oxygen therapy as ordered by the physician. Observation on 03/25/24 at 11:45 AM, revealed Certified Nursing Assistant (CNA) UU entered the resident's room to assist the resident to lunch. CNA UU removed R9's O2 cannula and placed the tubing and nasal cannula directly on the bed. The room lacked a storage container for the O2 cannula. CNA UU removed a trash filled bag out of the trash can, reached into the trash can and obtained a new trash bag out and placed R9's cannula into the trash bag, and laid the cannula back onto the bed. No hand hygiene completed between removing the trash and handling R9's cannula. Observation revealed a second nasal cannula stored directly on R9's walker and was not stored in a container. CNA UU applied the opened, unbagged nasal cannula to R9 and assisted R9 to the dining room. Observation on 03/26/24 at 12:10 PM, CNA SS entered the resident's room to assist the resident to the dining room. She removed R9's O2 cannula and placed the cannula/tubing directly on the bed and placed a magazine on top of the cannula. CNA SS removed O2 tubing/cannula from the walker and placed it on the resident. That cannula was not in a storage bag and was wrapped around the back of the walker with the cannula having contact with the top of the O2 tank. On 03/25/24 at 11:50 AM, CNA UU reported the resident's O2 cannula and tubing should be in a box but did not see one in her room. The resident's walker should have a bag to contain the O2 when not in use. On 03/26/24 at 12:10 PM, CNA SS reported she was not sure what to do with the O2, so she just put it on the bed and laid something on top of it so it would not slide off on the floor. She was unaware anything had to be on the walker for the O2 tubing to be stored in. On 03/26/24 at 12:20 PM, Licensed Nurse (LN) I reported everyone on O2 should have a three-compartment cart in their room for the O2. She also reported all walkers or wheelchairs that use O2 should have bags with the resident's name and date on it and changed weekly. Observation revealed LN I went into R9's room and found the O2 cart, in a closet behind a wheelchair, with piled clothing and blankets that covered the O2 cart. LNI removed the cart from the closet and placed it into R9's room to be utilized. The facility's policy for oxygen, lacked care of the tubing and cannulas. The facility failed to ensure good infection control techniques by the failure to store oxygen (O2) tubing and nasal cannula in a sanitary manner when not in use. - Resident (R) 60's signed physician orders dated 11/03/23 revealed the following diagnoses included neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system), and a history of urinary tract infection (infection of any part of the urinary system). The Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. The resident was dependent on staff for all daily cares and used a wheelchair for mobility. The resident had an indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) and was incontinent of bowel. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 11/03/23 revealed staff were to provide assistance to clean and dry the resident for bowel needs and the resident had an indwelling urinary catheter. Observation on 03/25/24 at 12:10 PM, revealed Certified Nursing Assistant (CNA) V emptied the resident's catheter. CNA V donned gloves and retrieved a graduated pitcher from the bathroom and removed the tubing from the catheter bag spigot. She drained the catheter bag and placed the tubing into the spigot of the drainage bag without cleansing the spigot. CNA V failed to remove her soiled gloves and CNA V and CNA UU transferred the resident from a full body mechanical lift to the bed. The resident had a bowel movement and required incontinence cares. CNA UU provided perineal cares and grabbed disposable wipes from the container with the soiled gloves. CNA V and CNA UU failed to remove their soiled gloves and placed a clean brief under the resident. CNA UU then went into the bathroom with the soiled gloves on, retrieved moisture barrier, and applied moisture barrier to the resident. With soiled gloves on, the brief was placed and fastened, and staff positioned the resident onto his side with positioning devices and placed positioning devices under his legs. CNA V then removed her gloves. CNA UU emptied the trash and then removed her gloves. Both CNA's left the resident's room without washing their hands. On 03/25/24 at 12:30 AM, CNA V reported she would usually use alcohol when emptying a catheter but thought there was no available alcohol in the resident's bathroom, so just did not use it. On 03/25/24 at 12:32 PM, CNA UU reported she should have changed her gloves during the incontinent care. On 03/28/24 at 08:00 AM, Administrative Nurse D reported she expected her staff to maintain good hand hygiene with personal care. Staff should change their gloves between dirty and clean. Staff with the clean gloves should handle the wipes and hand to the aide doing the perineal care. When emptying the catheter, gloves are required along with alcohol to the tubing to clean the tubing, to prevent urinary tract infections (UTI's). Hand washing and proper usage of gloves and disinfecting the tubing is a must. The facility's policy for Urinary Catheter Care, dated 02/2017, included: Staff shall use standard precautions while performing urinary catheter cares with residents. Review of the facility's policy for Standards of Care dated 04/01/23, revealed all staff are to maintain standard precautions when providing care to a resident. The facility failed to ensure good infection control techniques by the failure to change gloves between dirty and clean while performing peri-care for R60 and the failure to properly clean the catheter spigot when emptying R 60's indwelling urinary catheter. 34056 - Review of Resident (R)78's electronic medical record (EMR) revealed a diagnosis of multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord). The Modification of Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of thee, indicating severe cognitive impairment. She required extensive assistance of two staff for toileting and was incontinent of bowel. The Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 08/06/23, did not trigger. The Quarterly MDS, dated [DATE], documented the staff assessment for cognition revealed the resident was independent with daily decision making. She was dependent on staff for all ADLs and was always incontinent of bowel. The care plan for ADLs, dated 08/01/23, instructed staff the resident required assistance with all ADLs. Review of the resident's EMR, from 03/01/24 through 03/27/24, revealed the resident was dependent on staff for bowel incontinence and dressing. On 03/26/24 at 08:14 AM, Certified Nurse Aide (CNA) T and Certified Medication Aide (CMA) MM entered the resident's room to get her ready for the day. The staff completed peri-care due to the resident being incontinent of bowel. The staff then applied a clean brief without changing gloves. CNA T then began to dress the resident, putting her hand through the sleeve of the resident's clean shirt, without changing her gloves. On 03/26/24 at 08:14 AM, CNA T confirmed she had not changed her gloves after performing peri-care following the incontinent BM before she placed a new brief on the resident and began to dress her. CNA T stated she should have changed her gloves but had forgotten. On 03/26/24 at 08:19 AM, CMA MM stated she should have changed her dirty gloves before helping to put a clean brief on the resident. On 03/28/24 at 09:51 AM, Administrative Nurse D stated it was the expectation for staff to change their gloves after providing peri-care and before putting on a clean brief or assisting a resident to dress. The facility lacked a policy regarding changing gloves following peri-care. The facility failed to use appropriate hand hygiene after performing peri-care for this dependent resident. - Review of Resident (R)242's electronic medical record (EMR) included a diagnosis of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The Annual Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed severe impairment. He was dependent on staff for all ADLs. The Urinary Incontinence/Indwelling Catheter Care Area Assessment (CAA), dated 01/15/24, documented the resident was dependent on staff for toileting. The Medicare 5-Day MDS, dated [DATE], documented the staff assessment for cognition revealed severe impairment. He was dependent on staff for all ADLs. The indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) care plan, revised 03/25/24, instructed staff to position the catheter bag and tubing below the level of the bladder. Review of the resident's EMR revealed the following physician's order: Indwelling urinary catheter for neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system), 03/20/24. On 03/26/24 at 01:15 PM, Certified Medication Aide (CMA) NN entered the room to empty the resident urinary catheter. CMA NN drained the urine into a graduate (a vessel used to measure liquids). CMA NN then emptied the urine into the toilet, filled the graduate half-way with water from the resident's bathroom faucet to rinse, poured the rinse water into the toilet then placed the graduate upside down on the back of the toilet on top of paper towels up against the resident's tooth brush, tooth paste and shaving cream. On 03/26/24 at 01:15 PM, CMA NN stated the staff kept the graduate on the back of the toilet with the rest of the resident's things all the time. On 03/27/24 at 01:38 PM, Administrative Nurse D stated the staff should not place the graduate up against the resident's toothbrush and toothpaste. The facility policy for Urinary Catheter Care, dated 02/2017, included: Staff shall use standard precautions while performing urinary catheter cares with residents. The facility failed to use appropriate standard precautions while performing catheter care for this dependent resident with a urinary catheter.

The facility reported a census of 92 residents. Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for food borne bacteria. Findings included: - During an initial tour of the resident kitchenette, on 03/25/24 at 11:07 AM, the following areas of concern were noted in the kitchen of greenhouse 1202: 1. The inside of the toaster had a heavy build-up of crumbs. 2. The top of the stove had dried-on food debris. 3. A large plastic container of corn chips lacked a lid and there were corn chips on the floor. 4. The deep freeze had food debris on the bottom. 5. The silverware drawer contained wet silverware and food debris. 6. There were multiple greasy fingerprints on the hood of the range. During a tour of the kitchenette of the first floor, on 03/25/24 at 01:00 PM, the following areas of concern were noted: 1. The resident refrigerator contained a can of an opened energy drink which was unlabeled and undated. 2. The sink had a brownish substance on the back rim up against the wall. 3. The trash can had dried-on food debris and lacked a lid. During an initial tour of the kitchen, on 03/26/24 at 07:49 AM, the following areas of concern were noted: 1. The reach-in refrigerator racks had an extremely heavy build-up of a black substance in between the front lip of six white, plastic-covered racks. 2. The top of the ice machine and the oven contained a layer of dust. 3. A white, four-tiered cart, used to dry clean dishes, had ground in dirt and debris into the four plastic tiers and the handles of the cart, causing them to be discolored. 4. Ten knives plastic handles were deeply grooved and had ground in dirt and debris causing the handles to be discolored. The plastic container holding the knives contained food debris. 5. Three plastic containers holding spatulas, tongs and divider bars contained food debris in the bottom of the closed containers. 6. The inside of the microwave had dried-on food debris. 7. Two shelves over the cold cart had a layer of dust. 8. The shelf on the steam table, used to cut food for resident's consumption, had deep cuts causing the surface to be discolored and uncleanable. 9. Three doors of the cold cart had a large amount of ground-in food debris in the rubber seal of the doors. During a tour of the kitchen in green house 1212, on 03/25/24 at 10:55 AM, the following areas of concern were noted: 1. Two open cans of 2-cal (a nutritionally complete, high-calorie formula designed to meet the needs of people with increased protein and calorie requirements) were partially used and undated. 2. There was a mug of a milky substance was undated. 3. There was a plastic bag of cucumbers, undated. The cucumbers had a slimy appearance. 4. There were two pitchers of juice, undated. 5. Two cartons of juice concentrate to be used within 48 hours of thawing, lacked date. On 03/25/24 at 10:50 AM, Dietary staff DD stated the staff should date foods when opened. On 03/28/24 at 10:07 AM, Dietary staff DD stated the staff were responsible for keeping the kitchens and kitchenettes clean and sanitary. The facility policy for Food Safety Requirements, reviewed 01/2024, included: It is the policy of the facility to provide safe and sanitary storage, handling and consumption of all foods. The food service workers are responsible to adhere to the food safety requirements. The facility failed to prepare and serve food under sanitary conditions for the residents of the facility appropriately to prevent the potential for food borne bacteria.

