Every finding on record at Park Manor Ltd

Based on record review and interviews, the facility did not ensure that an alleged violation involving abuse was reported to the State Survey (SA) and law enforcement. This had the potential to affect 1 of 4 residents (R1) investigated for abuse.The facility reported the incident to the SA within five days following their investigation, but did not report the injury of unknown origin to the SA within 24 hours.Surveyor reviewed the facility's policy titled Abuse and Misconduct, which read in part, The administrator, Director of Social Services, and/or the Director of Nursing determined whether the suspicion/alleged incident is reportable (meets the definition of caregiver misconduct) to the Division of Quality Assurance and other officials.On 06/20/26, the facility submitted an alleged nursing home resident mistreatment, neglect, and abuse report to the State Agency (SA). The report stated the following:-On Monday, 06/15/26, R1 was noted by nursing staff to have bruising to upper right extremity, measuring 13 cm x 14.5 cm. DON immediately began an Injury of Unknown Origin investigation. Physical Abuse was ruled out and neglect was ruled out. The source of the bruising was determined to occur during a transfer with a mechanical lift. It was determined that this was the appropriate manner of transfer. Primary care physician and family updated. On Friday, 06/19/26, R1 began experiencing pain in the right extremity. Primary care physician was updated, and R1 was sent to the emergency department. Results on the evening of 06/19/26 indicated a humerus fracture of right extremity. Director of Social Services was contacted on 06/20/26 at 9:01 AM. Based on the presence of a significant injury, Director of Social Services reported the incident to the SA on 06/20/26. The facility reported abuse and neglect were ruled out on 06/15/26. The injury of unknown origin investigation conducted on 06/15/26 indicated that it was likely that the injury (bruise) was the result of the mechanical lift. The presence of the fracture on 06/19/2026 and notification of Director of Social Services on 06/20/26 of the fracture indicated that significant injury occurred that is not deemed physical abuse or neglect.On 06/22/26, the facility submitted a Misconduct Incident Report to the SA. The report had the following information:-R1 is alert and oriented. They were able to inform staff that no one had caused them any physical injury. R1 was unable to state how the injury happened. The effect on R1 is more than minor in that they suffered serious injury. The injury is not abuse as this was ruled out. The incident meets the definition of injury of unknown origin. R1 is being monitored, and their pain is being treated. R1 continues to state that no one physically harmed them. R1 has pain in their arm, and a reasonable person would conclude that the fractures and associated pain are more than minor.On 07/09/26, Surveyor reviewed R1's record. R1 was admitted to the facility on [DATE], after hospitalization for fractured femur. R1's diagnoses included stroke affecting right side, embolism and thrombosis requiring daily anti-coagulation therapy. R1's most recent Brief Interview for Mental Status confirmed R1 scored 12/15, indicating intact cognition.On 07/09/26, Surveyor reviewed the facility's investigation and confirmed the facility did complete staff interviews to determine how the injury may have occurred. R1's primary provider and Power of Attorney (POA) were updated. Staff continued ongoing assessment of R1's injury and reported changes to R1's primary provider. Surveyor determined the facility's investigation was thorough, however the initial report was not submitted within 24 hours of becoming aware of the injury and law enforcement was not updated for reporting suspicion of a crime.On 07/09/26 at 12:30 PM, Surveyor interviewed R2, R3, and R4. These residents reside in the same hall as R1. R2, R3, and R4 did not have concerns related to their care and denied any abuse.On 07/09/26 at 12:44 PM, Surveyor interviewed R1. R1 was lying in their bed and had partially removed the sling from their right arm. Certified Nursing Assistant (CNA) D was present in the room and encouraging R1 to eat. R1 reported they did not know how the injury to their arm occurred but denied anyone at the nursing home had hurt them. R1 stated they are good to me here.On 07/09/26, Surveyor interviewed RN C. RN C reported initially the bruise appeared to maybe have been caused from the blood pressure cuff of the automatic machine. RN C stated when the bruise started to appear larger on 06/18/26, staff considered the bruise may have been caused by the mechanical sit-to-stand. Surveyor and RN C did observe the blood pressure cuff machine and noted to have three sizes of cuffs. Surveyor and RN C observed the mechanical sit-to-stand lift and noted the sling was very thick and the top of the sling rounded, like a pool noodle. RN C reported R1 did not initially report any pain, but on 06/20/26 R1 did report pain, and it was determined to send R1 to the ER at that time. RN C confirmed the staff receive abuse training and denied any abuse occurring in the facility.On 07/09/26 at 1:10 PM, Surveyor interviewed CNA D. CNA D confirmed staff receive abuse training and denied any abuse occurring in the facility. CNA D reported they were called and interviewed after the bruise was noted on R1. CNA D stated they reported the only thing they had done was take R1's blood pressure and was not aware of any other incident occurring. CNA D reported they use the regular size blood pressure cuff on R1. CNA D denied knowing how the injury occurred.On 07/09/26 at 1:24 PM, Surveyor interviewed Director of Nursing in training (DON) E. DON E reported R1's bruise was thought to be caused from the blood pressure cuff, as the bruise appeared in a rectangular shape on R1's upper arm, that wrapped around, appearing the same shape as a blood pressure cuff. DON E confirmed R1 was receiving an anticoagulant medication. DON E reported R1's primary provider was updated on the injury right away and had been to the facility to see R1, and staff to monitor R1 and do not take blood pressure on right arm due to the injury. DON E stated R1's primary provider did not question the facility's assessment; the bruise may have been caused by the blood pressure cuff or the mechanical sit-to-stand, as R1's primary provider trusted the facility's assessment.On 07/09/26 at 1:45 PM, Surveyor interviewed Certified Occupational Therapy Assistant (COTA) F. COTA F reported R1 was in therapy at the time the injury occurred. COTA F denied knowing how the injury occurred and denied any accident happened or being aware of any abuse occurring.On 07/09/26 at 2:10 PM, Surveyor interviewed Social Services Director (SSD) G and Nursing Home Administrator (NHA) A. SSD G and NHA A explained they did not feel this injury was a reportable incident on 06/15/26, as R1 denied anyone abused her and the initial cause of the injury was determined to be caused by a blood pressure cuff or a mechanical lift. NHA A and SSD G stated an internal initial investigation was completed within 24 hours and abuse had been ruled out.On 07/09/26, Surveyor informed SSG, NHA A, R1's injury meets the definition of injury of unknown origin, as R1 could not state how the injury occurred, R1's injury was not witnessed, and R1's injury is suspicious due to the extent of the injury.SSD G and NHA A continued to express confusion with the reporting process, and stated the facility reported the incident as soon as they became aware of the fracture and did not feel R1's initial bruise met the definition of injury of unknown origin.

Based on Interview and record review, the facility did not ensure that all alleged violations involving abuse resulting in physical harm, pain or mental anguish are reported immediately, but not later than 2 hours after the allegation is made to the administrator of the facility (including to the State Survey Agency) and to other officials in accordance with State law through established procedures for 2 (R5, R8) of 6 residents. On 4/16/26 at 8:15 AM, R6 barricaded self in R5's room and threatened to harm R5. The facility did not report this within allotted time frames. On 6/4/25 at approximately 7:40 AM, Certified Nursing Assistant (CNA) D heard Registered Nurse (RN) E yelling at R8. This was not reported within allotted time frames.Findings include The facility policy titled Abuse and Misconduct last reviewed on 05/01/26, states under the section labeled Abuse .definitions, states: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in .mental anguish. The policy further defines mental abuse as the issue of verbal or nonverbal conduct which causes, or has the potential to cause, the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Example 1 On 05/06/26, Surveyor reviewed R6's medical record. R6 was admitted to facility on 03/19/2026 with diagnoses including unspecified dementia, unspecified severity, with other behavioral disturbance, R6's Minimum Data Set (MDS) assessment dated [DATE] indicated Brief Interview for Mental Status (BIMS) score was 12/15 (mildly impaired) R6's care plan had a problem and approaches with start date of 03/22/2026 of I have a behavior problem related to nursing home placement, with approaches of: *Explain all procedures to me before starting and allow me (5 minutes) to adjust to changes. *If I am safe, allow me my space. *If I pose a potential threat to injure self or others notify providers. S *If I wander or pace, initiate visual supervision during any acute episode. *Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. R6's care plan revised on 04/20/26 states: New behavior potentially causing harm to others, *Physically aggressive, *Poor impulse control, *verbally aggressive. Target behaviors, verbal threat of harm against others. Related to cognitive, impairment, disease process, infection and dementia. R6's medical record revealed on 04/16/26 at 8:15 AM, Social Worker (SW) C, became aware of an abuse allegation between R5 and R6 when staff overheard the argument between R5 and R6, who are husband and wife, in which R6 barricaded self in R5's room and threatened to kill R5. Staff immediately reported to SW C. The verbal abuse caused R5 immediate negative effects of fear, anger and emotional harm. The facility did not report the abuse to the SA (State Agency) within 2 hours of determining abuse occurred within 2 hours of becoming aware of incident/allegation. On 05/06/26 at 12:40 PM, Surveyor interviewed SW C who stated was not aware of need to report allegation of abuse within 2 hours if there was not physical harm. Example 2 On 05/06/26 at 10:15 AM, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE]. On 05/16/25, R8's Minimum Data Set (MDS) assessment noted a score of 99 for Brief Interview for Mental Status (BIMS) due to R8's severe cognitive impairment and inability to complete the assessment. R8's care plan includes a focus of impaired cognitive function or impaired thought process related to developmental delay or disability (initiated on 02/17/25) with interventions of face me when speaking and make eye contact. R8's care plan includes a focus of psychosocial well-being problem.may experience feelings of powerlessness.ineffective coping skills.(initiated on 02/17/25) with interventions including, allow me time to answer questions and to verbalize feelings, perceptions, and fears. R8's care plan includes a focus of vulnerable adult and at risk for potential abuse (initiated on 02/17/25) with interventions including, facility staff will follow policy and procedures and will be provided education on reporting allegations of abuse. R8's nurse's documented on 06/04/25 at 8:07 AM, Certified Nursing Assistant (CNA) D reported to Social Worker C at approximately 7:35-7:40 AM, CNA D heard Registered Nurse (RN) E yelling at someone in the dining room as CNA was walking toward the dining room from the 600 hall. CNA D stated it was clear to CNA D, RN E was upset and verbally aggressive. CNA D stated CNA D asked RN E what was going on. CNA stated RN E told CNA E that R8 was pounding on the table and stated something similar to the act being ridiculous and unnecessary. CNA D stated CNA D told RN E that R8 does this as a form of communication with another resident. CNA D stated R8 was visibly upset after the encounter and kept repeating the encounter. CNA D stated CNA F and Licensed Practical Nurse (LPN) G were present and witnessed the incident. On 05/06/26, Surveyor reviewed R8's medical record regarding the most recent vulnerability assessment completed prior to the incident. The assessment was dated 05/09/25 and indicated R8 was unable to report abuse/neglect concerns. On 05/06/26 at 2:54 PM, Surveyor interviewed SW C about the incident on 06/04/25. SW C acknowledged the event should have been reported within two hours to the police and the SA for verbal abuse.