The facility reported a census of 92 residents with 22 selected for review. Based on observation, interview, and record review, the facility failed to develop comprehensive care plans for four of the 22 residents reviewed. Resident (R)37 for use of support hose, R35 for fluid restriction, R78 for type of music, TV shows and religious preferences and R242 for shaving preferences. Findings included: - Review of Resident (R) 37's medical record revealed diagnoses that included Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear, chronic kidney disease, congestive heart failure (a condition with low heart output and the body becomes congested with fluid), and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain). The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of five, which indicated severe cognitive impairment. The resident required extensive assistance of staff for dressing and personal hygiene. The Cognitive Loss Care Area Assessment (CAA), dated 07/25/23, assessed the resident's risk factors of skin breakdown, weight loss and fluid imbalance. The ADL (Activity of Daily Living) Functional/Rehabilitation CAA dated 07/25/23 did not trigger. The Care Plan reviewed 03/20/24, instructed staff the resident had a functional deficit with ADLs due to dementia(progressive mental deterioration characterized by confusion and memory failure).The resident required moderate assistance with dressing. The care plan instructed staff to ensure the resident wore appropriate footwear, as she preferred tennis shoes. The care plan lacked the resident's preference for wearing support hose. Interview, on 03/25/24 at 02:10 PM, with a family member revealed R37 preferred to wear support hose and had multiple pairs of them in her drawers. The family member stated the resident often does not have them on and she assists R37 in putting them on when visiting the resident. Observation, on 03/26/24 at 11:38 AM, revealed Certified Medication Aide (CMA) M ambulated with the resident to the bathroom. The resident lacked support hose. Interview with CMA M at that time revealed the night shift washed the support hose and dried them on the towel rack in the bathroom, and they were wet this morning, but dry at this time. CMA M did not know the resident had several pairs of the compression hose in her drawers. Observation revealed several pairs of support hose in her drawer beneath the closet. Interview, on 03/28/24 at 10:00 AM, with Administrative Nurse D, confirmed the resident preference for support hose was not on the care plan, and not listed as a Task for certified staff to complete. The facility policy Standards of Care and Care Planning Practice dated 04/01/23, instructed staff the care plan should reflect resident centered items that are unique to that resident's care. The facility failed to include R37's preference for wearing support hose in her comprehensive care plan to promote a sense of well-being. 34056 - Review of Resident (R)78's electronic medical record (EMR) included a diagnosis of multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord). The Modification of the Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. It was very important for her to listen to music she liked, participate in religious services and do her favorite activities. She required total staff assistance with transfers, locomotion on and off the unit, and she had impaired range of motion (ROM) on bilateral (both) upper and lower extremities. The Activities Care Area Assessment (CAA), dated 08/06/23, documented the resident was at risk for decreased socialization and worsening depression. The facility would encourage active participation in facility functions to engage in sensory stimulation. The Quarterly MDS, dated [DATE], documented the staff assessment for cognition revealed the resident was independent with daily decision making. She was dependent on staff for all activities of daily living (ADL). The care plan for activities, revised 08/01/23, instructed staff the resident was dependent on staff for participation in activities. Her favorite activities included visiting, watching group activities, watching TV and listening to music. The care plan lacked the genre of music the resident enjoyed, TV shows she like to watch and lacked the resident's religion. Review of the resident's Activities Admission Data Collection, dated 08/01/23, documented it was very important for her to listen to the music she liked, participate in religious services and to do her favorite activities. The primary respondent for the assessment was the resident. Review of the resident's Activities Readmission Data Collection, 02/21/24, lacked activity preferences. Review of the facility's activity calendar revealed an activity of morning music would occur every morning at 09:30 AM and religious services would occur each Sunday morning at 09:30 AM and 11:00 AM. Review of the resident's EMR, from 03/01/24 through 03/27/24, revealed she participated in a social on three occasions and had visitors on two occasions. No other activities documented. On 03/26/24 at 08:14 AM, Certified Nurse Aide (CNA) T and Certified Medication Aide (CMA) MM entered the resident's room to prepare the resident for the day. The resident's room lacked a device to listen to music and her TV was not turned to a music station. On 03/27/24 at 09:48 AM, the resident sat in her wheelchair in the commons area facing the TV. The TV, which was tuned to a soap opera, had no volume. On 03/28/24 at 09:01 AM, the resident sat in her wheelchair in her room with CNA X. The TV was turned off and no music played in the resident's room. On 03/28/24 at 09:01 AM, the resident stated she prefers to listen to rap music. She stated she was a Baptist but had not been able to participate in a Baptist service for a long time. On 03/26/24 at 03:09 AM, CNA PP stated she was unsure of what the resident liked to watch on TV but staff would put her in the commons area in front of the TV so she was able to watch whatever was on at that time. On 03/27/24 at 08:14 AM, CNA T stated the resident's family would turn the TV on to a music station when they visited, but CNA T was unsure of what music the resident preferred. On 03/28/24 at 07:38 AM, Activity Staff Z stated the staff were responsible for activities in the green houses. On 03/28/24 at 09:01 AM, CNA X stated she was unsure of what music the resident preferred. On 03/28/24 at 09:51 AM, Administrative Nurse D stated it was important for the care plan to include the types of music and TV shows the resident enjoyed and should also include her religion. The facility policy for Standards of Care and Care Planning Practice, dated 04/01/23, included: Care plans should reflect resident-centered items that are unique to that resident's care. The facility failed to complete a person-centered comprehensive care plan to meet this dependent resident's activity preferences. - The Physician's Order Sheet (POS), dated 03/21/24, documented Resident (R)242 had a diagnosis of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The Annual Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed severe impairment. The resident was dependent on staff for all activities of daily living (ADL). The Functional Abilities Care Area Assessment (CAA), dated 01/15/24, did not trigger. The Medicare 5-day MDS, dated [DATE], documented the staff assessment for cognition revealed severe impairment. He was dependent on staff for all ADLs. The care plan for ADLs, revised 01/30/24, instructed staff the resident was dependent on staff for all ADLs. The care plan lacked staff instruction on facial shaving. Review of the resident's electronic medical record (EMR), from 02/27/24 through 03/26/24, revealed the resident was dependent on staff for personal hygiene, including shaving. On 03/25/24 at 01:50 PM, the resident sat in his room in his wheelchair. He was unshaven with scraggly overgrowth of facial hair. On 03/26/24 at 09:55 AM, the resident sat in his wheelchair in the dining room. He remained unshaven with scraggly overgrowth of facial hair. On 03/27/24 at 08:29 AM, the resident sat in his wheelchair in the commons area. He remained unshaven with scraggly overgrowth of facial hair. On 03/26/24 at 01:15 PM, Certified Medication Aide (CMA) NN stated residents were to be shaved on their shower days. On 03/27/24 at 11:13 AM, Certified Nurse Aide (CNA) RR stated residents were to be shaved on their shower days. On 03/26/24 at 12:26 PM, Licensed Nurse (LN) H stated the staff were to shave the residents on their shower days and whenever they wanted to be shaven. On 03/27/24 at 01:38 PM, Administrative Nurse D stated staff instruction for the resident's facial shaving should be included on the care plan. The facility policy for Standards of Care and Care Planning Practice, dated 04/01/23, included: Care plans should reflect resident-centered items that are unique to that resident's care. The facility failed to complete a person-centered comprehensive care plan to meet this dependent resident's preferences for facial shaving. 31078 - R35's physician orders revealed the following diagnoses included orthostatic hypotension (blood pressure dropping with change of position), essential (primary) hypertension (elevated blood pressure), viral hepatitis C (inflammatory condition of the liver), chronic obstructive pulmonary disease (COPD, a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), chronic kidney disease, and fluid overload (increase in the volume of extracellular and/or intravascular fluids). The Annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 09, indicating moderate cognitive impairment. The resident used a wheelchair or walker for mobility. The quarterly MDS dated [DATE], revealed no significant changes in status. The Dehydration/ Fluid Maintenance Care Area Assessment (CAA), dated 10/12/23, revealed R35 was on a fluid restriction, and nursing staff were to monitor the resident was drinking fluids. Review of the care plan dated 01/23/24, lacked guidance related to the resident's fluid restriction. The physician's order dated 04/23/23 revealed the following: The resident has a daily 2000 milliliter (ml) fluid restriction. Fluids include anything that is liquid at room temperature. During the day shift, the resident may have 480 ml at breakfast and 360 ml at lunch from dietary. The resident may have 360 ml during the shift from Nursing. A total for dayshift would be 1200 ml. During the evening shift, the resident may have 360 ml at supper from dietary. The resident may have 240 ml during the shift from nursing. A total for evening shift would be 600 ml. During the night shift, the resident may have 180 ml from nursing. A total for night shift would be 180 ml. Observation on 03/25/24 at 01:40 PM revealed the resident sat in his chair in his room with feet elevated. On 03/25/24 at 01:40 PM, the resident reported he was on an 1800 ml fluid restriction, but the staff did not bother him a whole lot because he has been on it a long time and just knows what he can drink and if he wants extra, he will just get it. On 03/26/24 at 11:55 AM, Certified Nursing Assistant (CNA) SS reported she did not know how staff monitored the resident's fluid restriction. She thought it was probably up to dietary to restrict his fluids and thought he usually had a coffee cup and a glass of fluid at each meal. She was unable to determine the amount of fluid would total for a cup of coffee and a glass of fluid. She reported there was no intake sheet to chart his fluids, but as long as he had no fluid in his room, nursing did not need to monitor his fluid intake. On 03/26/24 at 12:10 PM, Licensed nurse (LN) I reported she was not sure what the fluid restriction was. She knew they have a chart in the kitchen to tell how much each size glass held. There was no intake sheet that she was aware of and thought dietary measured the fluids. She reported staff did not monitor the resident's fluid intake. On 03/27/24 at 10:30 AM, Administrative Nurse F reported she would expect the resident's fluid restriction to be included on the care plan. On 03/27/24 at 04:30 PM, Administrative Staff A reported the facility had a new MDS staff but had to learn the process to get the assessments to reflect the resident's status. they know the MDS, care plan piece is not where it needs to be. On 03/25/24 a policy for Care Plans was requested and was referred to the MDS manual for instruction. The facility failed to include R35's fluid restriction for staff guidance on the comprehensive care plan.

- Review of Resident (R) 37's medical record revealed diagnoses that included Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear, chronic kidney disease, congestive heart failure (a condition with low heart output and the body becomes congested with fluid), and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain). The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of five, which indicated severe cognitive impairment. The resident required extensive assistance of staff for dressing and personal hygiene. The Cognitive Loss Care Area Assessment (CAA), dated 07/25/23, assessed the resident's risk factors of skin breakdown, weight loss and fluid imbalance. The ADL (Activity of Daily Living) Functional/Rehabilitation CAA dated 07/25/23 did not trigger. The Care Plan reviewed 03/20/24, instructed staff the resident had a functional deficit with ADLs due to dementia(progressive mental deterioration characterized by confusion and memory failure), The resident required moderate assistance with dressing. The care plan instructed staff to ensure the resident wore appropriate footwear, as she preferred tennis shoes. Interview, on 03/25/24 at 02:10 PM, with a family member revealed R37 preferred to wear support hose and had multiple pairs of them in her drawers. The family member stated the resident often does not have them on and she assists R37 in putting them on when visiting the resident. Observation, on 03/26/24 at 11:38 AM, revealed Certified Medication Aide (CMA) M ambulated with the resident to the bathroom. The resident lacked support hose. Interview with CMA M at that time revealed the night shift washed the support hose and dried them on the towel rack in the bathroom, and they were wet this morning, but dry at this time. CMA M did not know the resident had several pairs of the compression hose in her drawers. Observation revealed several pairs of support hose in her drawer beneath the closet. Interview, on 03/28/24 at 10:00 AM, with Administrative Nurse D, revealed the resident did not have a physician order for the support hose, but could wear them as her preference and this should be indicated on the care plan. The facility policy for Resident Rights, undated, included: The facility places a strong emphasis on individual dignity and self-determination for all residents. The policy instructed staff to encourage residents to dress per their individual preferences. The facility failed to ensure staff dressed R37 in support hose as her preference to promote her sense of well-being. 31078 - R60's physician orders revealed the following diagnoses that included diabetes mellitus type two (when the body cannot use glucose, not enough insulin is made or the body cannot respond to the insulin), neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system), and history of urinary tract infection (infection of any part of the urinary system). The Admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of eight, indicating moderate cognitive impairment. The resident was dependent on staff for all activities of daily living (ADLs) and used a wheelchair for mobility. The resident had an indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) and was incontinent of bowel. The resident had a diagnosis of neurogenic bladder and chronic urinary tract infection and received an antibiotic. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 11/03/23, R60 required assistance for ADLs to keep clean and dry with bowel needs. R60 had a urinary catheter due to urinary retention. R60's Care Plan dated 10/31/23 revealed the resident had an 18 French, five cubic centimeter (cc) balloon indwelling catheter for neurogenic bladder. Staff were to position the catheter bag and tubing below the level of the bladder and attach the leg bag when out of bed. The resident has bowel incontinence related to immobility and required routine check and change incontinent care, dated 12/04/23. Observation, on 03/25/24 at 12:10 PM, revealed Certified Nursing Aides (CNA) V and CNA UU transferred R60 to the bed with the use of a total body lift. The resident had a bowel movement, and staff removed the brief. At 12:24 PM, CNA VV walked into R60's room without knocking on the door when the resident was fully exposed during incontinent care and did not excuse herself. She stayed to collect pizza orders from staff in the room. The resident remained exposed during the conversation. On 03/25/24 at 12:30 PM, CMA VV reported she reported she knew better and was not thinking and knew she should have knocked before entering as well as she should have left the room as soon as she entered and saw the resident's genitals exposed. On 03/28/24 at 08:00 AM, Administrative Nurse D reported all staff whether nursing or not, should knock on the resident's door and wait for permission to enter. At no time would it be appropriate to enter a resident's room unannounced during resident care, much less to take a staff member's pizza order. The facility's policy for Resident Rights, undated, included the facility places a strong emphasis on individual dignity and self-determination for all residents. The facility failed to maintain R60s dignity by staff entering the room unannounced during personal care, and remained in the room when the resident was exposed. 34056 The facility reported a census of 92 residents with 22 residents sampled, including five residents reviewed for dignity. Based on observation, interview and record review, the facility failed to show respect and dignity to four Residents (R)31, regarding standing over the resident while feeding him and R 78, regarding the failure to use a dignity bag on the catheter collection bag, R 60, regarding not knocking on door before entering resident's room while cares were being given and R 37, regarding the facility not allowing the resident to wear compression stockings (specially made, snug-fitting, stretchy socks that gently squeeze the leg to promote circulation). Findings included: - Review of Resident (R)31's Physician Order Sheet, dated 03/21/24, documented the resident had a diagnosis of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The Significant Change Minimum Data Set (MDS), dated [DATE], lacked documentation of the resident's cognition. He was dependent on staff for all activities of daily living (ADL). The Nutritional Status Care Area Assessment (CAA), dated 02/06/24, triggered but was not completed. The Modification of Admission/Medicare 5-Day MDS, dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of two, indicating severe cognitive impairment. He was dependent on staff for all ADLs. The care plan for ADLs, revised 01/02/24, instructed staff the resident required substantial assistance of one for eating. On 03/26/24 at 11:49 AM, the staff served lunch to the resident in the dining room. Certified Nurse Aide (CNA) OO began to feed the resident his meal while standing over the resident, leaning in slightly toward and over the resident, as the resident was fed. On 03/26/24 at 01:10 PM, CNA OO stated he did not sit down next to the resident while he fed him his lunch because he did not want to. He liked to stand while feeding the residents. On 03/28/24 at 09:51 AM, Administrative Nurse D stated it was the expectation for staff to sit down next to a resident while assisting them with their meals and not to stand up over the residents. The facility policy for Resident Rights, undated, included: The facility places a strong emphasis on individual dignity and self-determination for all residents. The facility failed to show respect and dignity to this dependent resident while feeding him his meal. - Review of Resident (R)78's electronic medical record (EMR) revealed a diagnosis of neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying). The Modification of Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. She required extensive assistance of two staff for toileting and had an indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 08/06/23, documented the resident had an indwelling urinary catheter. The Quarterly MDS, dated [DATE], documented the staff assessment for cognition revealed the resident was independent with daily decision making. She was dependent on staff for all activities of daily living (ADLs) and had a urinary catheter. The care plan for the urinary catheter, dated 08/01/23, instructed staff to keep the catheter bag and tubing below the level of the bladder. On 03/25/24 at 10:35 AM, the resident sat in her wheelchair in her room. The catheter bag hung below the seat of her wheelchair and lacked a dignity bag. On 03/26/24 at 08:14 AM, the resident rested in bed in her room with the door open. The resident's catheter bag hung from the bed frame and lacked a dignity bag. On 03/26/24 at 08:14 AM, Certified Nurse Aide (CNA) T stated the resident did not have a dignity bag for her catheter bag because they (CNA T) could not find one. CNA T stated catheter bags typically would be in a dignity bag. On 03/26/24 at 08:19 AM, Certified Medication Aide (CMA) MM stated the resident did not have a dignity bag for her catheter bag. CMA MM stated she was unsure as to why the resident did not have a dignity bag. On 03/27/24 at 01:38 PM, Administrative Nurse D stated it was the expectation for staff to always use a dignity bag for all residents who have a catheter bag. The facility policy for Urinary Catheter Care, dated 02/2017, included: To protect the dignity of residents who need an indwelling catheter, drainage bags will be placed in a dignity bag. The facility failed to utilize a dignity bag to hold the catheter bag of this dependent resident with an indwelling urinary catheter.