Based on interview and record review the facility did not complete a thorough investigation regarding potential verbal and psychosocial abuse for 1 of 6 residents reviewed (R8),-The facility did not remove the accused staff member from the facility pending investigation-All present parties to the incident were not interviewed Findings include:On 05/06/26 at 12:15 PM, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE].On 05/16/25, R8's Minimum Data Set (MDS) assessment noted a score of 99 for Brief Interview for Mental Status (BIMS) due to R8's severe cognitive impairment and inability to complete the assessment.R8's care plan includes a focus of impaired cognitive function or impaired thought process related to developmental delay or disability (initiated on 02/17/25) with interventions of face me when speaking and make eye contact. R8's care plan includes a focus of psychosocial well-being problem.may experience feelings of powerlessness.ineffective coping skills.(initiated on 02/17/25) with interventions including, allow me time to answer questions and to verbalize feelings, perceptions, and fears. R8's care plan includes a focus of vulnerable adult and at risk for potential abuse (initiated on 02/17/25) with interventions including, facility staff will follow policy and procedures and will be provided education on reporting allegations of abuse.On 06/04/25 at 8:07 AM, Certified Nursing Assistant (CNA) D reported to Social Worker C that at approximately 7:35-7:40 AM, CNA D heard Registered Nurse (RN) E yelling at someone in the dining room as CNA was walking toward the dining room from the 600 hall. CNA D stated it was clear to CNA D RN E was upset and verbally aggressive. CNA D stated CNA D asked RN E what was going on. CNA D stated that RN E told CNA D R8 was pounding on the table and stated something similar to the act being ridiculous and unnecessary. CNA D stated CNA D told RN E that R8 does that as a form of communication with another resident. CNA D stated R8 was visibly upset after the encounter and kept repeating the encounter. CNA D stated CNA F and Licensed Practical Nurse (LPN) G were present and witnessed the incident.On 06/04/25 at 8:15 AM, SW C began the investigation in relation to allegation of verbal and emotional abuse to R8 which included interviews with staff and residents.On 05/06/26, Surveyor reviewed the most recent vulnerability assessment completed prior to the incident. The assessment was dated 05/09/25 and indicated R8 was unable to report abuse/neglect concerns.RN E is no longer working at the facility and was unavailable for interview.On 05/06/26 at 1:28 PM, Surveyor observed R8 in relation to demeanor. R8 appeared calm and in no distress. R8 was uninterviewable in relation to the incident.On 05/06/26 at 2:54 PM, Surveyor interviewed SW C about the incident on 06/04/25. Surveyor asked SW C about removing RN E from the floor while investigation was pending. SW C indicated RN E was in SW C's office for a short time before being allowed to the floor to continue the shift. Surveyor asked SW C about any education provided to the staff after the incident. SW C stated if there is nothing attached to the investigation, then nothing formal was completed. SW C acknowledged due to R8's severe cognitive impairments and inability to report feelings of fear or other negative effects, the one-hour time frame was not long enough to form a conclusion, and the event should have been investigated further. SW C acknowledged education should have been provided, RN E should have been removed pending further investigation, LPN G should have been interviewed, and the care plan interventions should have been followed in relation to the event.

Based on record review and interview, the facility did not provide Notice of Bedhold and Notice of Transfer to a resident or resident representative who were transferred from the facility to a hospital for 4 of 4 residents (R) (R4, R20, R33 and R34). Example 1 R4 was admitted to the facility on [DATE] and has an Activated Power of Attorney (APOA). On 06/11/25, R4 had a change in condition that required being sent to emergency room (ER). The facility contacted R4's APOA and left a voicemail regarding change in condition. The facility was unable to provide documentation to support that the APOA was provided a Notice of Bedhold or Notice of Transfer. On 07/08/25, R4 had a change in condition that required being sent to emergency room (ER) and subsequently admitted to hospital. The facility contacted R4's APOA who gave consent to send to hospital. The facility was unable to provide documentation to support that the APOA was provided a Notice of Bedhold or Notice of Transfer. On 07/17/25, R4 had a change in condition that required being sent to emergency room (ER). The facility contacted R4's APOA who gave consent to send to hospital. The facility was unable to provide documentation to support that the APOA was provided a Notice of Bedhold or Notice of Transfer. On 09/09/2025 at 2:15 P.M, Surveyor interviewed Nursing Home Administrator (NHA) A who requested Surveyor come to office to discuss facility resident transfers. NHA A showed Surveyor a Performance Improvement Project Worksheet named DC Planning/DC Process. Date initiated 03/23/25 and target completion date of 07/31/25 for licensed nurses to utilize when there is a resident discharge/transfer. NHA A stated facility has not educated all nurses on expectations as of survey date regarding the process. NHA A shared with Surveyor a Nursing Discharge Checklist dated 07/31/25 that under the section titled Day of Discharge (unplanned DC) indicates Complete a Progress Note (Transfer to ER/Hospital Summary) in Point Click Care regarding the discharge. Include the language Bed Hold Notice was provided to _____ within the note and all completed notifications regarding the discharge. Example 2 R20 was admitted to facility on 02/21/2025, diagnosis include displaced fracture of base of neck of right femur, subsequent encounter for wedge compression fracture of T11-T12 Vertebra. R20 has a BIMS score of 13/15, meaning R20 is cognitively intact. R20 makes own health care decisions. On 09/09/25, record review showed R20 transferred to the Emergency Department (ED) on 5/12/25 and 5/23/25. Bed hold notice is in medical record without a resident signature for 05/12/25 event. On 09/10/25, further record review noted nursing progress note, dated 05/12/25, stated .writer did place a call to Dr ., reported increased discomfort (from fall in room). Order received to transfer to ED for work up. Resident agreeable. Writer did also call . [R20's daughter] again, she is aware and in agreement. On 09/10/25, record review noted nursing progress note, dated 05/23/25, stated Dr.called re: CT scan results. Resident does have a T12 fracture .he will need to be fitted for back brace .now ordered resident to be seen at ED for evaluation and possible admit to hospital. Resident and daughter .aware and in agreement. Unsure if resident will return to facility. On 09/10/25 at 9:00 AM, Surveyor interviewed R20 if bed hold notice was provided prior to transfers to ED for dates 05/12/25 and 05/23/25, and R20 stated no bed hold information was offered. Example 3 R33 was admitted to the facility on [DATE] and diagnoses included heart failure. R33's most recent MDS assessment confirmed R33 scored 12/15 during BIMS, indicating intact cognition. R33 makes her own health care decisions. On 09/09/25, Surveyor reviewed R33's record and noted R33 was transferred to the ER on [DATE], 03/19/25, and 08/26/25. Surveyor reviewed bed hold notices in R33's record and noted bed hold did not include a signature. On 09/09/25, Surveyor requested additional documentation R33 was provided with notice of bed hold for ER transfers on 03/09/25, 03/19/25, and 08/26/25. On 09/10/25, the facility provided the following progress notes: -03/09/25, Writer contacted emergency contact daughter [name] updated on transfer to ER. -03/19/25, Left message for daughter, [name] of resident status. -08/26/25, Writer spoke with daughter, and she is aware of the fall and resident being transferred to the ER. On 09/10/25 at 6:59 AM, Surveyor interviewed Registered Nurse (RN) C. RN C stated the facility does provide notice of bed hold at the time of transfer. RN C was not able to describe the process or where the notice of bed hold could be found. On 09/10/25 at 8:25 AM, Surveyor interviewed R33. R33 stated she did not receive a notice for bed hold for any ER transfers. R33 stated maybe the facility called her daughter, but her daughter had not said anything to her. On 09/10/25 at 9:00 AM, Surveyor called R33's daughter and left a voicemail for a return call. Example 4 R34 was admitted to the facility on [DATE] and diagnoses included history of stroke. R34's most recent MDS assessment confirmed R34 scored 10/15 during BIMS, indicating mild cognitive impairment. R34 makes his own health care decisions. On 09/09/25, Surveyor reviewed R34's record and noted R34 was transferred to the ER on [DATE] and 03/25/25. Surveyor reviewed bed hold notices in R34's record and noted bed holds did not include a signature. On 09/09/25, Surveyor requested additional documentation R34 was provided with notice of bed hold for transfers to the ER on [DATE] and 03/25/25. On 09/10/25, the facility provided progress notes with the following: -03/17/25, Updated brother [name] of resident transfer. -03/25/25, Writer telephoned [name] niece and informed her that resident was sent to ER for an evaluation d/t no void all day. Right knee red swollen, sensitive, and hot to touch. [name] asked to be updated when nursing hears from the ER. On 09/10/25 at 6:59 AM, Surveyor interviewed RN C. RN C stated the facility does provide notice of bed hold at the time of transfer. RN C was not able to describe the process or where the notice of bed hold could be found. On 09/10/25 at 8:23 AM, Surveyor interviewed R34. R34 stated he was not notified of a bed hold when he transferred to the ER, and stated, It doesn't sound familiar.