The facility reported a census of 92 residents, which included 10 residents residing in one of the six Green Houses. Based on observation, record review, and interview, the facility failed to provide unstained towels and washcloths to the residents in one Green House. Findings included: - Interview, on 03/27/24 at 02:45 PM, with Resident (R)43 revealed certified staff does the laundry, and supplies towels and washcloths to the resident, however the towels are often stained, rough and/or worn. Observation at that time revealed a hand towel with a large gray stain over 3 percent of the towel. Observation, on 03/28/24 at 09:06 AM, revealed eight hand towels and two washcloths with stains of varying sizes with rough coarse texture and several with areas of worn texture. Interview, on 03/28/24 at 09:06 AM, with Certified Medication Aide/Certified Nurse Aide (CMA/CNA) AA, revealed all staff on all shift's complete laundry tasks and stained linen should be thrown away, and when the supply is low, more can be ordered. Interview, on 03/28/24 at 10:45 AM, with Administrative Staff A, revealed she expected staff to throw out stained linen and order more linen when needed. The facility policy Resident Rights revised 10/22, instructed staff to provide a safe, clean, comfortable, and homelike environment. The facility failed to ensure staff provided unstained, normal textured towels and washcloths to the residents in this Green House to promote a sense of well-being.

The facility reported a census of 92 residents with 22 residents selected for review which included six residents reviewed for activities. Based on observation, interview, and record review, the facility failed to ensure appropriate activities for five Residents (R)7, R20, R33, R37, and R78, of the six residents reviewed for activities. Findings included: - Review of Resident (R) 7's medical record, revealed diagnoses that included Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and major depressive disorder (major mood disorder). The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. The resident rated books, music, animals, and group activities as very important. The Activities Care Area Assessment (CAA), dated 10/23/23, did not trigger. The Care Plan reviewed 01/26/24, instructed staff to provide an activity program that was meaningful and of interest and provide opportunities for exercise and physical activity. Staff to plan activities during optimal times when pain and stiffness are abated. Review of the task Activities for the past 30 days revealed only two entries for active participation on 03/04/24 for social, and 03/22/24 for musical. Review of the March Activity Calendar indicated the following activities available: On 03/25/24 at 09:30 AM, chair exercises, 03:00 PM, UNO a card game, and 04:30 PM Bingo. On 03/26/24 at 09:30 AM, Noodle ball, at 03:00 PM- cards, and 06:00 PM -Table Talk. On 03/27/24 at 09:30 AM, Chair Yoga, at 03:00 PM- Bible study, and 06:00 PM- World Travel. On 03/28/24 at 10:00 AM- Bingo, and at 10:30 AM - group exercises. On 03/29/24 at 09:30 AM - Coffee Social, and at 03:00 PM --[NAME] in Corner, and at 06:00 PM- Residents Choice. On 03/30/24, Saturday at 09:00 AM -bingo, at 03:00 PM -manicures, and at 06:00 PM- Movie of Choice. On 03/31/24 Sunday at 09:00 Mass TV, 11:00 AM- First United Methodist church , and at 06:00 PM - Name Five. Observation on 03/25/24 at 03:00 PM, revealed lack of the activity UNO. Observation, on 03/26/24 at 09:30 AM, revealed lack of Noodle Ball and at 03:00 PM lack of cards being offered. Observation on 03/27/24 at 10:00 AM revealed lack of Chair Yoga and at lack of Bible Study and 03:00 PM being offered. Interview, on 03/25/24 at 12:17 PM, with R7 revealed she usually just watched TV in her room. She stated she usually just sat around, and the only activity was bingo once a week. Interview, on 03/26/24 at 07:35 AM, with Certified Medication Aide(CMA/CNA) M revealed staff did not have time to do any activities. Interview, on 03/26/24 at 07:54 AM, with Activity Staff Z, revealed the evening staff should do activities. Interview, on 03/27/24 at 03:10 PM, with CMA /CNA N, revealed evening staff did not provide activities and lacked tools/supplies to provide residents with activities Interview, on 03/27/24 at 03:30 PM, with CMA Q, revealed on nice days staff should encourage residents to go outside on the patio and often have cook outs. CMA Q revealed few structured activities provided. Interview, on 03/28/24 at 10:20 AM, with Administrative Staff A, confirmed activities in the Greenhouses have been an issue. The facility policy for Resident Rights, dated 10/2022, included: The resident has the right to choose which activities they wish to participate in, including social, religious and community activities. The facility failed to provide activities to the residents of this facility to increase their sense of well-being. - Review of Resident (R)20's medical record revealed diagnoses that included deep vein thrombosis (DVT- blood clots) in the right and left leg, heart disease, diabetes (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), dementia (progressive mental disorder characterized by failing memory, confusion) and unstageable pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction and the wound is covered by a layer of dead tissue). The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with a BIMS score of nine, which indicated moderate cognitive impairment. The resident had no impairment in her upper or lower extremities, dependent on staff for Activities of Daily Living (ADL). R20 rated having books, newspaper, and magazines to read, listening to music, having animals around, keep up with the news, and do favorite activities as very important. The Activities Care Area Assessment (CAA), dated 02/05/24, did not trigger. The Care Plan reviewed 02/21/24, instructed staff the resident had little, or no activity involvement related to disinterest and resident wishes. The resident's preferred activities include bingo, crocheting, and adult coloring books. The resident preferred TV channels include news, Hallmark, Discovery, [NAME], and home decorating channels. Observation, on 03/26/24 at 09:45 AM, revealed the resident seated in her wheelchair in her room. Certified Medication Aide (CMA) XXX and CMA Y assisted R20 to pivot transfer into her bed. The TV was on a shopping channel and CMA XXX or CMA Y did not ask the resident regarding her preference for the channel. The resident's embroidery supplies were out of her reach. Observation, on 03/27/24 at 09:20 AM, revealed the resident's television was on the shopping channel. Interview, on 03/26/24 at 10:09 AM, with R20, revealed she likes to read and embroider. R20 stated she would enjoy a book club. R20 stated she enjoyed watching old movies on TV. Interview, on 03/26/24 at 07:54 AM, with Activity Staff Z, revealed the evening staff should do activities. Interview, on 03/27/24 at 02:55 PM, with Certified Nurse Aide QQ, revealed the residents usually do not want to attend activities, but thought someone does bingo for the residents. Interview, on 03/27/24 at 02:56 PM with CNA YYY, revealed she provided one on one visits with the residents and the residents liked getting their nails done, but there were no structured activities as she did not think the residents would participate. Interview, on 03/28/24 at 10:20 AM, with Administrative Staff A, confirmed activities in the Greenhouses have been an issue. The facility policy for Resident Rights, 10/2022, included: The resident has the right to choose which activities they wish to participate in, including social, religious and community activities. The facility failed to provide activities to the residents of this facility to increase their sense of well-being. - Review of Resident (R)33's medical record revealed diagnoses that included heart failure, vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain ), and major depressive disorder (major mood disorder). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief interview for Mental Status (BIMS) score of 15, which indicated normal cognitive function. The resident rated doing favorite activities and go outside when the weather was good as very important. The Activities Care Area Assessment (CAA) dated 05/06/23 did not trigger. The Care Plan reviewed 02/16/24, instructed staff to encourage the resident to participate in activities of her choice and provide opportunities for social interaction. Review of the March Activity Calendar indicated the following activities available: On 03/25/24 at 09:30 AM -chair exercises, at 03:00 PM- UNO a card game, and 04:30 PM- Bingo. On 03/26/24 at 09:30 AM- Noodle ball, at 03:00 PM- cards, and 06:00 PM -Table Talk. On 03/27/24 at 09:30 AM - Chair Yoga, at 03:00 PM- Bible study, and 06:00 PM- World Travel. On 03/28/24 at 10:00 AM- Bingo and at 10:30 AM - group exercises. On 03/29/24 at 09:30 AM - Coffee Social, at 03:00 PM- [NAME] in Corner, and at 06:00 PM- Residents Choice. On 03/30/24 - Saturday at 09:00 AM -bingo, at 03:00 PM- manicures, and at 06:00 PM- Movie of Choice. On 03/31/24- Sunday at 09:00- Mass TV, at 11:00 AM -First United Methodist church , and at 06:00 PM - Name Five. Interview on 03/25/24 at 12:50 PM with R33, revealed the facility provided bingo once a week and would like to participate in more frequent bingo games. R33 stated she would also like to play cards. Observation on 03/25/24 at 03:00 PM, revealed lack of the activity UNO provided to the residents. Observation, on 03/26/24 at 09:30 PM revealed lack of Noodle Ball and at 03:00 PM lack of cards offered to the residents. Observation on 03/27/24 at 10:00 AM, revealed lack of Chair Yoga, and at 03:00 PM, Bible Study was not offered to the residents. Interview on 03/25/24 at 12:50 PM with R33, revealed the facility provided bingo once a week and would like to participate in more frequent bingo games. R33 stated she would also like to play cards. Interview, on 03/26/24 at 07:35 AM, with Certified Medication Aide( CMA) M revealed staff did not have time to do activities. Interview, on 03/26/24 at 07:54 AM, with Activity Staff Z, revealed the evening staff should do activities. Activity Staff Z stated the facility provided one bingo game per week. Interview, on 03/26/24 at 02:20 PM, with Licensed Nurse G, revealed the resident only came out of her room for bingo. Interview, on 03/28/24 at 10:20 AM, with Administrative Staff A, confirmed activities in the Greenhouses have been an issue. The facility policy for Resident Rights, 10/2022, included: The resident has the right to choose which activities they wish to participate in, including social, religious and community activities. The facility failed to provide activities to the residents of this facility to increase their sense of well-being. - Review of Resident (R) 37's medical record revealed diagnoses that included Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain). The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of five, which indicated severe cognitive impairment. R37 rated music, animals and doing favorite activities as very important. The resident required moderate/partial assistance for mobility. The Activities Care Area Assessment (CAA), dated 07/25/23, did not trigger. The Cognitive Loss/Dementia CAA dated 07/25/23, assessed the resident with risk factors that included decreased socialization and need to encourage active participation in facility functions. The Care Plan, reviewed 03/20/24, instructed staff to provide the resident with materials for individual activities as desired. The resident likes knitting/crocheting, puzzles, some reading material and simple coloring. The resident preferred educational programs and game shows. The resident enjoys arts/crafts, bingo card games, baking, group discussions and was independent on staff with activity participation. Review of the Task tab Activities in the electronic medical record for the last 30 days, revealed an entry on 03/04/24 for social and on 03/22/24 for music. No other activity participation provided. Observation, on 03/25/25 at 02:20 PM, revealed the resident sleeping in her recliner in her room. Review of the March Activity Calendar indicated the following activities available: On 03/25/24 at 09:30 AM -chair exercises, at 03:00 PM- UNO a card game, and 04:30 PM -Bingo. On 03/26/24 at 09:30 AM -Noodle ball, at 03:00 PM- cards, and 06:00 PM- Table Talk. On 03/27/24 at 09:30 AM -Chair Yoga, at 03:00 PM- Bible study, and 06:00 PM- World Travel. On 03/28/24 at 10:00 AM Bingo, and at 10:30 AM group exercises. On 03/29/24 at 09:30 AM Coffee Social, and at 03:00 PM [NAME] in Corner, and at 06:00 PM Residents Choice. On 03/30/24 Saturday at 09:00 AM bingo, at 03:00 PM manicures, and at 06:00 PM Movie of Choice. On 03/31/24 Sunday at 09:00 Mass TV, 11:00 AM First United Methodist church , and at 06:00 PM Name Five. Observation on 03/25/24 at 03:00 PM, revealed lack of the activity UNO. Observation, on 03/26/24 at 09:30 revealed lack of Noodle Ball and at 03:00 PM lack of cards. Observation on 03/27/24 at 10:00 AM revealed lack of Chair Yoga and at lack of Bible Study and 03:00 PM. Interview, on 03/25/24 at 02:10 PM, with a family member revealed the facility did not provide many activities. Interview, on 03/26/24 at 07:35 AM, with Certified Medication Aide (CMA) M revealed staff did not have time to do activities. Interview, on 03/26/24 at 07:54 AM, with Activity Staff Z, revealed the evening staff should do activities. Interview, on 03/27/24 at 03:10 PM, with CMA N, revealed evening staff did not provide activities and lacked tools for providing them. Interview, on 03/27/24 at 03:30 PM, with CMA Q, revealed on nice days staff should encourage residents to go outside on the patio and would have cook outs. CMA Q revealed few structured activities as residents do not want to attend. CMA Q stated R37 did attend bingo games. Interview, on 03/28/24 at 10:20 AM, with Administrative Staff A, confirmed activities in the Greenhouses have been an issue. The facility policy for Resident Rights, 10/2022, included: The resident has the right to choose which activities they wish to participate in, including social, religious and community activities. The facility failed to provide activities to the residents of this facility to increase their sense of well-being. 34056 - Review of Resident (R)78's electronic medical record (EMR) included a diagnosis of multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord). The Modification of the Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. It was very important for her to listen to music she liked, participate in religious services and do her favorite activities. She required total staff assistance with transfers, locomotion on and off the unit, and she had impaired range of motion (ROM) on bilateral (both) upper and lower extremities. The Activities Care Area Assessment (CAA), dated 08/06/23, documented the resident was at risk for decreased socialization and worsening depression. The facility would encourage active participation in facility functions to engage in sensory stimulation. The Quarterly MDS, dated [DATE], documented the staff assessment for cognition revealed the resident was independent with daily decision making. She was dependent on staff for all activities of daily living (ADL). The care plan for activities, revised 08/01/23, instructed staff the resident was dependent on staff for participation in activities. Her favorite activities included visiting, watching group activities, watching TV and listening to music. Review of the resident's Activities Admission Data Collection, dated 08/01/23, documented it was very important for her to listen to the music she liked, participate in religious services and to do her favorite activities. The primary respondent for the assessment was the resident. Review of the resident's Activities Readmission Data Collection, 02/21/24, lacked activity preferences. Review of the facility's activity calendar revealed an activity of morning music would occur every morning at 09:30 AM and religious services would occur each Sunday morning at 09:30 AM and 11:00 AM. Review of the resident's EMR, from 03/01/24 through 03/27/24, revealed she participated in a social on three occasions and had visitors on two occasions. No other activities documented. On 03/26/24 at 08:14 AM, Certified Nurse Aide (CNA) T and Certified Medication Aide (CMA) MM entered the resident's room to prepare the resident for the day. The resident's room lacked a device to listen to music and her TV was not turned to a music station. On 03/27/24 at 09:48 AM, the resident sat in her wheelchair in the commons area facing the TV. The TV, which was tuned to a soap opera, had no volume. On 03/28/24 at 09:01 AM, the resident sat in her wheelchair in her room with CNA X. The TV was turned off and no music played in the resident's room. On 03/28/24 at 09:01 AM, the resident stated she prefers to listen to rap music. She stated she was a Baptist but had not been able to participate in a Baptist service for a long time. On 03/26/24 at 03:09 AM, CNA PP stated she was unsure of what the resident liked to watch on TV but staff would put her in the commons area in front of the TV so she was able to watch whatever was on at that time. On 03/27/24 at 08:14 AM, CNA T stated the resident's family would turn the TV on to a music station when they visited, but CNA T was unsure of what music the resident preferred. On 03/28/24 at 07:38 AM, Activity Staff Z stated the staff were responsible for activities in the green houses. On 03/28/24 at 09:01 AM, CNA X stated she was unsure of what music the resident preferred. On 03/28/24 at 09:51 AM, Administrative Nurse D stated the staff were to do the activities in the green houses. Administrative Nurse D was unsure of how church services were set up for the green houses. The facility policy for Resident Rights, dated 10/2022, included: The resident has the right to choose which activities they wish to participate in, including social, religious and community activities. The facility failed to implement an ongoing resident centered activity program for this dependent resident.

The facility reported a census of 92 residents. Based on observation, interview, and record review, the facility failed to complete an accurate Minimum Data Set (MDS) for two residents, that included Resident (R)31, regarding the failure to complete the Care Area Assessments (CAA) for nutrition and pressure ulcers (PU) and R 33, regarding the failure to complete CAAs for psychotropic drugs, pain and mood state. Findings included: - Review of Resident (R)31's electronic medical record (EMR) included the following diagnoses included Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness) and dementia (progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS), dated [DATE], lacked documentation for cognition. The resident had a significant weight loss, without a prescribed weight loss regimen and was at risk for the development of pressure ulcers (PU) with one unhealed stage III (full thickness pressure injury extending through the skin into the tissue below) PU at the time of the assessment, present on admission. The Nutritional Status and Pressure Ulcer/Injury Care Area Assessments (CAA), dated 02/06/24, triggered but lacked an analysis of findings. The care plan for PUs, revised 02/07/24, instructed staff to turn and reposition the resident off his back and from side to side as often as possible. Weight loss was to be expected for the resident due to his terminal diagnosis. On 03/27/24 at 04:30 PM, Administrative Staff A stated the facility was aware of the MDSs were not being completed properly. The facility had a new MDS coordinator who was currently learning the process to complete the MDSs and CAAs appropriately. The facility policy for Expanded Assessment Areas, revised 05/20/17, included: The facility utilized the Resident Assessment Instrument (RAI) for accurate completion of the Minimum Data Set (MDS) and Care Area Assessment (CAA). The facility failed to complete an accurate MDS for this dependent resident regarding the failure to complete the Nutrition and PU CAAs. 28560 - Review of Resident (R)33's medical record revealed diagnoses that included heart failure, vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain) and major depressive disorder (major mood disorder). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief interview for Mental Status (BIMS) score of 15, which indicated normal cognitive function. The resident received antipsychotic (class of medications used to treat psychosis and other mental emotional conditions), antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension), antidepressant, (class of medications used to treat mood disorders and relieve symptoms of depression), anticoagulant (medications used to treat the blood from forming clots), diuretic (medications to promote the formation and excretion of urine), opioid (narcotic pain medications) medications, and antibiotic (medication used to treat infections). The Psychotropic (medications that affect mood) Drug Use Care Area Assessment (CAA), dated 05/06/23 was undeveloped. The Pain CAA dated 05/06/23, was not developed. The Mood State CAA dated 05/06/23, was not developed. Interview, on 03/27/24 at 02:20 PM, with Administrative Nurse F confirmed the CAAs were not developed for some residents. Interview, on 03/27/24 at 04:30 PM, with Administrative Staff A, confirmed the MDS and CAAs were lacking in completeness for some residents. The facility followed the Resident Assessment Instrument (RAI) manual when completing the CAAs. The facility failed to ensure staff completed the CAAs for this resident to develop a comprehensive care plan as required.

The facility census totaled 92 residents with 22 residents included in the sample. Based on observation, interview, and record review, the facility failed to revise care plans for two residents. Resident (R)9, related to the failure to care plan a fall with a fractured foot that required a special walking boot, and R9, related to skin care for a pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Findings included: - R9's physician orders revealed the following diagnoses: diabetes mellitus (when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) and right great toe fracture (broken toe). The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident was dependent on a walker or wheelchair for mobility. The resident had no recent falls. Review of the Quarterly MDS dated [DATE] revealed a BIMS score of 15. The resident used a walker and wheelchair for mobility. The resident had a fall with major injury since last MDS. The resident received Physical Therapy and Occupational Therapy (PT, OT) for rehabilitation. The Activities of daily living (ADL) Functional/ Rehabilitation Care Area Assessment (CAA) dated 01/04/24 revealed the resident had impaired balance and transition during transfers, and functional impairment in activity. The care plan failed to resvise the care plan to include the fall on 01/28/24 which resulted in a fractured right great toe and use of a walking boot. The physician orders dated 01/29/24 revealed the resident was to wear a surgical boot on the right foot when getting out of bed and off at bedtime, for a fracture of the right great toe. Review of the Reported Incident revealed on 01/28/24 at 03:15 AM, R9 fell from her bed. The fall resulted in a skin tear to her right elbow and a fractured right great toe. R9 was to wear a walking shoe until the fracture healed. Observation on 03/25/24 at 11:45 AM, revealed Certified Nurse Aide (CNA) UU assisted R9 to the dining room. R9 wore the walking boot. On 03/25/24 at 11:50 AM, the resident reported she fell out of bed about 5 weeks ago and had to wear the fracture boot until her fractured toe healed. On 03/27/24 at 10:30 AM Administrative Nurse F reported the care plan should have been revised to include her fall with a fracture and interventions. On 03/25/24, a policy for Care Plans was requested and was referred to the MDS manual for instructions. The facility failed to revise R9's care plan regarding this resident's fall/interventions to guide staff with cares. 28560 - Review of Resident (R)20's medical record revealed diagnoses that included deep vein thrombosis (DVT blood clots) in the right and left leg, heart disease, diabetes (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), dementia (progressive mental disorder characterized by failing memory, confusion), and unstageable pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction and the wound is covered by a layer of dead tissue). The Quarterly Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. The resident had an unstageable pressure ulcer present upon admission/reentry. The resident had no impairment in function range of motion in her upper or lower extremities and was dependent on staff for Activities of Daily Living (ADL). The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with a BIMS score of nine, which indicated moderate cognitive impairment. The resident had no impairment in her upper or lower extremities, was dependent on staff for ADL, and at risk for pressure ulcers with no current pressure ulcer injury. The Pressure Ulcer Care Area Assessment (CAA), dated 02/05/24, assessed the resident due to impairment with functional mobility, recent acute illness, and incontinence. Licensed staff were to assess R20's skin each week and initiate proper interventions to prevent skin breakdown, and caregivers assist with repositioning as needed. The Care Plan reviewed 02/21/23, instructed staff the resident admitted to hospice. The resident had a potential for impairment of skin integrity related to fragile skin. An intervention added 11/21/23, instructed staff to avoid positioning the resident on her heals and use foam always off-loading boots when in bed due to a deep tissue injury (DTI) to the left heel following hospitalization (11/13-11/20/23). Staff instructed to apply skin prep (a solution when applied that forms a protective waterproof barrier on the skin) to bilateral (both) heels daily. The care plan failed to include the right heel pressure ulcer which developed on 02/09/24 and failed to include updated interventions for off loading devices. On 02/29/24, the physician instructed staff to apply skin prep to bilateral heels daily. A Skin/Wound New Observation note dated 02/09/24, indicated the resident developed a 1.5 by 1 centimeter (cm) deep tissue injury to her right heel. This note indicated staff to continue to utilize the off-loading boots. A Skin/Wound Weekly Observation note, dated 02/13/24, indicated the DTI measured 3.3 cm by 4.5 cm and staff instructed to continue the use of off-loading boots. A Skin/Wound Weekly Observation note, dated 02/20/24, indicated the DTI measured 4 cm by 6 cm, with a mushy feeling. A Skin/Wound Weekly Observation note, dated 03/07/24, indicated the DTI measured 6 cm by 3.5 cm with a depth of 1 cm, with wound edges intact. The note indicated a treatment of skin prep to both heels and float the heel off the bed with pillows. A Skin/Wound Weekly Observation note, dated 03/12/24, indicated the DTI measured 7 cm by 4 cm with no depth. This note indicated the area improved with softness decreased. A Skin/Wound Weekly Observation note, dated 03/19/24, indicated the DTI measured 5.2 cm by 7.4 cm with a dark colored eschar (dead tissue) and no changes in treatment. A Skin/Wound Weekly Observation note, dated 03/26/23, indicated the DTI measured 4.5 cm by 6.3 with 100% eschar with no changes in treatment. An Interdepartmental Team (IDT) Comprehensive Care Review dated 02/15/24, indicated the resident had a new DTI to her right heel with a wound treatment of offloading the heels by floating the heels. An Interdepartmental Team (IDT) note, dated 02/22/24, indicated the right heel decreased in size. An Interdepartmental Team (IDT) note, dated 03/01/24, indicated the right heel as mushy with the appearance