Based on staff interview and record review, the facility did not accurately code Minimum Data Set (MDS) 3.0 assessments for 4 residents (R) (R43, R25, R35 and R34) of 18 sampled residents. Findings: The facility's policy titled, COMPREHENSIVE ASSESSMENTS reviewed 4/18/2024, states in part: . 7. A significant error is an error in an assessment where: a. The resident's overall clinical status is not accurately represented (i.e., miscoded) on the erroneous assessment and/or results in an inappropriate plan of care; and b. The error has not been corrected via submission of a more recent assessment. 8. A significant error differs from a significant change because it reflects incorrect coding of the MDS and NOT an actual significant change in the resident's health status. Example 1 R43 was admitted on [DATE] with a Brief Interview of Mental Status (BIMS) unable to complete or assess. Diagnoses included dementia, psychotic disorder, and anxiety. R43 was marked for no Preadmission Screening and Resident Review (PASARR) level II with diagnosis. On 07/15/24 at 10:55 AM, Surveyor asked Director of Nursing (DON) B for R43's PASARR level II and was this was readily provided to Surveyor. The MDS indicator in the Long Term Care Survey Process (LTCSP) program showed no PASSAR level II. Review of the annual MDS dated [DATE] is the last MDS that addresses section 1500 PREADMISSION SCREENING AND RESIDENT REVIEW. The MDS section 1500 has No checked. On 07/15/24 at 11:13 AM, MDS Coordinator, MDSC F, who works remotely, returned phone call to Surveyor. Surveyor informed MDSC F that the MDS has under section 1500 marked No, that there is no PASARR level II completed. MDSC F acknowledged the MDS was coded inaccurately. Example 2 R35 was admitted on [DATE] with a BIMS of 15 and diagnoses of schizoaffective disorder (mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder) and anxiety. R35 had an admission 5-day MDS dated [DATE] with section 1500 marked No, for completion of PASARR level II with diagnosis. Surveyor reviewed the medical record and noted that R35 has a PASARR level II completed. Example 3 R34 was admitted on [DATE] with a BIMS of 15 and diagnoses of schizoaffective disorder, anxiety, and depression with an annual MDS date 04/10/24 under section 1500 marked No, for completion of PASARR level II. Surveyor reviewed the medical record and noted a PASARR level II was completed. Example 4 R25 was admitted on [DATE] with a BIMS of 15 (indicating normal cognitive function) on the annual MDS dated [DATE]. R25 had diagnoses of bipolar II, anxiety, and depression. On 07/15/24 at 12:55 PM, Surveyor reviewed medical chart for R25 and found the annual MDS dated [DATE] has under section 1500 marked No for completion of PASARR level II with diagnosis. Surveyor reviewed the medical record and noted the PASARR level II was completed. On 07/16/24 at 1:38 PM, Surveyor interviewed DON B asking why R25, R35, and R34 were incorrectly coded on the MDS for no PASARR level II being completed. DON B informed Surveyor this information is incorrect and will be given to MDS coordinator for correction. On 07/18/24 at 7:53 AM, Surveyor noted in the medical chart that R43, R25, R35 and R34 have a 'Sig. Change' in process for this correction. 47657 Example 5 R25 had an error in Section N0415, wherein the use of a high-risk drug class of an antipsychotic use was not identified as being taken. R25 was admitted to the facility on [DATE] with a diagnosis of adjustment disorder with depressed mood. On 07/17/24 at 8:04 AM, Surveyor reviewed R25's physician orders which indicated a physician order dated 03/29/23 for Aripiprazole (an antipsychotic) 10 mg one time daily for antidepressant augmentation with a gradual dose reduction on 04/12/24 to Aripiprazole 5mg one time daily for antidepressant augmentation. On 07/18/24 at 9:22 AM, Surveyor reviewed R25's annual MDS dated [DATE] and a quarterly MDS completed on 06/29/24 which were not coded accurately identifying R25 receives an antipsychotic. On 07/17/24 at 2:29 PM, Surveyor interviewed DON B, asking about the inaccurate MDS entries. DON B stated the expectation would be that a resident on an antipsychotic be accurately coded on the MDS.

Based on observation, record review and interview, the facility did not ensure care plans were reviewed and revised to reflect changes in care for 2 of 18 residents (R45 and R6). According to the Resident Assessment Instrument, The comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. The care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving. The facility policy entitled Comprehensive Person-Centered Care Planning and last reviewed on 05/15/24 with a Policy Statement: A comprehensive person-centered care plan that includes measurable objectives and goal dates to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident Section 12 of policy stated, The interdisciplinary team reviews and updates the care plan: a. When there has been a significant change in the resident's condition b. When the desired outcome is not met. c. When the resident has been readmitted to the facility from a hospital stay; and d. At least quarterly, in conjunction with the required quarterly MDS assessment. Example 1 R45 was admitted to the facility on [DATE] with a diagnosis of retention of urine and has an indwelling urinary catheter since admission. R45's care plan revised on 06/05/24 states for toilet use resident does have an indwelling foley catheter (chronic), dependent upon staff for catheter management. On 07/15/24 at 9:42 AM, Surveyor interviewed R45 regarding management of catheter. R45 stated independence with emptying urinary bag and reports to staff the amount of urine emptied from bag each time. R44 confirmed preference managing the catheter independently. On 07/17/24 at 11:26 AM, Surveyor interviewed Certified Nursing Assistant (CNA) D regarding management of catheter. CNA D confirmed R45 usually manages catheter on own as is a very private person and doesn't like assistance. On 07/18/24 at 9:00 AM, Surveyor interview Director of Nursing (DON) B, who stated R45 was admitted with catheter and has always managed it independently and confirmed the care plan does not reflect current approaches accurately. Example 2 R45's care plan for fall risk was revised on 06/05/24 with an intervention of assuring call light is within reach. On 07/15/24 at 9:43 AM, Surveyor interviewed R45 stating recently having a fall, but was not aware of any interventions put into place to prevent further falls. On 07/17/24 at 12:06 PM, Surveyor reviewed R45's medical record and noted the care plan was not revised to reflect interventions: On 05/08/24 at 11:15 PM, R45 had a fall investigation that determined the root cause was due to R45 wearing socks. An intervention was documented to have R45 wear gripper socks. On 7/9/24 at 2:57 AM, R45 had a fall investigation that determined the root cause was due to R45 attempting to go to bathroom as felt catheter leg bag was full. An intervention was documented to have staff do frequent checks of catheter bag. On 07/18/24 at 9:00 AM, Surveyor interview DON B, who confirmed the care plan does not reflect current interventions accurately. Example 3 R6 was admitted to facility on 10/09/23 with diagnosis of unspecified dementia and reduced mobility. R6's care plan problem for moderate risk for falls revised on 05/30/24, states current interventions of ensuring clear pathways in room and hall, ensure call light within reach and ensure personal items are within reach. On 07/15/24 at 10:14 AM, Surveyor observed a sign hanging on walker stating, Take me with you, an alarm on bed and an alarm on wheelchair to alert staff of self-transfers. On 07/17/24 at 10:38 AM, Surveyor interviewed Licensed Practical Nurse (LPN) E regarding R6's current fall interventions that were observed. Surveyor asked where to locate them in the care plan. LPN E pulled up R6's record and confirmed inability to locate current interventions of alarms and reminder sign on R6's care plan. On 07/17/24 at 10:49 AM, Surveyor interviewed DON B who stated DON B was not aware that current interventions were not accurately documented in care plans.

Based on interview and record review, the facility did not develop a comprehensive person-centered care plan for 2 of 18 sampled residents (R46 and R60). The facility did not develop a care plan for R46 and R60 for respiratory care. Findings: The facility policy titled, COMPREHENSIVE PERSON-CENTERED CARE PLANNING reviewed 05/15/24, states in part: .Policy Interpretation and Implementation 1) The interdisciplinary team (IDT), in conjunction with the resident and representative and/or family, develops and implements a comprehensive, person-centered care plan for each resident . 3) The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . Example 1 R46 was admitted on [DATE] with diagnoses of pneumonitis (inflammation of lung tissue due to non-infectious causes, which results in cough without mucus or phlegm, shortness of breath and fatigue), sepsis, acute bronchitis, acute respiratory failure with hypoxia (is a below-normal level of oxygen in your blood). R46 had doctor's orders that include budesonide for acute respiratory failure with hypoxia. Albuterol nebulizer as needed for shortness of breath. Mucus relief tablet for cough. R46 had a progress note in the medical chart dated 04/14/2024 titled Infection Note. Note text: Resident is receiving antibiotic for aspiration pneumonia with no adverse effects noted. Resident also receiving budesonide nebulizer treatment in conjunction with albuterol nebulizer treatment, both scheduled. Lungs auscultate faint inspiratory wheezes prior to nebulizer, resolved post nebulizer, occasional throat clearing, cough noted. Does not appear short of breath, oxygen saturation was 92% on room air. On 07/17/24 at 9:36 AM, Surveyor asked Director of Nursing (DON) B for a comprehensive care plan regarding R46's respiratory care. On 07/17/24 at 9:53 AM, DON B provided discharge summary dated 04/30/24 care plan General Nutrition & Hydration. No care plan found that was specific to respiratory cares provided. Example 2 R60 was admitted on [DATE] with diagnoses of Respiratory Syncytial Virus (RSV causes infections of the lungs and respiratory tract), acute bronchiolitis due to RSV, acute respiratory failure with hypoxia, dependence on supplemental oxygen. R60 had doctor's orders that included albuterol nebulizer for shortness of breath. Guaifenesin as needed for a cough. Oxygen every shift for shortness of breath. On 07/17/24 at 8:47 AM, Surveyor was unable to find a respiratory care plan and asked DON B to provide this. On 07/17/24 at 9:37 AM, Surveyor interviewed DON B. DON B informed Surveyor that there was no comprehensive respiratory care plan on the resident, but we are starting one now.

Based on observation, record review and interview, the facility did not implement enhanced barrier precautions consistent with current infection control standards of practice for 1 of 3 residents reviewed on enhanced barrier precautions (R29). This is evidenced by: Surveyor requested and reviewed the facility policy titled Infection Prevention and Control dated as most recently reviewed on 2/20/2023. The policy in part read: Standards of Practice: Centers of Disease Control (CDC) Association for Professionals in Infection Control (APIC) Enhanced Barrier Precautions Implementation of Personal Protective Equipment in Nursing Homes to Prevent the Spread of Novel or Targeted Multi-Drug-resistant Organisms (MDRO's) updated: July 29, 2019. Enhanced Barrier Precautions expands the use of PPE beyond situations in which exposure to blood and body fluids is anticipated, refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include . Wound Care: any skin opening requiring a dressing. Surveyor reviewed R29's record and noted: R29's diagnosis included: 3/12/24: Encounter for orthopedic aftercare following surgical amputation 3/12/24 Acquired absence of right leg below knee R29's medical record directs staff on isolation as follows: Onset: 3/12/24 Enhanced Barrier Precautions PPE Requirements: Gloves and Gowns Route of Transmission: Direct Contact On 7/16/24 at 10:29 AM, Surveyor observed Registered Nurse (RN) C enter R29's room without gown or gloves. Surveyor observed a Personal Protective Equipment (PPE) cart outside R29's room. The room door had signage that read STOP: Transmission Based Precautions: Contact Precautions with Gown, Gloves and may come out of room boxes checked. The PPE cart outside R29's room had a sign that read Gloves and Gowns ONLY. The PPE cart contained gloves, gowns, garbage bags, face masks and Sani-hands wipes. RN C placed gauze, tape and scissors on a towel placed on R29's foot of the bed. RN C cut the tape with scissors, performed hand hygiene and donned gloves. RN C did not don a gown. RN removed tape and dressing from R29's lower leg/stump. RN C then dampened the incision with saline, removed gloves, performed hand hygiene when done wiping stump. No redness with 2 open areas on top of stump. RN C was not wearing a gown with direct contact with R29. Surveyor asked RN C what precautions R29 is on and what should be worn for direct contact/wound treatment. RN C indicated R29 is on Enhanced Barrier precautions/contact precautions. RN C then said, Oh shucks I was yapping too much and didn't put on a gown. RN C then stepped out of room to PPE cart and donned a gown. RN C expressed it is required for her to don a gown and gloves before any direct contact with R29 as part of enhanced barrier precautions/contact precautions and she should have donned a gown prior to any contact with R29. RN C was observed completing the remainder of R29's wound care with expected enhanced barrier precautions. On 07/16/24 at 2:50 PM, Surveyor interviewed Director of Nursing (DON) B about R29's incisional wounds and expected precautions for any staff contact with R29. DON B expressed R29 has areas on the incision line which are chronic and non-healing. The areas have no infection. The areas were last cultured on 5/14/24 with no growth noted. R29 is on enhanced barrier precautions with the expectation to wear gown and gloves with any close contact with her including wound care to keep area free of infection. RN C should have donned gown and gloves prior to any direct contact with resident per the facility policy and standards of practice.

Based on interview and record review, the facility did not ensure that 1 of 3 residents reviewed for falls had adequate supervision and assistance to prevent accidents. A thorough fall investigation was not completed to determine staff used a mechanical lift with 1 assist for (R1), This is evidenced by: Surveyor reviewed facility's undated policy titled Falls - Clinical Protocol, which read in part: 2. LPN's [Licensed Practical Nurse] should alert the supervisor (RN). The nurse will complete an assessment .5. Incident Scene Investigation (ISI) tool completed by staff who found resident, or who was present at the time - as completely as possible and as soon as possible but definitely before that person shift ends .7. If an LPN is the charge nurse, supervisor (RN) should review and follow up LPN documentation with their assessment of any problems or injuries . Review of facility's undated policy titled Safe Resident handling, read in part: Ready Stand (Mechanical Lift) - 2 caregivers . Surveyor reviewed R1's medical record. R1's diagnoses include hypertension, orthostatic hypotension, and Alzheimer's disease. Review of Minimum Data Set (MDS) 11/24/23 quarterly assessment documented R1 having Brief Interview of Mental Status score of 8. A score of 8 is identified as having moderate cognitive impairment. R1 requires substantial/maximum assistance of staff for transfers. Review of R1's comprehensive care plans document on 11/29/23 R1 transfers with assist of one. R1's current resident care card documents transfers with a 4 wheeled walker and gait belt with assist of 2. Additional instructions: May use e-z stand PRN [as needed]. Alert nurse to changes in ability. Surveyor reviewed R1's interdisciplinary notes documented on 12/20/23 at 6:52 p.m. by LPN C. R1 was transferred to emergency department for chest pain/angina pectoris and vitals of pulse 72, respiratory rate 22 and blood pressure 222/114. The interdisciplinary notes did not document a description of events that occurred prior to the transfer to the hospital. On 12/21/23, the notes document R1 returned from the emergency department at 7:30 a.m. with diagnoses of vasovagal syncope, and chest pain. The emergency nurse reports all vitals, labs, and EKG at hospital are within normal limits. On 01/08/24 at 12:02 p.m., Surveyor interviewed Registered Nurse (RN) D, asking if any incidents occurred with a resident fall from an e-z stand lift and how many staff are to assist. RN D indicated no current incidents of a resident falling from a mechanical lift and two staff are to assist with any type of mechanical lift. Surveyor asked about R1's return to facility on 12/20/23 and if this was related to a fall. RN D indicated it sounds like a fall and could not fully recall. RN D could not locate documentation of an investigation for R1's incident. At 12:12 p.m., Surveyor interviewed Certified Nursing Assistant (CNA) E. CNA E indicated a fall occurred a while ago and did not recall when and indicated two staff are to assist with all lift transfers. On 01/08/24 at 2:50 p.m., Surveyor interviewed LPN C and Director of Nursing (DON) B, asking about the events that occurred prior to R1 being transferred to the emergency room . LPN C indicated being called over the radio to R1's room. CNA F said R1 was unresponsive in the lift and while in the e-z stand CNA F lowered R1 to the floor. LPN C indicated only CNA F was in the room when LPN C arrived. LPN C indicated R1 is a pivot transfer or assist of two with e-z stand transfer depending on his ability. Surveyor asked if any incident reports were written about the transfer to the floor from the e-z stand lift by one CNA. LPN C indicated only the documentation about being transferred to the emergency room . DON B indicated no other reports were written and the incident should have been written in the interdisciplinary notes. Surveyor asked DON B if lowering to the floor is considered a fall. DON B indicated lowering a resident to the floor is considered a fall and an investigation should have taken place. DON B indicated having no knowledge until today that CNA F was the only one using the lift and R1 being transferred to the floor from the lift as no investigation had been completed. On 01/08/24 at 3:25 p.m., Surveyor interviewed Nursing Home Administrator (NHA) A, asking about staff reporting of a fall. NHA A indicated it is expected a change in plane is considered a fall and should be reported, investigated, and reviewed by the interdisciplinary team. The RN that was called to R1's room should have recognized this as a fall and completed further documentation. Surveyor asked if the RN completed any assessment documentation about the incident. NHA A and DON B indicated there was no documentation from RN G. NHA A indicated it is expected the RN complete documentation of an assessment if an LPN collected the data. On 01/08/24 at 3:46 p.m., Surveyor interviewed RN G, asking about the events that occurred with R1 on 12/20/23. RN G indicated being called to R1's room by LPN C. R1 was on the floor and complained of chest pain and told LPN C to send R1 to the emergency room . In the room was the mechanical lift and wheelchair. RN G indicated knowing he was lowered from the floor from the lift and should be considered a fall. RN G indicated not knowing CNA F was the only aide transferring R1 in the lift. RN G stated RN G should have started a fall investigation and should have signed off on LPN C's charting. On 01/09/24 at 10:51 a.m., Surveyor had a phone interview with Social Worker (SW) H about CNA F not following the care plan. SW H indicated after finding out yesterday of neglect when the CNA F did not follow the care plan for two staff assist with the transfer the facility will be filing a misconduct report to the State Agency.

Based on observation, interview and record review, the facility did not establish and implement an ongoing infection prevention and control program to prevent and control the onset and spread of infection to the extent possible as evidenced by the cumulative failures of the following 5 observations. Staff did not practice appropriate donning of Personal Protective Equipment (PPE) and hand hygiene with the care and services of a resident in Transmission-Based Precautions (TBP) for Clostridium difficile (R55), a very contagious bacterium. Staff did not practice appropriate hand hygiene with a dressing change for R179. Staff did not practice appropriate hand hygiene after incontinence cares with R44. Staff did not ensure 2 of 4 residents (R1 and R58) were given the opportunity to wash their hands prior to meal service. This is evidenced by: According to the National Institute of Health (NIH), together with the World Health Organization (WHO), one of the main actions in preventing and controlling the spread of the spore-forming bacterium of Clostridium difficile (C. diff) is to ensure that hands are washed thoroughly with soap and water. C. diff passes through the feces of infected individuals in the form of spores, which can survive for a long time on any surface, such as toilet and sink areas, clothing, sheets, medical equipment, cart handles, and furniture, if these items are not regularly and appropriately cleaned. It is possible for anyone to spread the infection (to themselves or others) because they have not performed hand hygiene properly or kept patient surroundings clean. The NIH and WHO recommends that gloves be worn (together with gown and application of other contact precautions) and hands washed with soap and water if exposure to C. diff is suspected or proven. Even when gloves have been worn, handwashing with soap and water is essential because alcohol-based hand rubs are known to be ineffective against C. diff spores. The facility policy and procedure titled Infection Prevention and Control was reviewed by Surveyors. The facility directs staff on Contact Precautions for Clostridium difficile infections and states, Use contact precautions with residents known or suspected to be infected with epidemiologically important microorganisms that can be transmitted by direct contact with the resident (hand or skin-to skin contact that occurs when performing resident care activities that require touching the resident's skin) or by indirect contact with environmentally surfaces or resident care items in the resident's environment. In addition to Standard Precautions for Contact Precautions, personnel should wear a gown and gloves when they will come into direct contact with the resident or their environment . DQA (Division of Quality Assurance) memo number 11-025 outlines Resident Hand Hygiene. Included in the memo is the following: Resident handwashing is an integral component of all nurse aide training program curriculum. Nurse aides are trained to offer, encourage and/or assist residents to perform handwashing to include but not limited to; before eating . Nursing home feeding assistants are trained to assist residents to wash their hands before eating. Resident (R) 55 has medical diagnoses that include but are not limited to surgical aftercare of digestive system- cholecystectomy, cancer, anemia, coronary artery disease, renal failure, diabetes mellitus, chronic obstructive pulmonary disease, respiratory failure, chronic respiratory failure with hypoxia, pyothorax without fistula, atrial fibrillation and morbid obesity. Surveyor reviewed the most recent Minimum Data Set Assessment completed for R55, which was an annual assessment with an Assessment Reference Date of 5/31/23. According to this assessment, R55 required extensive assistance of staff to meet the most basic tasks of bed mobility, bathing, dressing and toileting. R55 was assessed as being totally dependent on staff for the tasks of personal hygiene, has