of a blood blister. An Interdepartmental Team (IDT) note, dated 03/14/24, indicated the resident had a DTI to the right heel with stable wound margins. The resident had DVT's to both lower legs and was on hospice for end-of-life cares. The resident had a pressure redistributing mattress on her bed and used a pillow to float her heels off the surface. Observation, on 03/26/24 at 09:45 AM, revealed the resident seated in her wheelchair in her room. Certified Medication Aide (CMA) XXX and CMA Y assisted R20 to pivot transfer into her bed. CMA Y placed a pillow under the resident's calves to elevate her heels off the bed. Observation, on 03/26/24 at 10:30 AM, revealed the pillow remained under the resident's calves, but her heels laid directly on the bed. Licensed Nurse (LN) G removed the resident's socks and revealed her right heal with blue black eschar. The left heel skin was pink and intact. Interview, at that time with LN G, revealed staff applied specialized foam boots to R20's bilateral heels and the left pressure ulcer heeled, but she developed a pressure ulcer on her right heel despite the boots. LN G stated the resident could move her foot in the boot causing a shift in the off-loading ability of the boots, so staff used pillows to off load her heels. LN G confirmed the pillow ineffective in keeping the resident's heels offloaded and obtained a blanket for additional off-loading. LN G stated R20 received hospice services, and she would inform hospice of the need for more effective off-loading device. Observation, on 03/26/24 at 02:05 PM, with Administrative Nurse E, revealed the readmitted to the facility with a deep tissue injury to her left heel. The resident had bilateral DVT in her lower extremities. The resident wore specialized pressure relieving boots and with treatments, the left heel injury resolved, however, the right heel injury developed inspire of the pressure relieving boots, so staff used pillows to elevate her heels off the bed. Administrative Nurse E confirmed the pillows may not maintain their buoyancy over time to keep the heels off the bed. Administrative Nurse E measured the right heel blue/black eschar as 4.5 cm by 6.3 centimeters and then applied skin prep to both heels. Administrative Nurse E confirmed the care plan lacked updated interventions for the right heel pressure ulcer and need for alternative means to float the resident's heels. Observation, on 03/27/24 at 09:20 AM, revealed the resident sitting up in her bed, eating breakfast. A pillow and blanket positioned under the resident's calves, but her right and left heel lay directly on the surface of the mattress. Interview, at that time with CMA P, revealed the resident did move her feet when in bed. Observation on 03/27/24 at 09:59 AM, revealed Consulting Therapy Staff GG, applied a foam shelf-like positioning device with elevated lateral (outer edges) sides. Consulting Therapy Staff GG stated she was consulted for R20's heel positioning needs due to the development of the DTI to her right heel. Consulting Therapy Staff GG stated she felt this device was a more appropriate device for floating R20's heels. Interview, on 03/28/24 at 10:00 AM, with Administrative Nurse D, stated she would expect licensed nursing staff to revise the care plan to include the development of the right heel pressure ulcer and assess effectiveness of heel floating interventions and initiate alternatives. The facility policy Standards of Care and Care Planning Practice dated 04/01/23, instructed staff instructed staff to ensure that all services are provided to the resident to ensure the care plan is resident centered and specific to the unique needs of each resident. The facility failed to review and revise R20's care plan to include the development of the right heel deep tissue injury and assess the effectiveness of off-loading interventions for the prevention/healing of her deep tissue injury.

The facility reported a census of 92 residents with 22 residents sampled, including five residents reviewed for Activity of Daily Living (ADL). Based on observation, interview and record review, the facility failed to provide appropriate care to one dependent Resident (R)241, regarding facial shaving. Findings included: - The Physician's Order Sheet (POS), dated 03/21/24, documented Resident (R)242 had a diagnosis of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The Annual Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed severe impairment. The resident was dependent on staff for all activities of daily living (ADL). The Functional Abilities Care Area Assessment (CAA), dated 01/15/24, did not trigger. The Medicare 5-day MDS, dated [DATE], documented the staff assessment for cognition revealed severe impairment. He was dependent on staff for all ADLs. The care plan for ADLs, revised 01/30/24, instructed staff the resident was dependent on staff for all ADLs. Review of the resident's electronic medical record (EMR), from 02/27/24 through 03/26/24, revealed the resident was dependent on staff for personal hygiene, including shaving. On 03/25/24 at 01:50 PM, the resident sat in his room in his wheelchair. He was unshaven with scraggly overgrowth of facial hair. On 03/26/24 at 09:55 AM, the resident sat in his wheelchair in the dining room. He remained unshaven with scraggly overgrowth of facial hair. On 03/27/24 at 08:29 AM, the resident sat in his wheelchair in the commons area. He remained unshaven with scraggly overgrowth of facial hair. On 03/26/24 at 01:15 PM, Certified Medication Aide (CMA) NN stated residents were to be shaved on their shower days. On 03/27/24 at 11:13 AM, Certified Nurse Aide (CNA) RR stated residents were to be shaved on their shower days. On 03/26/24 at 12:26 PM, Licensed Nurse (LN) H stated the staff were to shave the residents on their shower days and whenever they wanted to be shaven. On 03/27/24 at 01:38 PM, Administrative Nurse D stated staff were expected to shave residents on their shower days and as needed. The facility policy for Activities of Daily Living (ADL), revised 01/2024, included: A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition. The facility failed to provide appropriate care to this dependent resident regarding facial shaving.

The facility reported a census of 92 residents with 22 residents selected for review and included three residents reviewed for pressure ulcers. Based on observation, interview, and record review, the facility failed to ensure alternative methods of pressure relief provided for one Resident (R)20, of the three residents reviewed for pressure ulcers. Findings included: - Review of Resident (R)20's medical record revealed diagnoses that included deep vein thrombosis (DVT blood clots) in the right and left leg, heart disease, diabetes (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), dementia (progressive mental disorder characterized by failing memory, confusion), and unstageable pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction and the wound is covered by a layer of dead tissue). The Quarterly Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. The resident had an unstageable pressure ulcer present upon admission/reentry. The resident had no impairment in function range of motion in her upper or lower extremities and was dependent on staff for Activities of Daily Living (ADL). The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with a BIMS score of nine, which indicated moderate cognitive impairment. The resident had no impairment in her upper or lower extremities, was dependent on staff for ADL, and at risk for pressure ulcers with no current pressure ulcer injury. The Pressure Ulcer Care Area Assessment (CAA), dated 02/05/24, assessed the resident due to impairment with functional mobility, recent acute illness, and incontinence. Licensed staff were to assess R20's skin each week and initiate proper interventions to prevent skin breakdown, and caregivers assist with repositioning as needed. The Care Plan reviewed 02/21/23, instructed staff the resident admitted to hospice. The resident had a potential for impairment of skin integrity related to fragile skin. An intervention added 11/21/23, instructed staff to avoid positioning the resident on her heals and use foam off-loading boots when in bed at all times due to a deep tissue injury (DTI) to the left heel following hospitalization (11/13-11/20/23). Staff instructed to apply skin prep (a solution when applied that forms a protective waterproof barrier on the skin) to bilateral (both) heels daily. On 02/29/24, the physician instructed staff to apply skin prep to bilateral heels daily. A Skin/Wound New Observation note dated 02/09/24, indicated the resident developed a 1.5 by 1 centimeter (cm) deep tissue injury to her right heel. This note indicated staff to continue to utilize the off-loading boots. A Skin/Wound Weekly Observation note, dated 02/13/24, indicated the DTI measured 3.3 cm by 4.5 cm and staff instructed to continue the use of off-loading boots. A Skin/Wound Weekly Observation note, dated 02/20/24, indicated the DTI measured 4 cm by 6 cm, with a mushy feeling. A Skin/Wound Weekly Observation note, dated 03/07/24, indicated the DTI measured 6 cm by 3.5 cm with a depth of 1 cm, with wound edges intact. The note indicated a treatment of skin prep to both heels and float the heel off the bed with pillows. A Skin/Wound Weekly Observation note, dated 03/12/24, indicated the DTI measured 7 cm by 4 cm with no depth. This note indicated the area improved with softness decreased. A Skin/Wound Weekly Observation note, dated 03/19/24, indicated the DTI measured 5.2 cm by 7.4 cm with a dark colored eschar (dead tissue) and no changes in treatment. A Skin/Wound Weekly Observation note, dated 03/26/23, indicated the DTI measured 4.5 cm by 6.3 with 100% eschar with no changes in treatment. An Interdepartmental Team (IDT) Comprehensive Care Review dated 02/15/24, indicated the resident had a new DTI to her right heel with a wound treatment of offloading the heels by floating the heels. An Interdepartmental Team (IDT) note, dated 02/22/24, indicated the right heel decreased in size. An Interdepartmental Team (IDT) note, dated 03/01/24, indicated the right heel as mushy with the appearance of a blood blister. An Interdepartmental Team (IDT) note, dated 03/14/24, indicated the resident had a DTI to the right heel with stable wound margins. The resident had DVT's to both lower legs and was on hospice for end-of-life cares. The resident had a pressure redistributing mattress on her bed and used a pillow to float her heels off the surface. Observation, on 03/26/24 at 09:45 AM, revealed the resident seated in her wheelchair in her room. Certified Medication Aide (CMA) XXX and CMA Y assisted R20 to pivot transfer into her bed. CMA Y placed a pillow under the resident's calves to elevate her heels off the bed. Observation, on 03/26/24 at 10:30 AM, revealed the pillow remained under the resident's calves, but her heels laid directly on the bed. Licensed Nurse (LN) G removed the resident's socks and revealed her right heal with blue black eschar. The left heel skin was pink and intact. Interview, at that time with LN G, revealed staff applied specialized foam boots to R20's bilateral heels and the left pressure ulcer heeled, but she developed a pressure ulcer on her right heel despite the boots. LN G stated the resident could move her foot in the boot causing a shift in the off-loading ability of the boots, so staff used pillows to off load her heels. LN G confirmed the pillow ineffective in keeping the resident's heels offloaded and obtained a blanket for additional off-loading. LN G stated R20 received hospice services, and she would inform hospice of the need for more effective off-loading device. Observation, on 03/26/24 at 02:05 PM, with Administrative Nurse E, revealed the readmitted to the facility with a deep tissue injury to her left heel. The resident had bilateral DVT in her lower extremities. The resident wore specialized pressure relieving boots and with treatments, the left heel injury resolved, however, the right heel injury developed inspire of the pressure relieving boots, so staff used pillows to elevate her heels off the bed. Administrative Nurse E confirmed the pillows may not maintain their buoyancy over time to keep the heels off the bed. Administrative Nurse E measured the right heel blue/black eschar as 4.5 cm by 6.3 centimeters and then applied skin prep to both heels. Administrative Nurse E confirmed the care plan lacked updated interventions for the right heel pressure ulcer and need for alternative means to float the resident's heels. Observation, on 03/27/24 at 09:20 AM, revealed the resident sitting up in her bed, eating breakfast. A pillow and blanket positioned under the resident's calves, but her right and left heel lay directly on the surface of the mattress. Interview, at that time with CMA P, revealed the resident did move her feet when in bed. Observation on 03/27/24 at 09:59 AM, revealed Consulting Therapy Staff GG, applied a foam shelf-like positioning device with elevated lateral (outer edges) sides. Consulting Therapy Staff GG stated she was consulted for R20's heel positioning needs due to the development of the DTI to her right heel. Consulting Therapy Staff GG stated she felt this device was a more appropriate device for floating R20's heels. Interview, on 03/28/24 at 10:00 AM, with Administrative Nurse D, stated she would expect staff to assess effectiveness of heel floating interventions and initiate alternatives. The facility lacked a policy specific for pressure ulcers. The facility policy Standards of Care and Care Planning Practice dated 04/01/23, instructed staff instructed staff to ensure that all services are provided to the resident to ensure the care plan is resident centered and specific to the unique needs of each resident. The facility failed to provide effective heel off-loading interventions in a timely manner for the prevention/healing of R20's deep tissue injury.