an indwelling Foley catheter and is frequently incontinent of bowel function. R55 is predominantly on bedrest. R55 has undergone numerous hospital visits (9) since admission to the facility 6/23/22, some of which required antibiotic treatment. The last hospital stay was 6/5/23, in which R55 was found to have developed Clostridium difficile (C. diff) infection, requiring Transmission Based Precautions (TBP) and diligent staff practices to prevent transmission of this bacterium to themselves and other residents. On 7/17/23 at 10:10 AM, Surveyor observed Certified Nursing Assistant R (CNA) conduct morning cares for R55 with the resident's consent. The following was noted: CNA R entered the room donned with a gown and gloves. CNA R removed two pitchers from the over the bed table, one contained water and the other was empty of its contents, in which R55 stated was root beer. CNA R then placed a clean towel over the surface of the table and placed a filled basin of water on the top of this towel with additional bathing supplies. CNA R offered R55 bathing but R55 refused and stated, Just wash down there, referring to the perineal areas as he had an incontinent bowel episode. CNA R proceeded with appropriate cleansing of first the front perineum, also conducting catheter care at this time, rolled R55 onto the left side and began to clean up the large incontinence of feces. Once finished with cleaning up the feces, CNA R retrieved a container of special cream from the nightstand, opened this and applied the cream to the front perineal region. CNA R then replaced the cover and placed it back onto the nightstand. CNA R stated to Surveyor that R55's significant other made the cream at home and brought it in for the resident's use. CNA R did not remove the soiled gloves from cleaning up the feces and wash her hands and don new gloves prior to picking up this container of cream, causing the container to now become contaminated with C. diff bacterium. CNA R then placed a clean heavy soaker pad and brief under R55 and fastened the brief tabs. CNA R then emptied the basin of water in the toilet and began to put away the supplies, still with the same gloves on her hands in which she cleaned up the feces. CNA R then removed the gloves, but did not wash her hands, and covered R55 with the top sheet, removed the blanket on R55's request, pulled up the shades on the window. CNA R then donned a new pair of gloves, but still, did not wash her hands, and removed the garbage from the garbage canister and placed it into the soiled hamper in R55's room. Then CNA R washed her hands with soap and water. CNA R then picked up the water pitcher from the nightstand without gloves on, took it down the hall to fill with ice, returned and opened a bottle of root beer for resident and poured the soda into the pitcher. CNA R then moved the over the bed table closer to R55 and clipped the call light to R55's top sheet. Note: These items are touchable surfaces for R55 and potentially contaminated with C diff bacterium. Gloves should have been worn with touching these items. CNA R then left the room without again washing her hands. Surveyor remained in the room in order to interview R55. During the interview at 10:35 AM, Resident Services Aide/Certified Nursing Assistant P (RSA/CNA) entered the room. Without gloves, RSA/CNA P picked up the empty water pitcher from the over bed table, stated, I am going to change this out for you, removed the straw from the used pitcher, placed it into the soiled hamper, took the pitcher into the hall and placed it onto a cart with additional empty pitchers as well as fresh water pitchers to be passed to additional residents. RSA/CNA P then placed a pitcher of fresh ice water on R55's table. RSA/CNA P did not don gloves prior to touching the water pitcher and straw, and did not wash her hands afterwards. On 07/17/23 at 1:16 PM, Surveyor met with CNA R to discuss the observation and asked her what education and knowledge she had regarding caring for an individual with Clostridium difficile infection. CNA R stated that she is supposed to wear a gown and gloves with cares or emptying the catheter bag and that she needs to wash her hands with soap and water. Surveyor then explained the handling of the cream with the soiled gloves and the potentially contaminated items she handled without gloves (sheet, call light, over the bed table, beverage pitchers, etc) and explained to her that anything the resident may have touched is potentially contaminated with the bacterium. CNA R acknowledged that she should have washed her hands after cleaning up the feces and put on a new pair of gloves before handling all the other objects and then washed her hands again afterwards before leaving the room. On 7/18/23 at 11:36 AM, Surveyor approached Director of Nursing B (DON) in her office. Also present were Nursing Home Administrator A (NHA) and Social Services Director T (SSD). Surveyor asked DON B what the expectations of staff were regarding Clostridium difficile transmission prevention. DON B stated that if staff were entering the room of an infected resident, no need to don PPE if only talking to resident and not touching anything in the room. However, staff were to don gloves and gown prior to conducting any cares of if they will touch the resident or any objects in the room. They are then to wash with soap and water upon leaving room. Surveyor explained the observation made above. DON B acknowledged several breaks in infection control practices by CNA R and stated additional training will be completed. DON B also stated RSA P should have donned a pair of gloves prior to entering the room knowing that she would be handling a used water pitcher. 30570 Surveyor received policy titled Park Manor, Wound Care dated 4/30/2023. The policy in part states: Procedure: Wash and dry hand thoroughly. Put on exam gloves, loosen tape and remove dressing .pull glove over and discard in appropriate receptacle, wash and dry your hands thoroughly with soap and water or hand sanitizer .put on new pair of gloves and redress as ordered. On 7/17/23 at 9:43 AM, Surveyor observed dressing change to R179's incision to back of her neck. R179 was admitted to the facility on [DATE] with diagnosis of fracture of cervical spine with spinal fusion. Surveyor observed R179 lying in bed with a clean packaged dressing on a towel at bedside. Registered Nurse (RN) C was at bedside with gloved hands and supplies. RN C removed R179's dressing and tape from the back of her neck. The dressing was discarded by RN C. RN C obtained clean tape and clean dressing from package and applied the dressing with tape to the back of R179's neck. RN C did not remove her gloves, perform hand hygiene and don clean gloves after handling the dirty dressing and before proceeding to apply clean dressing. Surveyor spoke with RN C after the observation about infection control expectations. RN C expressed she should have removed her gloves, performed hand hygiene and donned clean gloves when going from removing the dirty dressing and before applying the clean dressing. Surveyor asked RN C why that would be important. RN C expressed it would be important to prevent infection and contamination of R179's incision. Surveyor asked RN C about supplies for hand hygiene. RN C expressed she did not have hand gel in her pocket and should get some and place it in pocket so she can perform hand hygiene between dirty and clean tasks at bedside. On 07/17/23 at 10:40 AM, Surveyor spoke with DON B about the observation. DON B expressed she would expect staff to remove gloves, perform hand hygiene and don clean gloves when going from removing dirty dressing to applying a clean dressing. Hand gel can be used if the dressing is not saturated, and hand washing should be done if the dressing is saturated. Surveyor requested the facility policy regarding infection control practices with wound care. 46694 The facility policy, entitled Hand Hygiene, dated 4/30/2023, states, .Applying and Removing Gloves 1. Perform hand hygiene before applying non-sterile gloves .4. Hold the removed glove in the gloved hand and remove the other glove by rolling it down the hand and folding it into the first glove. 5. Perform hand hygiene. Resident (R) 44 was admitted to the facility on [DATE] and has diagnoses that include cerebral palsy and autistic disorder. On 07/16/23 at 12:58 PM, Surveyor observed incontinent cares on R44 with CNA D and CNA E. Handwashing after taking off gloves was not done when caring with this resident who was incontinent of both urine and stool by both CNAs. CNA E then touched her own hair with her bare hands, rolled it between her fingers and put her hair in her mouth. CNA E then left the room followed by Surveyor to the nurse's station and was taking her hair out of the rubber band and putting it back into the rubber band before using ABHR at the nurse's station. On 07/18/23 at 8:30 AM, Surveyor interviewed CNA D regarding the proper use of hand hygiene in relation to glove use. CNA D replied when you take off your gloves you need to at least use hand sanitizer to clean your hands. On 07/18/23 at 10:56 AM, Surveyor interviewed DON B, Surveyor asked what is the proper hand hygiene when it comes to glove use. DON B replied whenever you take off the gloves you must use hand sanitizer. 47657 On 07/17/23, Surveyor observed R1 receive breakfast tray with no hand sanitization provided prior to eating. R1 can feed self and noted to use fingers to eat pieces of cut up French toast. On 07/17/23, Surveyor observed R58 was handed glass of juice. No hand sanitization provided prior to eating. R58 can feed self with cueing.

Based on observation, interview and record review, the facility did not ensure that prior to the installation or use of bed rails, the facility attempted to use alternatives, ensure the resident is assessed for the use of bed rails, which includes a review of risks including entrapment; and informed consent is obtained from the resident or if applicable, the resident representative for 1 of 1 resident (R) R15. The facility did not ensure the grab bars are appropriate for R15, assess risk of entrapment versus benefit, and did not obtain consent from representative. This is evidenced by: R15 was admitted to facility on 10/32/22 and has diagnosis that include diagnosis of dementia with behavior disturbances and Parkinson's disease. R15's most recent quarterly Minimum Data Set (MDS), dated [DATE], indicated problem with both short term and long-term memory, and severely impaired cognitive skills for daily decision-making regarding tasks of daily life. This would put R15 at risk for entrapment with the use of bedrails. R15's quarterly MDS, dated [DATE], indicated requires extensive assistance with two-person for transfers and bed mobility. R15 is on psychotropic medications that can affect his ability to safely use the bedrails. R15's care plan, dated 03/01/23, with a target date of 3 months, states potential for trauma-falls. Interventions include right side grab bar, mat on floor beside bed, and pull-apart alarm when in bed. Utilize devices/restraint as ordered. On 07/16/23, Surveyor observed bilateral grab bars on R15's bed on the 3 days of survey. On 07/16/23 and 07/17/23, Surveyor observed a motion sensor alarm between bed and door attached to a pole. Surveyor reviewed documentation entitled, Purpose of note: assessment for use, dated 05/09/23, which states that bed rails are not used, and other supportive devices which includes grab bar on right side. The assessment does not include risk of entrapment and indicated that no other alternatives were trialed. The assessment indicated the benefit/purpose is to enable better sitting, balance, positioning, comfort/security, and enable bed mobility The facility did not assess for the risk of entrapment, attempt alternative interventions before implementing bilateral grab bars, obtain informed consent, nor obtain physician order for bed rails. On 07/27/23, LPN L stated that the motion alarm was there because R15 often puts legs over the side of the bed, and it alerts staff to prevent falls and that is why the mat is next to bed as well. On 07/18/23 at 7:56 am, Surveyor interviewed Certified Nursing Assistant (CNA) Manager F, who stated that on a good day, R15 may use the grab bars, but hasn't seen him use them for a while. On 07/18/23 at 1:56 pm, Surveyor interviewed Director of Nursing (DON) B regarding assessment documented by nursing on 05/09/23 of bilateral grab bars on R15's bed and care plan interventions of use of asked if additional information regarding alternative interventions trials, risk versus benefit assessment, signed consent by R15's representative and manufacturer guidelines for grab bars. DON B stated she was unable to locate any further information regarding the care plan discrepancies, risk versus benefit assessment, signed consent or manufacturer guidelines. On 07/18/23 at 2:19 pm, Surveyor interviewed Nursing Home Administrator (NHA) A, along with two maintenance men. NHA A, stated that maintenance does weekly checks of bed rails and the measurement between R15's mattress and grab bar is 1. NHA A stated, there is no signed consent, risk versus benefits documentation, and was unable to provide manufacture guidelines of bed rails and stated R15 has had no recent falls from bed.