The facility reported a census of 94 residents. The sample included 21 residents with 3 residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to provide appropriate interventions to keep 1 sampled resident (#92), as safe as possible, to prevent major injury falls. Resident #92 fell and experienced a [MEDICAL CONDITION] which required sutures, and 2 neck fractures which required treatment in a hospital emergency department. Findings included: - The signed physician order [REDACTED].#92, documented the resident admitted to the facility, on 5/7/14. It included the following diagnoses; [MEDICAL CONDITION] ((stroke) sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), [MEDICAL CONDITION] (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk) and dementia (progressive mental disorder characterized by failing memory, confusion). The significant change MDS (minimum data set), dated 3/28/19, documented the resident had a BIMS (brief interview for mental status) score of 3, which revealed severely impaired decision making. He/she required extensive assistance with bed mobility, transfer, ambulation, and toileting. His/her balance was not steady and was only able to stabilize with staff assistance. He/she required a wheelchair for mobility. The resident had 1 injury fall during the assessment period. The cognition CAA (care area assessment), dated 4/9/19, documented he/she removed from Hospice services, 3/22/19, due to stabilization. The resident required extensive assistance with his/her ADL's (activities of daily living) and required staff to anticipate his/her needs. The resident required staff assistance for ambulation, and used a wheelchair for mobility. The resident had a fall during the previous 3 months, and he/she was identified at risk for falls. The significant change MDS, dated [DATE], documented the resident had severely impaired decision making. The resident required total assistance from staff for transfers, and extensive assistance with bed mobility and personal hygiene. He/she did not ambulate and had one major injury fall since the prior assessment. The fall care plan, dated 4/9/19, documented staff to continually assess the resident's room for clutter that would increase a fall risk. In addition, on 12/7/18, apply non-skid socks at HS (bed time) and low bed/floor mat at the resident's bedside. In addition, on 3/10/19, staff should toilet the resident before and after meals. In addition, on 4/13/19, staff should toilet the resident before 6:00 am. If the resident was awake, staff should get the resident up for breakfast. The resident may crawl onto the mat from the bed. The Morse fall risk (assessment used to determine fall risk), dated 5/15/19, revealed a score of 90, which identified the resident being a high risk for falls. Review of the clinical records, from 12/7/18 to 6/13/19, documented the resident had a history of [REDACTED]. On 3/10/19, the resident fell in his/her room. On 6/11/19, the resident had a stroke that affected his/her left side. The DPOA (durable power of attorney) chose not to have the resident hospitalized . Staff updated the care plan for use of a full body mechanical lift for transfers. On 6/12/19, at approximately 8:15 am, staff dressed the resident while he/she was in the bed. Staff left the resident's room for approximately 1 to 2 minutes to obtain the mechanical lift. During that time, when staff re-entered into the resident's room, the resident had fallen on the floor next to his/her bed. The resident sustained [REDACTED]. On 7/2/19 at 2:46 pm, direct care staff O, reported the resident required a mechanical lift for transfers. The resident required a bed in the lowest position and a fall mat by his/her bed. On 7/3/19 at 9:22 am, direct care staff P, reported the resident required a mechanical lift for transfers, a low bed, and fall mats by the bed for fall prevention. The resident returned from the hospital with a neck brace. On 7/3/19 at 9:40 am, direct care staff Q, reported he/she dressed the resident in his/her bed, and put the mechanical lift sling underneath him/her. Direct care staff Q verified he/she slid the resident's floor mat underneath the bed, so the mechanical lift would fit under the bed. He/she then lowered the bed to approximately knee high, left the resident's room, and when he/she returned to the resident's room with the mechanical lift, the resident was face down, directly on the floor. The resident had blood on the floor from a laceration on his/her forehead. When the resident returned from the hospital, the resident was on [MEDICATION NAME] (pain medication), wore a neck brace, and returned on end of life care. On 7/3/19 at 10:13 am, licensed nursing staff F, reported he/she entered the resident's room after the fall. The resident was positioned on his/her stomach, with his/her head slightly tilted toward the left, almost face first. The resident had a laceration in the middle of his/her forehead. The resident's mattress was approximately 1 1/2 foot from the floor, and the resident was not on the fall mat, because the mat had been moved so the mechanical lift could be used. On 7/3/19 at 12:39 pm, administrative nursing staff B, reported he/she entered the resident's room when staff called for assistance, and verified the resident did not have a fall mat under him/her. The resident required staff assistance with bed mobility, and in hind sight, staff should have placed the fall mat at the resident's bedside, and not move it other than when staff used the mechanical lift for transferring the resident. The resident received cervical fractures, and when he/she returned from the hospital, the resident had a neck brace related to the fractures. The facility's fall management program, revised in 2019, documented each resident would be provided adequate supervision and assistive devices to prevent accidents. Staff should monitor and document the resident's response to interventions intended to reduce falling or the consequences of falling. The facility failed to provide care planned interventions to reduce injury falls to this cognitively impaired dependent resident. The resident fell face first from the bed, approximately 1 1/2 foot, directly onto the floor, which lacked the fall mat. The resident experienced a [MEDICAL CONDITION] which required sutures, and 2 neck fractures which required treatment in a hospital emergency department.

The facility reported a census of 94 residents with 4 residents reviewed for accidents. Based on observation, interview, and record review the facility failed to ensure adequate supervision for one (#1) of the four residents reviewed. Resident #1 fell when arising from the toilet unassisted, having been left unattended by staff and fractured his/her nose. Findings included: - Review of the resident's electronic and hard copy clinical record evidenced [DIAGNOSES REDACTED]. The resident's admission MDS (minimum data set), dated 9/8/18, included a BIMS (brief interview of mental status) score of 3/15, which indicated the resident severely impaired of cognition. The assessment evidenced the resident exhibited little interest or pleasure in doing things and felt down and tired. The resident needed extensive assistance of staff for ADLs (activities of daily living) including toileting and transfers; the resident's balance was unsteady and he/she was only able to stabilize with assistance. Additionally, the assessment identified the resident had a history of [REDACTED]. A Fall Risk Assessment, dated 9/1/18, identified the resident scored 40. The fall risk range indicated 25-45 equaled a moderate risk for falls. The facility provided a care plan, undated, which staff indicated was prior to the fall, This plan of care lacked any fall interventions, however identified standards of care, which included general safety precautions, such as keeping pathways clear and beds in a low position. Review of the facility investigation identified staff toileted the resident around 12:35 AM on 10/5/18. The staff left the resident on the toilet to get a clean/dry brief, from the closet. When not finding a brief in the closet, the staff went to the nursing desk to report to the charge nurse the resident was out of briefs and upon returning to the resident's room, the resident was found on the floor in the doorway of the bathroom, with his/her head pointing towards the bed. The CNA (certified nurse aide) notified the charge nurse of the fall. Upon assessment by the nurse, the resident was sent to the hospital ER (emergency room ) for evaluation due to a head injury with non-reactive pupils. A radiology report indicated a fractured nose. The resident returned to the facility with an intervention to prevent further falls of education to staff to not leave the resident alone on the toilet. Review of the coaching/counseling paper, dated 10/5/18, identified the staff failed to have the necessary supplies for toileting of the resident. The plan of action included the staff would meet quality nursing care standards through regular toileting and having all necessary supplies available. The staff member refused to sign the document. A termination document, dated 10/8/18 was included. Administrative nursing staff A, reported the staff never worked another shift after receiving the coaching and essentially self-terminated by not returning to work. Nursing notes, dated 10/5/18 at 5:45 AM, evidenced at 12:35 AM, the direct care staff reported the resident had fallen. Entering the resident's room, the nurse found the resident laying in a pool of blood, on the floor between the bathroom and the resident's bedroom. On 11/6/18 at 3:50 PM the resident sat in the lobby area, in a recliner with his/her feet elevated on the footrest. The resident appeared to sleep, with eyes closed and lack of movement. At 5:00 PM observation identified the resident seated in the dining room at table in a high-backed wheelchair, with foot pedals in place. The resident's spouse was present and visiting with the resident who occasionally nodded his/her head. The resident appeared pale and with a fading bruise under the resident's left eye. Ongoing intermittent observations identified the resident ate well, with the spouse feeding the resident and providing fluids as well. At 5:45 PM the spouse voiced pleasure that the resident ate very well tonight and how much improved the resident was tonight. At 5:51 PM the spouse wheeled the resident in the wheelchair from the table to the recliner area, stating to the resident that a visitor was coming. At that time, direct care staff F and G placed a gait belt to the resident's waist, removed the foot pedals from the wheelchair, and stood the resident to transfer into the recliner. Staff raised the resident's foot rest on the chair and made the resident comfortable. On 11/7/18 at 7:35 AM, direct care staff H and I removed the fall mats from the bedside, raised the bed height, then provided arising cares to the resident. The staff placed a gait belt on the resident, stood the resident with cueing and encouraged the resident to take a few steps to turn and sit into the wheelchair. Staff then propelled the resident to the dining room for breakfast. On 9:27 AM, direct care staff H and I provided a toileting opportunity to the resident and provided a safe transfer onto the toilet. Staff found no briefs in the supply closet, and one staff exited the bathroom to find briefs while the other remained with the resident. On 11/7/18 at 7:46 AM, direct care staff H reported the staff check on the resident frequently, he/she was mostly kept in the lobby area during the daytime hours, per family request for the socialization as well as staff observing the resident frequently. Staff reported the resident was left on the toilet alone by a staff member and the resident fell and broke his/her nose. The staff reported the staff continue to toilet the resident, however he/she was never left alone, nor was any resident identified at risk for falling. On 11/7/18 at 3:05 PM, direct care staff J reported that any resident requiring assistance with toileting should never be left alone on the toilet, unless care planned differently. Staff J added, especially residents at risk for falling, staff should never leave them on the toilet unattended. On 11/7/18 at 3:55 PM administrative nursing staff B reported upon admission, staff implement a care plan including the baseline care plan and the facility wide standards of care. The staff indicated some standards of care for falls would include a high/low bed and other fall interventions. On 11/7/18 at 4:10 PM, administrative nursing staff A reported that upon receiving notification of the fall with fracture the facility reported the incident and upon completing the investigation the facility realized the deficient practice and immediately began a plan of action. The facility policy, dated 9/16, for Fall Management instructed to never leave residents needing assistance, unattended on the toilet or commode. The facility failed to ensure adequate supervision for this resident during toileting, resulting in a fall in the bathroom for this resident requiring assistance of one staff member for toileting. The fall resulted in a fractured nose.

The facility reported a census of 92 residents with 24 selected for review including 4 residents reviewed for accidents. Based on observation, interview and record review, the facility failed to implement planned interventions to prevent falls for 1 of the 4 residents reviewed for accidents. Resident #72 sustained a fractured humerus (bone in the upper arm) as a result of a fall. Findings included: - Review of the physician examination note for resident #72, dated 6-1-17, included [DIAGNOSES REDACTED]. arm). The annual MDS (minimum data set), dated 4-3-17, assessed the resident with impaired vision, and a BIMS (brief interview for mental status) of 3 indicating severe cognitive impairment, required extensive assistance of 2 person for bed mobility, extensive assistance of 2 persons for transfers, extensive assistance of 1 person for toilet use, required extensive assistance of 3 person for ambulation in his/her room, impairment in range of motion in the lower extremity on one side and unsteady balance. The CAA (care area assessment), for falls, dated 4-17-17, for activities of daily living, advised staff the resident had left sided weakness from a stroke over a year ago and required extensive assistance of 1 or 2 staff, can make some positional adjustments in bed mobility using his/her side rail, but also received extensive assistance at times. The resident required 2 persons for transfer and 1-2 person assistance for ambulation. The resident fell on [DATE] with contusions to his/her left hip and ribs. The resident had a [DIAGNOSES REDACTED]. The care plan, in place at the time of the fall, on 5-24-17, advised staff the resident required 1-2 person assistance with a gait belt and walker, staff to place jingle bells on the resident's bed (initiated 4-9-16) to alert staff of movement, place the bed in the lowest position (8-1-16) , and keep the door open as much as the resident allows (8-17-16). The care plan, revised 5-24-17, advised staff to monitor the resident at shift change with direct care staff for one week to ensure the bed was in low position, the resident was comfortable, night light on, and bells at the appropriate location. The resident required 1-2 person assistance with a gait belt and walker but was not ambulating, at that time, due to fracture in the left arm, place the bed in the lowest position, keep the door open all the times except during activities of daily living (8-17-16). The fall risk assessment, dated 5-14-17, assessed the resident at risk for falls. The nurses' note, dated 5-24-17 at 2:30 am, documented the resident was on the floor in front of his/her closed bathroom door, on his/her left side. The resident stated his/her left forehead area and left arm were painful and the resident was unable to raise his/her left arm. Staff assessed the resident, notified the responsible parties and the resident was sent to the emergency room . The fall investigation form, dated 5-24-17, revealed staff heard the resident call out and staff found the resident positioned on the floor in front of his/her closed bathroom door. This form documented the bed was in a higher position (than the lowest setting) with the warning bells noted on the blanket at the end of the resident's bed. The X-ray report, dated 5-24-17, documented the resident experienced a closed post traumatic fracture of the proximal (close to the shoulder) left humerus. The physician's orders [REDACTED]. Observation, 6-5-17 at 7:20 pm, revealed the resident seated in his/her wheelchair with his/her left arm in a sling. Direct care staff F and V, transferred the resident from his/her wheelchair, with a gait belt and pivot and step technique, onto the toilet in his/her bathroom. The resident stated his/her arm was painful, and did not know why. The resident followed staff directions for the transfer, and was able to bear weight on his/her right side, and had noticeable weakness in the left lower extremity. Upon completing a brief change, clothing change, and oral care, staff transferred the resident from the toilet to his/her wheelchair, and then from the wheelchair to his/her bed. Staff F lowered the resident's bed to the lowest position, and pulled the sheet and blanket up around the resident. Staff F ensured the set of jingle bells were attached to the resident's blanket. Interview, on 6-5-17 at 8:45 am, with direct care staff X, revealed the resident required his/her bed to be in the lowest position and staff attached a set of jingle bells to the resident's blanket to alert staff of his/her movements. Staff X stated the resident could not ambulate by him/herself as he/she had a stroke and had weakness on his her left side. Staff X stated the resident had a poor memory and did not use his/her call light. Interview, on 6-5-17 at 9:15 am, with a family member, revealed the resident sustained [REDACTED]. The family member stated he/she did not think the facility provided enough staff on evening and night shifts as staff could not see/hear the resident attempt to get up out of bed. Interview, on 6-5-17 at 7:45 pm, with direct care staff F, revealed the resident's bed should be in the lowest position, and the jingle bells should be attached to the resident's blanket so if the resident moves in bed, staff would be alerted to the movement. Staff F stated the resident lacked the ability to use the call light due to cognitive status, and sometimes yelled out if he/she needed to toilet, or would attempt to get out of bed to take him/herself to the bathroom, but physically could not safely balance or ambulate unassisted. Staff F stated he/she usually made rounds with the oncoming shift. Staff F stated he/she could not recall if he/she made rounds with the oncoming shift on 5-23-17. Interview, on 6-5-17 at 9:34 pm, with direct care staff D, revealed he/she made frequent checks of the residents at night. Staff D revealed he/she worked alone in the house for the most part, and called the nurse (who worked between 2 houses) for assistance. Staff D stated he/she was responsible for processing the resident's personal laundry, and starting the meal preparation for lunch and supper for the next day. Staff D stated the resident did not use his/her call light for assistance, but called out at times. Staff D stated the resident did make attempts to get out of his/her bed at night and staff placed the bed in the lowest position and attached a set of jingle bells on the resident's bedcovers to alert staff of movements. Staff D stated he/she went into the laundry room to process laundry and in other resident's rooms when needed and could not hear the jingle bells. Staff D stated on 5-23-17, he/she was folding laundry at the dining area table, and did not hear the resident's jingle bells prior to the resident yelling out. Staff D stated he/she found the resident on the floor in front of the closed bathroom door. The resident voiced pain in his her left arm. Staff D stated the resident's bed was not in the lowest position. Staff D could not recall if he/she made rounds with the previous shift. Interview, on 6-5-17 at 9:52 pm, with licensed nursing staff P revealed the resident was at risk for falls and staff should place his/her bed in the lowest position and ensure the jingle bells were attached to the blanket/sheet that covered the resident. Staff P revealed he/she worked between two houses and received a call from direct care staff D on 5-23-17 at approximately 11:00 pm, requesting assistance. Staff P stated he/she assessed the resident and sent him/her to the emergency room for evaluation. Staff P stated the resident voiced pain in his/her left arm and the emergency room evaluation revealed a fracture of the humerus. Staff P stated the resident's bed height was knee level and should be kept at the lowest level, approximately 10 inches. Staff P stated either the resident kicked off the blanket with the jingle bells or the blanket was not placed on the resident when placed in bed as the blanket and jingle bells were found at the foot of the bed. Staff P acknowledged if the lone staff member assisted another resident in his/her room, the jingle bells could not be heard. Staff P stated he/she expected staff to make rounds at the beginning of the shift, approximately 10:00 pm, and frequently throughout the night. Interview, on 6-6-17 at 10:33 am, with administrative staff G, revealed the resident assessed at risk for falls, required his/her bed in the lowest position and required a set of jingle bells attached to his/her sheet/blanket. Staff G stated the resident did not use his/her call light with a cognitive deficit that resulted in lack of memory for the physical deficits (weakness in the left arm and leg and inability to ambulate safely) caused by his/her stroke. The facility policy for falls, revised 9-2016, advised staff to keep the bed in the lowest position with casters locked, observe the resident every 60 minutes at a minimum, keep a night light on at night, and provide an individualized toileting program. The facility policy for change of shift rounds, revised 5-24-17, advised the off going staff to perform rounds with the oncoming shift at the end of each shift change and visually check each resident. The facility failed to provide interventions (bed in lowest position and use of jingle bells) as care planned for this cognitively impaired resident at risk for falls, who sustained a fall with fracture.

The facility census totaled 98 residents with 8 included in the sample. The sample included the review of 4 residents at risk for the development of pressure ulcers. Based on observation, interview, and record review, the facility failed to consistently provide assessments of pressure ulcers, failed to change the treatment for [REDACTED]. (#2, #4, #5 and #6) Resident #4 developed four Stage 2 pressure ulcers and one Stage 3 pressure ulcer. Findings included: - Review of resident #4's physician's review of orders, dated [DATE], identified the resident with the [DIAGNOSES REDACTED]. Review of the annual MDS (Minimum Data Set-a required assessment) dated [DATE], identified the resident with a BIMS (Brief Interview for Mental Status) score of ,[DATE] (indicating severely impaired cognition), required supervision with oversight in bed mobility and transfers, was at risk for the development of pressure ulcers, without pressure ulcers, and used a pressure relieving device in the bed. Review of the quarterly MDS dated [DATE] identified the resident with a BIMS score of ,[DATE] (indicating moderately impaired cognition), required limited assistance from one staff with transfers, supervision from one staff with bed mobility and walking in the room, was at risk for the development of pressure ulcers, had one Stage 1 pressure ulcer (intact, not open), and used a pressure reducing device for the chair and the bed. Review of the Pressure Ulcer CAA (Care Area Assessment-a further assessment) dated [DATE] revealed the resident had a history of [REDACTED]. The CAA identified staff monitored the resident's skin on a regular weekly basis per the facility's nursing standard. The CAA identified staff applied a moisture barrier cream to the resident's buttocks as a preventative measure, used a pressure relieving mattress but the resident refused a chair cushion. The assessment identified the resident at risk for impaired skin integrity due to the resident's incontinence, [MEDICAL CONDITION], and decreasing mobility. Review of the care plan, dated [DATE], directed staff to apply moisturizing lotion after each bath, monitor floor of the resident's room for wet pull ups, assist the resident with toileting as he/she allowed as the resident frequently refused help with toileting and personal cares and became agitated easily, and encourage/remind the resident to keep his/her feet elevated when seated. Encourage the use of wraps every day. Weekly skin assessment by licensed nurse and [MEDICATION NAME] ointment to buttocks every shift and PRN until resolved. Review of the physician ' s review of orders, dated [DATE], identified the staff could use skin care - implement facility wound protocol for treatment of [REDACTED]. Review of a wound assessment sheet revealed staff documented on [DATE] that the resident had a Stage I (intact, but reddened) area on the left buttock that measured 0.8 cm (centimeters) x 0.5 cm in size. The assessment lacked documentation that staff initiated a treatment. The medical record lacked evidence staff notified the physician of the impairment in the resident's skin. Review of the [DATE] TAR (Treatment Administration Record) revealed on [DATE], staff initiated a treatment order for staff to apply DuoDerm (an occlusive dressing) to the resident's buttocks and change the dressing every ,[DATE] days. Further review of the TAR revealed guidance to staff to conduct a skin assessment weekly by a licensed nurse. According to the TAR, a licensed nurse had conducted a skin assessment once during the month, on [DATE]. The next wound assessment, dated [DATE] or 11 days after the initiation of the DuoDerm treatment, identified the resident now had 5 open areas on the left buttock. The staff identified four of the open areas as Stage 2 (Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater) and one of the open areas as a Stage 3 (Full thickness skin loss involving damage to, or necrosis (dead/dying tissue) of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue). The staff assessment identified the Stage II areas measured 0.5 cm, 0.6 cm, 0.6 cm and 1.1 cm in size. The staff documented the one Stage III as 0.8 cm in size and identified the treatment as Duoderm (an occlusive dressing). The record lacked evidence staff notified the physician of the development of multiple pressure ulcers. Review of the resident's laboratory testing revealed on [DATE] the resident had a stool specimen that tested positive for [DIAGNOSES REDACTED] ([MEDICAL CONDITION]-"C. diff", is a species of Gram-positive spore-forming bacterium that is best known for causing antibiotic-associated diarrhea). On [DATE], the nurse on the ,[DATE] shift and the ,[DATE] shift completed a resident summary that identified the resident used a pressure reducing device while in the chair, but was not on a turning/repositioning program. On [DATE], the nurse on the ,[DATE] shift also completed a resident summary that identified the resident used a pressure reducing device while in the chair and not on a turning/repositioning program. On [DATE] at 1:22 p.m., direct care staff F and G and licensed nurse H put on gowns, gloves and entered the resident's room. Observation revealed the resident sat in the recliner without it being reclined. Staff F and G attempted to use a walker and assist the resident to stand, but he/she refused, so staff F removed the gown and gloves, left the room and returned with a sit to stand mechanical lift. Nurse H stated that since the resident had been diagnosed with [REDACTED]. Staff F and G placed the resident in the mechanical lift, and raised the resident into a standing position. Staff G removed the resident's brief, while nurse H looked at the resident's buttocks. Observation of the resident's buttocks revealed the resident's coccyx was a bright red and there was a duoderm on the left buttock. The skin around the duoderm was also bright red. The duoderm was intact and dated [DATE]. Nurse H stated he/she looked at the resident's buttocks every day to make sure the duoderm remained in place. Observation of the recliner revealed a foam cushion was in the seat of the recliner. Nurse H stated the facility had just placed the cushion in the recliner "yesterday" to help offload the residents' buttocks since he/she was "sitting so much". Staff F and G then asked the resident if he/she needed to use the restroom (the resident stated no), placed a clean brief on the resident, pulled up his/her pants and sat the resident back in the recliner and left the resident's room at 1:38 p.m. Observations revealed the resident remained in the recliner without a position change through observations at 1:57 p.m., 2:10 p.m., 2:23 p.m., 2:38 p.m., 2:45 p.m., 2:57 p.m., 3:10 p.m., 3:23 p.m., 3:35 p.m., 3:41 p.m., and 3:50 p.m. On [DATE] at 4:04 p.m., after no position change for 2 hours and 26 minutes, direct care staff I and M put on gowns, hair coverings, masks, foot coverings and gloves and entered the room. The staff assisted the resident to stand, using the mechanical lift. The duoderm remained in place, and observation of the resident's buttocks revealed they were reddened. The staff changed the resident's incontinent brief, then assisted the resident to sit in the recliner again. Staff I stated at that time that the resident had become weaker in the previous weeks because he/she had gotten sick and he/she no longer wanted to get up out of the recliner, which was why staff I thought the resident had developed the areas. Staff I said the resident "used to be" independent, but now staff had to check on him/her every 2 hours and the staff needed to use a lift to help the resident. On [DATE] at 1:25 p.m., direct care staff F stated that the resident no longer liked to stand, but they had to check the resident's brief and change it because the resident had "sores starting on (his/her) back side." On [DATE] at 2:23 p.m., direct care staff I stated that the resident did not usually take snacks, so he/she was glad the resident took them today, since he/she needed them