Based on observation, interview and record review the facility did not ensure that residents who are unable to carry out activities of daily living (ADLs) received necessary services to maintain good nutrition for 2 of 3 sampled residents (R37 and R65). R37 prefers to eat in his room and requires staff assistance. Staff did not provide a breakfast tray or assistance for R37. R65 was not assisted with meal while repeatedly making attempts to reach food bowls that were placed out of her reach. This is evidenced by: Example 1 R37 was admitted to facility on 1/29/20. Diagnoses include right side paralysis after stroke, major depressive disorder, type 2 diabetes with insulin use, and dehydration. R37's care plan, dated 6/15/23, indicated R37 has a self-care deficit requiring assist of 1:1 with eating, staff to encourage intake. R37 chooses to have meals in his room, staff to provide relaxed mealtime environment, offer alternatives, and record intake. Record revealed few weights have been taken over the last year due to R37's refusals. R37 has had a -9.62% weight loss; 1/3/23 weight #151.8, 7/11/23 weight #137.2. On 02/01/23, staff performed Heimlich maneuver on R37 due to a choking incident. Speech Therapy (ST) referral was made. ST recommendation for soft diet with regular liquids and supervision during meals due to R37's refusals to get out of bed to eat. 07/17/23, continuous observation, 3 hours and 51 minutes: -7:00 AM, Surveyor observed R37 lying in his bed sleeping. -8:00 AM, Surveyor observed R37 lying in his bed sleeping. Meal cart arrived to dining room. Surveyor observed staff serving and providing meal assistance in the dining room. -9:33 AM, Surveyor observed R37 lying in his bed sleeping, R37 has not been offered or received a meal tray. Surveyor observed meal carts returned to kitchen. Surveyor interviewed Certified Nursing Assistant (CNA) F. CNA F reported that she has not had a chance to assist R37 yet and she does not think that anyone else has assisted him either. CNA F stated that residents can have a grab and go breakfast, consisting of oatmeal, boiled eggs, or yogurt. -9:47 AM, Surveyor observed R37 lying in his bed sleeping, Surveyor asked R37 if he had breakfast this morning and he replied that he would have something. -10:51 AM, Surveyor observed R37 lying in his bed sleeping. Surveyor observed CNA meal intake sheets on nurses' desk by Licensed Practical Nurse (LPN) G. Surveyor asked LPN G if she could confirm R37's breakfast intake. Surveyor observed LPN G reviewed intake sheets and R37's intake was not documented. LPN G stated she would have to ask staff. Surveyor observed LPN G ask the following staff if they had assisted R37 with breakfast. Paid Feeding Assistants H, J and K, and CNAs F and I. All staff replied that they had not assisted R37 with breakfast meal. Surveyor reviewed R37's meal intake sheet for the previous week, completed by CNAs. There was no documentation of meal intake for supper on 7/9, supper on 7/10, supper on 7/11, and breakfast on 7/15. Surveyor reviewed electronic version of meal intake documentation for the previous week, which was not consistent with CNA documentation. Documentation indicated 70% supper on 7/9, 50% supper on 7/10, 70% supper on 7/11 and 10% breakfast on 7/15. On 07/17/23 at 1:16 PM, Surveyor interviewed LPN L. LPN L reported that R37 did not have breakfast this morning. On 07/18/23 at 7:22 AM, Surveyor interviewed Registered Nurse (RN) M. RN M reported that the nurse on duty is responsible for supervision of paid feeding assistants. On 07/18/23 at 8:33 AM, Surveyor interviewed CNA D. CNA D reported that the CNA assigned to R37's hall is responsible to ensure that R37 is offered and assisted with meals, unless a paid feeding assistant is scheduled, then the paid feeding assistant is responsible. On 07/18/23 at 1:55 PM, Surveyor interviewed Director of Nursing (DON) B. DON B reported that she was not aware R37 had not been served breakfast on 7/17/23, stated that documentation for meal intake for breakfast on 7/17/23 was 70%. DON B stated that all residents should receive a meal tray or grab and go breakfast. Facility protocol is if a resident tray is returned to the kitchen untouched, the kitchen is to call the unit where that resident resides and update the nurse. DON B stated that it is the nurses' responsibility to ensure residents are offered all meals. 17661 Example 2 Resident (R) 65 has medical diagnoses that include, but are not limited to Alzheimer's disease, dementia, and delusional disorders. According to the most recent Minimum Data Set Assessment (MDSA), which was a quarterly assessment with an Assessment Reference Date (ARD) of 4/18/23, R65 requires staff to set up the meal tray and supervise resident during the meal. According to the Certified Nursing Assistant (CNA) care card, which was provided to Surveyor 7/17/23 and is not dated, R65 Prefers to eat meals in the dining room. I eat my food very fast and get overwhelmed with multiple choices, please offer me 1 food item and 1 drink item at a time. I also do better sitting by myself or I might grab my table mates food . According to the Comprehensive Care Plan developed for R65, the following problems were noted: 1. Impaired Cognition/Memory Loss: I am unable to make my needs known. I am forgetful, am unable to make my own Health Care Decisions. I need you to continue to offer me daily choices and decisions for care times, meals and activities . Because I have Alzheimer's dementia, have a history of Parkinson's vascular dementia do not hear well. (Last revised 6/14/23) 2. Self Care Deficit: . Needs supervision/cues for Eating (3/1/23) . Goal . Feed self after set up and food handed to resident . 3. Potential for alteration in nutrition (11/29/22 and last revised 4/20/23): Because I eat my food rapidly, hand me 1 food item at a time, served in a bowl . Surveyor reviewed the Interdisciplinary Team Notes and noted the following entry: - 07/11/2023 05:01 PM: . EATING: requires setup help only from staff for eating; to provide encouragement and supervision; to prepare his/her plate & food; eats in dining area . - Surveyor then reviewed assessments completed for R65 and noted that on 7/11/23, the facility completed an assessment regarding Activities of Daily Living and included in this assessment was R65's eating abilities. According to this assessment, R65 . requires setup help only from staff for eating; to provide encouragement and supervision; to prepare his/her plate & food; eats in dining area . On 7/16/23, Surveyor observed R65's meal service for the noon meal. The following was noted: - At 11:38 AM, clothing protectors were passed out and placed on tables; R65 was seated at a table for six individuals and picked it up and covered her upper body with same as if it were a blanket - At 11:43 AM, meal cart arrived and taken down the 600 Hallway. - At 11:49 AM, CNA L went around the room with wet wipes to clean residents' hands. - At 11:51 AM, a meal cart arrived on unit. - At 12:03 PM, all residents served at the table except for R65 at this time (5 peers); R65 looked around the room. Registered Nurse M (RN) instructed staff to move R65 to a different table. R65 was placed at a separate table from others by herself. - At 12:09 PM, the second meal cart arrived on the unit. - At 12:17 PM, R65 was served her meal by CNA N. Each item was placed into separate bowls covered with a matching plate. CNA N gave R65 one bowl containing pureed meat and pushed the tray out of R65's reach. - At 12:19 PM, R65 ate this first bowl of food on her own without any issues. - From 12:19 PM - 1:26 PM, R65 repeatedly reached in front of her for an additional bowl of food to eat, but was unable to reach it. R65 repeatedly moved her wheelchair to the corner of the table in order to enhance her reach for the food. R65 was not able to move around the table, as there was a portable floor-standing air conditioning unit on the left side of the table blocking her passage. At one point, R65 took the nearly finished glass of apple juice and tried to manipulate the tray with the bottom of the glass but the tray was too far away and the glass fell on to the edge of the tray, spilling the juice onto the table. Repeated attempts to reach the tray of food caused R65 to run her right arm and hand through the spilled apple juice. There were two additional staff members assisting other residents at one table. However, neither of them looked towards R65 or acknowledged that she needed more food from her tray to assist her. At 1:27 PM, CNA R approached R65 with a clip board to document meal intake. Surveyor asked CNA R what type of assistance R65 required with meal service. CNA R stated that R65 needs to be supervised and placed at a table by herself because she is handsy and will grab other residents' food. Surveyor then asked what it means to supervise a resident. CNA R stated, We need to sit and watch her and give her food one by one. Surveyor then explained to CNA R that R65 was not supervised or assisted with the meal and that she repeatedly attempted to obtain food items from her tray but was unable, and no staff observed the need or monitored her in order to provide her with additional food items. CNA R then removed the plates from the other two bowls on R65's tray, which contained pureed peas in one and pureed bread in the other. CNA R handed R65 the peas, but did not re-heat them prior to giving them to her. Within one minute, R65 had finished the peas and CNA R handed R65 the bread, which she ate just as fast. This was a continuous observation of 1 hour 17 minutes in which R65 was not offered or assisted with her meal. On 7/18/23 at 11:36 AM, Surveyor interviewed Director of Nursing B (DON) in her office. Also present were Nursing Home Administrator A (NHA) and Social Services Director T (SSD). Surveyor asked DON B what the expectation of staff was for meal service for R65. DON B stated that R65 is to sit by herself at a table as she is easily distracted and should also be given one or two things at a time, as she will shovel the food into her mouth or she will mix it all up into one bowl. DON B further stated that staff are to supervise R65 and encourage her. The observation above was explained to DON B and the additional two staff in the room. DON B stated, Someone should have been watching her more closely.

Based on observations, interviews and record reviews, the facility did not ensure 3 of 7 residents (R65, R15 and R58) reviewed for risk of pressure injury development, received the necessary treatment and services to promote healing of existing skin impairments or prevent new pressure injuries from developing. R65 was observed on three occasions in which there was no repositioning offered for extended periods of time. R15 was observed on two occasions in which repositioning and toileting was not completed. R58 was observed on two occasions in which staff did not reposition or toilet. This is evidenced by: According to the National Pressure Injury Advisory Panel (NPIAP) 2019, page 115, . Repositioning and mobilizing individuals is an important component in the prevention of pressure injuries. The underlying cause and formation of pressure injuries is multifaceted; however, by definition, pressure injuries cannot form without loading, or pressure, on tissue. Extended periods of lying or sitting on a particular part of the body and failure to redistribute the pressure on the body surface can result in sustained deformation of soft tissues and, ultimately, in tissue damage . According to Wound Care Education Institute (2018), for immobile or bed bound individuals, a full change in position should be conducted a minimum of every two hours. Some individuals require more frequent repositioning due to their high risk status. Surveyor reviewed the facility policy for repositioning, last revised 4/20/23. This policy states, in part, . Repositioning is a common, effective intervention for prevention skin breakdown, promoting circulation and providing pressure relief .Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning . A turning/repositioning program includes a continuous consistent program for changing the resident's position and realigning the body . Residents who are in a chair should be on an every 2-3 hour repositioning schedule . Example 1 R65 has medical diagnoses that include, but are not limited to Alzheimer's disease, dementia, delusional disorders, repeated falls, and nontraumatic intracerebral hemorrhage. The most recent Minimum Data Set Assessment (MDSA) completed for R65 was a quarterly assessment with an Assessment Reference Date of 4/18/23. According to this MDSA, R65 has both short-term and long-term memory impairment and severely impaired daily decision-making abilities. R65 requires extensive assistance of staff to meet most basic needs of bathing, dressing, toileting and personal hygiene. R65 is non-ambulatory and requires the use of a mechanical lift for transfers. R65 was also assessed as being incontinent of both bowel and bladder function. Surveyor then reviewed the Comprehensive Care Plan (CCP) developed for R65 and noted the following: Under Self Care Deficit dated 3/1/23 and last revised 7/11/23, under Repositioning the CCP directs staff to follow repositioning needs per care card. Surveyor then reviewed the care card, and noted there was no category to inform the reader of what R65's needs were in regards to repositioning. The only indication given regarding R65's needs was listed under Restoratives and stated, in part, . Will be continent of bladder with staff assisting to toilet Prompted Voiding . Assist with toileting q (every) ___ hours (time frame left blank) . Offer toileting prior to activities such as therapy, treatments, etc. Staff will assist resident with toileting upon waking, prior to meals, before activities and prior to sleep . There was no directive on what R65's repositioning needs were. Surveyor then reviewed the Braden Scale for Predicting Pressure Sore Risk. The most recent Braden assessment was dated 3/1/23 and scored R65 18 (scores 15 -18 indicates mild risk for skin breakdown). According to this assessment, the following was noted: MOBILITY: slightly limited - makes frequent though slight changes in body/extremity position independently FRICTION/SHEAR: potential problem - moves with minimum assistance, some sliding with repositioning, occasionally slides down in bed/chair ACTIVITY: walks occasionally - walks occasionally during day, very short distances with or without assistance, in bed/chair most of time Note: Resident no longer ambulates and is transferred with a mechanical lift. MOISTURE: occasionally moist - skin is occasionally moist, requiring an extra linen change approximately once a day Note: Resident is incontinent of bowel and bladder NUTRITION: excellent - eats most of every meal, never refuses meal, eats 4 proteins per day, occasionally eats between meals, no supplement SENSORY PERCEPTION: slightly limited - responds to verbal commands, can't always communicate pain or need to reposition ADDITIONAL RISK FACTORS: incontinence, cognitive deficit, difficulty expressing needs INTERVENTIONS: Staff anticipates needs, provides prompt peri care with incontinence, ongoing skin monitoring, encourages repositioning and good nutrition/hydration Surveyor then reviewed Interdisciplinary Team Progress Notes for R65's current functional status level. On 07/08/2023, an entry was made regarding mobility and stated, MOBILITY: slightly limited - makes frequent though slight changes in body/extremity position independently FRICTION/SHEAR: potential problem - moves with minimum assistance, some sliding with repositioning, occasionally slides down in bed/chair ACTIVITY: chair-fast - ability to walk is severely limited or none, can't bear weight and/or is assisted to chair or wheelchair . On 07/11/2023, an entry regarding Activities of Daily Living was entered and stated, BED MOBILITY: requires one aide assist for bed mobility, to position extremities and trunk with involved weight-bearing & little self-performance, TRANSFERS: requires two aides assist to transfer to provide weight-bearing support during transfers; WALKING: N/A (not applicable) - resident does not walk . TOILETING: requires two aide assist for toilet use; to provide transfer and personal hygiene frequently; GROOMING/HYGIENE: requires one aide assist for personal hygiene; to provide all hygiene tasks for the resident BATHING: requires one aide assist for bathing; to wash his/her entire body, EQUIPMENT: wheelchair, type: manual. Surveyor conducted three continuous observations of R65 in which repositioning and toileting assistance was not offered or attempted. They were as follows: OBSERVATION 1: 7/16/23 At 9:28 AM upon Surveyor's arrival to the facility, R65 was seated in a wheelchair in dining area. R65 was placed at a table for 6 with a personal alarm attached to the back of the wheelchair and clipped to the back of the shirt. R65 was watching the television and would periodically put her head down chin to chest and close her eyes. At 10:35 AM, R65 remained at the table with no staff approaching to offer or encourage repositioning or toileting. She was given an 8 ounce glass of orange juice and drank 100%. R65 continued to vacillate between watching the television and putting her head down chin to chest and close her eyes. At 10:51 AM, CNA E approached R65 and asked if she wanted some more juice. CNA E returned to R65 about 1 minute later with 8 ounces apple juice. At 10:59 AM, R65 stuck the right pointer finger into the juice and stirred the juice with the finger. R65 then began to drink the juice. There were no offers or attempts made at that time to reposition R65. At 11:09 AM, Staff Q (Housekeeper) approached the dining area. There were three additional residents seated at the table with R65 at that time. Staff Q passed out colored pieces of paper to each of the residents and taped these to the table. She then passed out round plexi-glass discs to each and had each of the residents trace the disc onto the paper. They then glued colored letters in the middle of the circle they drew. Staff Q did the task for R65, holding R65's finger on the letter to hold it in place for the glue to set. Once the activity was completed, R65 sat at the table with no staff approach to offer and encourage repositioning or toileting. At 11:38 AM, clothing protectors were passed out on the tables in preparation for the noon meal. Meals were then passed out to all the residents in the dining room. At 12:03 PM, R65 was moved to a different table. At 12:17 PM, R65 was served her meal. Resident sat unassisted during this meal from 12:17 - 1:26 PM at which time CNA R approached. Surveyor asked CNA R what R65's needs were regarding toileting and repositioning. CNA R stated that R65 is assisted with morning cares by the night shift between 5:00 AM - 6:00 AM, in which they also get her up into the wheelchair. CNA R stated that sometimes R65 will tell the staff that she needs to use the toilet, but not often. CNA R stated R65 is always incontinent of bowel and bladder function but will also go on the toilet and have results. She also stated that R65 is taken to the bathroom after meals, but was not assisted on this day. In fact, CNA R stated that R65 was not attended to since she was assisted up by the night shift. At 1:43 PM, CNA R took R65 to her room then left to retrieve a mechanical lift and returned at 1:46 PM with Registered Nurse S (RN) to assist. At 1:47 PM, R65 was assisted to stand with the mechanical lift and placed onto the toilet. Her incontinent brief was saturated with urine. Note: This observation was a time frame of 4 hours 19 minutes in which R65 was not offered or attempts made by staff to reposition or toilet. OBSERVATION 2: 7/17/23 R65 was observed at 7:26 AM fully dressed seated in her wheelchair in the dining area. From 7:26 AM - 8:25 AM, no staff approached to offer or attempt repositioning. At 8:25 AM, Activities Aide O (AA) placed R65 at a table for her meal and handed her a bowl of pureed French toast. From 8:25 AM - 8:35 AM, R65 ate and completed her meal. At 9:03 AM, Licensed Practical Nurse G (LPN) approached R65 with medications. At 9:22 AM, R65 began to wander around the room in her wheelchair, moving between other residents and the dining room tables. R65 continued to do this until 9:35 AM, at which time she positioned herself at a table. At 10:37 AM, staff moved R65 to her room. Surveyor entered the room and noted CNA I and CNA R were assisting R65 with the mechanical lift and placement on the toilet. Again, Surveyor was informed that R65 was assisted by the night shift between 5:00 AM - 6:00 AM and that they had not done any cares for R65 yet this day. This is an observation of 3 hours 11 minutes in which R65 was not offered or attempts made for repositioning or toileting. OBSERVATION 3: 7/18/23 At 7:17 AM, Surveyor noted R65 was seated pin her wheelchair at the table in the dining area of the second floor unit. R65 was fully dressed, head down chin to chest with hands folded as if in prayer, on the table. R65's eyes were closed. There was an empty coffee cup in front of her. At 7:32 AM, R65 woke up and took the cup in her hand by handle, looked around the room and sipped the empty contents. R65 placed the cup back on the table and puts her head down again. R65 closed her eyes. At 8:09 AM, R65 was moved to an over bed table in the corner of an internal wall in the dining area in preparation for the morning meal. R65 was served one bowl of her meal at 8:14 AM, which consisted of pureed scrambled eggs in one bowl and 4 ounces of orange juice. R65 finished eating all of her tray contents at 8:42 AM, at which time Registered Nurse M (RN) approached her with an additional cup of coffee. R65completed this coffee at 8:47 AM. From 8:47 AM- 9:36 AM, R65 moved repeatedly around the room in her wheelchair, going between table, approached additional residents and approached and left other tables, until finally she rested at one of them and appeared to have fallen asleep. At 9:55 AM, an activity started of painting in which R65 participated. This activity ended at 11:19 AM and residents were positioned at tables for the noon meal. R65 began to maneuver herself around the room, once again propelling herself between tables and additional residents, until 11:35 AM, when Surveyor ceased the observation, approached RN M and asked what the expectations for repositioning and toileting R65 were. RN M stated R65 should be repositioned and toileted at least every two hours. Surveyor explained the observation made. RN M stated, Yeah, she should have been taken to the bathroom. At 11:34 AM, Surveyor approached CNA R, who was responsible for R65 on this day, and again, explained the observation made and asked CNA R what happened to prevent R65 from being assisted. CNA R stated, Yeah, I know. I just didn't get to her yet because of the call lights going off and doing cares. I will take her before she eats lunch. This observation began at 7:17 AM and ended at 11:35 AM (4 hours 18 minutes) when Surveyor went to talk to Director of Nursing B (DON) regarding the observations made over the course of the survey. At 11:36 AM, Surveyor approached DON B in her office. Also present was Nursing Home Administrator A (NHA) and Social Services Director T (SSD). Surveyor asked DON B what the expectations were for repositioning and toileting regarding residents at risk for development of pressure injury or skin impairments DON B stated the expectations depend on the resident and their comorbidities, and indicated residents are individually assessed and evaluated by therapy for cushion use in wheelchairs. DON B further stated that her expectation for residents at risk would be at least every two hours. The observations conducted were explained to all staff present in the room. DON B again stated her expectation for R65 was to be repositioned and toileted every two hours. 