to help his/her sores heal. On [DATE] at 1:22 p.m., licensed nurse H stated the facility had put a cushion in the seat of the resident's recliner yesterday to try and offload the resident's buttocks, since he/she liked to sit in the chair so much. The resident's family member had talked to the resident and convinced him/her since he/she had pressure sores on his/her bottom to lay down in bed during the night. On [DATE] at 4:50 p.m., Administrative nurse B stated the resident had "chronic issues" with open areas that developed, then closed, then reopened. Nurse B stated he/she thought there should have been another wound assessment between the two that he/she provided, but nurse B could not find another assessment. Nurse B agreed that the wounds had gotten worse, but he/she believed it was because the resident had [DIAGNOSES REDACTED] and had issues with diarrhea. He/she said the resident had been independent in his/her room prior to getting sick, so staff should have recognized that the resident was weaker during that time and needed more help. Nurse B said the staff probably was expecting the resident to return to become more independent, once his/her illness resolved. On [DATE] at 9:50 a.m., a nurse from Physician T's office stated the physician lacked knowledge regarding the resident's multiple pressure ulcers, and the nurse had looked thoroughly into the resident's chart at the office, and it lacked any notification from the facility staff regarding the resident's development of pressure ulcers in [DATE]. Review of the facility's undated Pressure Ulcer Prevention Protocol, identified staff were to conduct weekly skin assessments for pressure ulcers using an EZ graph and were to include staging, size, depth, drainage, tunneling, odor, degree of healing and an assessment of pain associated with the pressure areas. The protocol also identified any pressure ulcer which did not demonstrate healing would have interventions changed in a timely manner. The facility failed to change the treatment once a resident developed a Stage I pressure ulcer, failed to conduct weekly skin assessments and failed to develop a plan to address the resident's increased dependence on staff for repositioning needs. The resident developed four Stage 2 pressure ulcers and one Stage 3 pressure ulcer. - Review of resident #6's physician's review of orders, dated [DATE], identified the resident with the [DIAGNOSES REDACTED]. mental disorder characterized by failing memory, confusion). The annual MDS (Minimum Data Set-a required assessment) dated [DATE] identified the resident with a BIMS (Brief Interview for Mental Status) score of ,[DATE] (indicating severely impaired cognition), required extensive assistance from two staff with bed mobility, transfers, toilet use, extensive assistance from one staff with personal hygiene, eating, at risk for the development of pressure ulcers, had no pressure ulcers, used a pressure reducing device for the bed, and was on a turning/repositioning program. Review of the quarterly MDS dated [DATE] identified the resident with a BIMS score of ,[DATE], required extensive assistance from two staff with bed mobility, transfers, toilet use, personal hygiene, required extensive assistance from one staff with eating, at risk for the development of pressure ulcers, had no pressure ulcers, used a pressure reducing device for the bed, and was on a turning/repositioning program. Review of the Pressure Ulcer CAA (Care Area Assessment) dated [DATE] identified the resident at risk for the development of pressure ulcers due to [DIAGNOSES REDACTED]. enough insulin made or the body can't respond to the insulin), impaired mobility, pain, bowel and bladder incontinence, and cognitive impairment. Review of the care plan, dated [DATE], identified the resident at risk for impaired skin integrity and directed staff to reposition the resident at least every 2 hours and to assist with repositioning as needed. It also guided staff to conduct weekly skin assessments by a licensed nurse, to monitor the resident's skin during dressing, peri-care and bathing for signs of potential skin breakdown (such as redness, discoloration or open areas) and notify the charge nurse of abnormal findings. Other interventions included staff to provide good peri-care with each incontinent episode, apply moisturizing skin lotion to skin after each bath and PRN (as needed), monitor for any unusual brusing or signs/symptoms of infections and to report any bruising noted to the licensed nurse. On [DATE] at 1:20 p.m., observation of the resident revealed he/she sat in a recliner in the lobby, with his/her feet up. The resident sat with his/her eyes open. The resident remained in the lobby, seated in the reclined recliner without a position change through observations at 1:35 p.m., 1:48 p.m., 2:01 p.m., 2:15 p.m., 2:30 p.m., 2:42 p.m., 2:54 p.m., 3:03 p.m., 3:14 p.m., 3:25 p.m., 3:38 p.m., 3:50 p.m., 4:02 p.m., 4:11 p.m., and 4:25 p.m. At 4:34 p.m., after sitting in a reclined recliner for over 3 hours, direct care staff I and M transferred the resident from the recliner into his/her wheelchair, then took the resident to the bathroom. Once in the bathroom, observation of the resident's buttocks revealed the buttocks were a deep, ruddy, red color. The staff failed to provide repositioning services for the resident every 2 hours as planned. On [DATE] at 1:18 p.m., direct care staff F said the resident needed help with all ADLs (Activities of Daily Living), including toileting, repositioning in bed, and eating. Staff F said staff were to reposition all residents that could develop a pressure ulcer every 2 hours, whether the residents had one or not, and that included resident #6. On [DATE] at 5:09 p.m., licensed nursing staff N stated the staff were to reposition the residents that needed assistance with moving at least every 2 hours. On [DATE] at 4:50 p.m., Administrative nurse B stated staff were to make sure all residents were repositioned every 2 hours. Review of the resident's undated policy on Pressure Ulcer Prevention Protocol revealed guidance to staff that resident with risk factors were to have position changes at least every 2 hours during the daytime. The facility staff failed to provide repositioning assistance for a resident every 2 hours as planned for this cognitively impaired, dependent resident who was risk for pressure ulcers. - Review of resident #5 ' s diagnoses, located on the admission and discharge summary sheet dated [DATE], identified the resident with the [DIAGNOSES REDACTED]. enough insulin made or the body can't respond to the insulin), [MEDICAL CONDITION] ([MEDICAL CONDITION] changes to one or many joints characterized by swelling and pain), and delusional disorder (an untrue persistent belief or perception held by a person although evidence shows it is untrue). Review of the significant change in status MDS (Minimum Data Set-a required assessment) dated [DATE] identified the resident with a BIMS (Brief Interview for Mental Status) score of ,[DATE] (indicating severely impaired cognition), required extensive assistance from 2 staff with bed mobility, transfers, toilet use, and personal hygiene, was at risk for the development of pressure ulcers, did not have pressure ulcers, used pressure reducing devices for the chair, bed, and was on a turning/repositioning program. Review of the quarterly MDS dated [DATE] identified the resident with short and long-term memory problems, with inattention and disorganized thinking that did not fluctuate, required extensive assistance from 2 staff with bed mobility, transfers, toilet use, personal hygiene, at risk for the development of pressure ulcers, had no pressure ulcers, used a pressure reducing device for the chair/bed, and staff utilized a turning/repositioning program for the resident. Review of the Pressure Ulcer CAA (Care Area Assessment-a further assessment), dated [DATE] revealed the resident had a decrease in mobility, and had lost a significant amount of weight which placed the resident at risk for impaired skin. Other contributing factors included the resident's [DIAGNOSES REDACTED]. Review of the care plan, dated [DATE], revealed the resident was at risk for impaired skin integrity related to diabetes. It directed staff to apply skin protectant to the resident's buttocks as needed, monitor an area on the resident's inner thigh (looks like birthmark) that the resident had said that he/she had for years. If staff noted changes, (such as irregular borders, color or size changes) notify physician. Turn and reposition the resident at least every 2 hours, the facility's licensed nurses were to conduct a weekly skin assessment, monitor skin during care for signs of potential skin breakdown, and apply moisturizing skin lotion to skin after each bath and PRN (as needed). Review of the nurse's notes revealed on [DATE] at 9:43 a.m., staff documented an open spot on the right side of the buttocks. [MEDICATION NAME] (type of moisture barrier) applied. The resident's medical record lacked an assessment of the open area. Review of the [DATE] TAR (Treatment Administration Record) revealed on [DATE] staff received an order to check open area on right buttock and apply [MEDICATION NAME] until resolved. Staff signed the order three times a day as completed starting on [DATE]. On [DATE], the staff sent a fax to the physician asking for an order for [REDACTED]. On [DATE], the staff sent a fax to the physician with the following information: Patient sore on left buttock is increasing in size (Previous documentation identified open areas on the right buttock and coccyx). There was a spot starting on right buttocks. Staff placed DuoDerm on both, patient has been spending more time in recliner. Pressure cushion was not being used in recliner and wheel chair. Wound to be checked, cleaned and DuoDerm changed every 5 days until resolved. Is this acceptable? On [DATE], physician extender responded with agree with above. On [DATE] at 8:38 a.m., direct care staff K entered the resident's room and used a sit to stand mechanical lift to transfer the resident from the wheelchair onto the toilet. Observation revealed a foam cushion in the resident's wheelchair. Staff K removed the resident's wet brief, then assisted the resident to sit on the toilet. The resident voided, staff K obtained a brief and assisted the resident to stand. Observation of the resident ' s buttocks revealed two small, undated DuoDerm dressings (an occlusive dressing) on each ischial tuberosity (when a person is in a seated position, his or her weight typically rests on a section of bone called the ischial tuberosity). Direct care staff J entered the resident's room at that time, carrying a small cup of [MEDICATION NAME] (moisture barrier cream) and was going to place it on the resident ' s buttocks, but said he/ she saw a new reddened area on the right buttock, so staff J left to get licensed nurse A, the charge nurse. Staff K applied a clean brief and pulled up the resident's pants, but had the resident remaining standing in the mechanical lift, waiting on nurse A. On [DATE] at 8:50 a.m., direct care staff K transferred the resident from the sit to stand lift into the resident s electric recliner. Staff K then reclined the resident back in the chair and left the resident's room. On [DATE] at 9:55 a.m., licensed nurses A and O entered the resident's room to look at the resident's buttocks but the resident refused. Staff A and O said they would try again right before lunch when staff assisted the resident to the toilet again. On [DATE] at 10:55 a.m., direct care staff L and licensed nurse A used a sit-to-stand mechanical lift, assisted the resident stand, then lowered the resident's dry brief. Observation of the resident ' s buttocks revealed the reddened area on the right buttock from earlier in the morning was no longer present. The DuoDerm on the right buttock had edges that were starting to curl up, and, as a result, observation of the open area was noted. There was no drainage, the wound bed was red and the edges of the wound were reddish/purple in color. Licensed nurse A tried to uncurl the duoderm and lay it back over the wound, then stated it was good enough, and said it would stick better when the resident sat on it some more. The other duoderm on the left buttock remained intact. The staff transferred the resident to the toilet and then into the wheelchair. Observation revealed the resident sat on a foam cushion in the wheelchair. On [DATE] at 8:50 a.m., direct care J, stated that the resident had one area that was really opened, and a reddened area on the other buttock that looked like it could develop into something, which was why staff were using the DuoDerm. On [DATE] at 9:55 a.m., licensed nurse A stated the resident had developed an open area and when he/she measured the area on [DATE] and it was 8 mm (millimeters) x 5 mm at that time and was looking good. However, licensed nurse P worked yesterday ([DATE]) and must have thought it looked worse, because nurse P put a duoderm on both buttocks, one that had an open area and the other buttock had another area that nurse P thought looked like it might be starting to open. Nurse A stated the resident sat on a foam cushion, but that was a cushion the resident always had. On [DATE] at 9:58 a.m., licensed nurse O stated hospice had ordered a gel cushion for the resident, but it had not arrived yet. Nurse O did not say when hospice ordered the cushion, or how long before it would be in. On [DATE] at 10:55 a.m., licensed nurse A stated that he/she was going to talk to the hospice staff again. Nurse A said the nursing staff had just started the [MEDICATION NAME] ointment on [DATE] and it had only been used for a day when licensed nurse P started to use the DuoDerm. Nurse A said that was not long enough to see if the [MEDICATION NAME] would work. On [DATE] at 4:50 p.m., Administrative nurse B, stated staff should have done an assessment on the resident ' s open area when it first developed, then did one weekly. Review of the facility's undated Pressure Ulcer Prevention protocol, directed staff to conduct weekly skin assessments for pressure ulcers using an EZ graph that included staging, size, depth, drainage, tunneling, odor, degree of healing and assessing the resident's pain associated with pressure areas. Staff failed to complete comprehensive assessments of a resident's newly-developed pressure ulcer. - Review of the closed medical record for resident #2 revealed a physician's review of orders dated [DATE] that identified the resident had the [DIAGNOSES REDACTED]. glucose, there's not enough insulin made or the body can't respond to the insulin), and [MEDICAL CONDITION] (inability of the kidneys to excrete wastes, concentrate urine and conserve electrolytes). Review of the annual MDS (Minimum Data Set-a required assessment) dated [DATE] identified the resident with short and long-term memory problems, modified independent in making decisions regarding tasks of daily life, and had daily inattention and disorganized thinking. The assessment also identified the resident required extensive assistance from one staff with bed mobility and transfers, was at risk for the development of pressure ulcers, did not have any pressure ulcers, used a pressure relieving device while in the chair and bed, and was on a turning/repositioning program. Review of the quarterly MDS dated [DATE] identified the resident with a BIMS (Brief Interview for Mental Status) score of ,[DATE] (indicating severely impaired cognition), required extensive assistance from two staff with bed mobility, transfers, was at risk for the development of pressure ulcers, had no pressure ulcers, used a pressure relieving device for the bed/chair, was on a turning/repositioning program, and staff applied nonsurgical dressings other than to feet. Review of the Pressure Ulcer CAA (Care Area Assessment-a further assessment), dated [DATE], identified that resident had no significant change from the prior comprehensive assessment. It identified the resident at moderate risk for the development of pressure ulcers. It also identified the resident had a [DIAGNOSES REDACTED]. The care plan for skin integrity, dated [DATE] directed staff to assist with repositioning at least every 2 hours, a licensed nurse was to conduct a weekly skin assessment, monitor skin during dressing, peri-care and bathing for signs of potential skin breakdown (such as redness, discoloration or open areas) and notify the charge nurse of abnormal findings - particularly to feet and hands. Provide good peri-care with each incontinent episode, apply moisturizing lotion to skin after each bath and PRN (as needed). Review of the nurse's notes revealed the following: On [DATE] at 9:30 a.m., RN (Registered Nurse) noted small open area on lt (left) buttocks as received via nurse shift report, barrier cream applied per orders. Will continue to monitor. On [DATE] at 1:00 p.m., family and hospice staff both looked at small areas of skin breakdown. Review of the [DATE] TAR (Treatment Administration Record) revealed staff wrote an order for [REDACTED]. Review of the medical record revealed it lacked a comprehensive assessment of the resident's open areas. Review of the medical record revealed the resident expired in the evening of [DATE]. The facilty failed to conduct a comprehensive assessment of a resident's newly-developed pressure ulcer.