47657 Example 2 The facility policy, entitled Skin Care Policy and Procedure dated 08/22/22, states: Promoting skin integrity is a multidisciplinary action. The intent is that the resident does not develop pressure injuries unless clinically unavoidable and that the facility provides care and services to promote the prevention of pressure injury development . R15 was admitted to facility on 10/31/22 and has diagnosis that include dementia with behavior disturbances and Parkinson's disease. R15's most recent quarterly Minimum Data Set (MDS), dated [DATE], indicated problems with both short term and long-term memory, and severely impaired cognitive skills for daily decision-making regarding tasks of daily life. R15's quarterly MDS, dated [DATE], indicated extensive assistance with two-persons for transfers, toilet use, and bed mobility, and requires total dependence with one-person for locomotion. R15's quarterly MDS, dated [DATE], indicated risk of developing pressure ulcers. R15's Care Plan, dated 03/07/23, states resident requires extensive assist with Activities of Daily Living (ADL) and intervention to reposition every 1-hour when up. On 07/17/23 at 7:06 am, Surveyor observed R15 in lounge in a Broda chair. Surveyor conducted continuous visual observation. On 07/17/23 at 10:46 am, Surveyor observed R15 taken to his room for toileting and repositioning. On 07/18/23 at 7:50 am, Surveyor observed R15 brought to lounge. On 07/18/23 at 10:09 am, Surveyor observed R15 taken to room for toileting and repositioning. Note: This observation was a time frame of 3 hours 3 minutes in which R15 was not offered or attempts made by staff to reposition or toilet. Example 3 R58 was admitted to facility on 08/05/22, and has a diagnosis that include Alzheimer's disease, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and other reduced mobility. R58's significant change MDS assessment, dated 06/02/23, indicated problem with both short term and long-term memory, and severely impaired cognitive skills for daily decision-making regarding tasks of daily life. R58's significant change MDS assessment, dated 06/02/23, indicated total dependence with assist of two people for transfers, locomotion, and toilet use, placing R58 at high risk for skin breakdown. R58's significant change MDS assessment, dated 06/02/23, indicated risk of developing pressure ulcers. R58's care pan, dated 08/12/22, states: Potential for impaired skin integrity with interventions to include reposition every two hours while in bed. The care plan does not address repositioning when in wheelchair. On 07/17/23 at 7:08 am, Surveyor observed R58 taken in wheelchair to lounge for breakfast. Surveyor conducted continuous visual monitoring until 11:11 am. No observations were observed of R58 being removed from lounge or repositioned while in wheelchair. On 07/18/23 at 7:50 am, Surveyor observed R58 being wheeled out of room and to lounge for breakfast. On 07/18/23 at 9:51 am, Surveyor observed R58 offered and taken in wheelchair to activity area. No repositioning or toileting was completed. Continued visual monitoring. On 07/18/23 at 11:30 am, Surveyor observed R58 still sitting in activities, no offering of repositioning or toileting was completed. Note: This observation was a time frame of 4 hours 22 minutes in which R58 was not offered or attempts made by staff to reposition or toilet. On 07/18/23 at 9:25 am, Surveyor interviewed DON B regarding facility standards of practice for skin breakdown and prevention. DON B stated that a skin assessment and Braden scale are completed upon admission, and with each Minimum Data Set (MDS) or new skin concern development. Interventions would be put into place on care plan based on the assessment and comorbidities. They would get therapy involved for appropriate chair cushions. A repositioning schedule would be developed based on individual needs. DON B stated she would expect a minimum standard of practice of every 2-3 hours being repositioned

Based on observation, interviews and record reviews, the facility did not ensure 3 of 10 residents reviewed for bowel and bladder incontinence or indwelling Foley catheters (R65, R37 and R15) received appropriate treatment and services to prevent Urinary Tract Infections (UTI) and to restore continence to the extent possible. -R65 was observed for extended periods of time on three separate occasions in which staff did not offer or attempt toileting services. -R37 has an indwelling Foley catheter with orders to change every month. There is no documentation to support routine change of R37's catheter. -R15 was observed on two separate occasions for extended periods of time in which toileting assistance was not provided. This is evidenced by: Acello, [NAME] RN MSN. The Long-Term Care Nursing Desk Reference. Chapter 13, pages 214-215 offers the following discussion on urinary incontinence in Long Term Care: . Incontinence is a medical problem that is, in many instances, beyond the resident's control. Incontinence is not a normal consequence of aging and can frequently be cured or improved . Incontinence in long-term care facilities can often be linked to the facility's staff. Over time, staff become insensitive to incontinence . the sensation of needing to use the toilet is one of the last to be lost in cognitively impaired residents. Their problem is often one of communication. They are unable to communicate the need to use the bathroom . Effective urinary management is assessment-based and individualized to the resident . It involves toileting the resident at times in which he or she is most likely to eliminate . The facility policy titled Standards of Care, which was last revised 4/30/23, stated, in part, Care will be provided to each resident based on assessment of needs, identifying and maintaining each resident's individuality, maximizing their strengths, promoting their independence and respecting their right to privacy while maintain dignity and respect . Under the section of Toileting the policy directs staff to toilet residents every two to three hours if the resident is unable to determine their own need. Example 1 R65 has medical diagnoses that include, but are not limited to Alzheimer's disease, dementia, delusional disorders, repeated falls, and nontraumatic intracerebral hemorrhage. The most recent Minimum Data Set Assessment (MDSA) completed for R65 was a quarterly assessment with an Assessment Reference Date of 4/18/23. According to this MDSA, R65 has both short-term and long-term memory impairment and severely impaired daily decision-making abilities. R65 requires extensive assistance of staff to meet most basic needs of bathing, dressing, toileting and personal hygiene. R65 is non-ambulatory and requires the use of a mechanical lift for transfers. R65 was also assessed as being incontinent of both bowel and bladder function. Surveyor then reviewed the Comprehensive Care Plan (CCP) developed for R65 and noted the following: Under Self Care Deficit dated 3/1/23 and last revised 7/11/23, under Repositioning the CCP directs staff to follow Repositioning needs per care card. Surveyor then reviewed the care card, and noted under toileting, . Assist of two. Relies on others to anticipate needs . This then directs staff to the toileting plan. Under Restoratives in this care card stated, in part, . Will be continent of bladder with staff assisting to toilet Prompted Voiding . Assist with toileting q (every) ___ hours (time frame left blank) . Offer toileting prior to activities such as therapy, treatments, etc. Staff will assist resident with toileting upon waking, prior to meals, before activities and prior to sleep . Surveyor then reviewed the Continence Assessment completed for R65, dated 7/9/23. The assessment stated R65 is a risk for urinary incontinence related to immobility, fall history, generalized weakness and Dementia . R65 was identified as having functional urinary incontinence as she has limited mobility and requires staff assistance with meeting her toileting needs. Surveyor conducted three continuous observations of R65 in which toileting assistance was not offered or attempted. They were as follows: OBSERVATION 1: 7/16/23 At 9:28 AM upon Surveyor's arrival to the facility, R65 was seated in a wheelchair in dining area. R65 was placed at a table for 6 with a personal alarm attached to the back of her wheelchair and clipped to the back of her shirt. R65 was watching the television and would periodically put her head down chin to chest and close her eyes. At 10:35 AM, R65 remained at the table with no staff approaching to offer or encourage repositioning or toileting. R65 was given an 8 ounce glass of orange juice and drank 100%. R65 continued to vacillate between watching the television and putting her head down chin to chest and close her eyes. At 10:51 AM Certified Nursing Assistant E (CNA) approached R65 and asked her if she wanted some more juice. CNA E returned to R65 about 1 minute later with 8 ounces apple juice; At 10:59 AM, R65 stuck the right pointer finger into the juice and stirred the juice with the finger. R65 then began to drink the juice. There were no offers or attempts made at that time to toilet R65. At 11:09 AM, Staff Q (Housekeeper) approached the dining area and began a short activity with R65 and other residents. Once the activity was completed, R65 sat at the table with no staff approach to offer and encourage toileting. At 11:38 AM, clothing protectors were passed out on the tables in preparation for the noon meal. Meals were then passed out to all the residents in the dining room. At 12: 03 PM, R65 was moved to a different table. At 12:17 PM, R65 was served her meal. R65 remained in the dining room at the table until 1:26 PM, when CNA R approached to write down the meal intake. Surveyor asked CNA R what R65's needs were regarding toileting and repositioning. CNA R stated that R65 is assisted with morning cares by the night shift between 5:00 AM - 6:00 AM, in which they also get her up into the wheelchair. CNA R stated that sometimes R65 will tell the staff that she needs to use the toilet, but not often. CNA R stated R65 is always incontinent of bowel and bladder function but will also go on the toilet and have results. CNA R also stated that R65 is taken to the bathroom after meals, but was not assisted on this day. In fact, CNA R stated that R65 was not attended to since she was assisted up by the night shift. At 1:43 PM, CNA R took R65 to her room then left to retrieve a mechanical lift and returned at 1:46 PM with Registered Nurse S (RN) to assist. At 1:47 PM, R65 was assisted to stand with the mechanical lift and placed onto the toilet. R65's incontinent brief was saturated with urine. RN S removed the brief and rolled a paper towel around it and placed it on R65's bed, while CNA R retrieved a clean pair of slacks, as R65's were wet with urine. RN S then left the room and CNA N entered the room to assist. R65 was brought to a stand with the lift and CNA R proceeded to cleanse R65's front perineum and buttocks from behind the resident, cleansing only the vaginal region and buttocks. There was no cleansing of the groin and thighs of the urine. R65 was assisted to the wheelchair and CNA R took the paper towel wrapped brief down the hall to dispose of it. At 2:00 PM, Surveyor approached CNA R and asked her what she has been taught regarding perineal care after incontinence episodes. CNA R stated, we do pericare in the mornings wash with soap and water, rinse and dry and use wet wipes during the day. Surveyor explained the observation made and stated the frontal perineal cleansing was not thorough in removing the urine. CNA R stated, I tried to go from behind. I guess I didn't get the front very good. Note: This observation was a time frame of 4 hours 19 minutes in which R65 was not offered or attempts made by staff to toilet, increasing the risk for the development of a UTI. Also, if R65 was not tended to since being assisted to her wheelchair by the night shift, this would be an additional 3-4 hours in which she did not receive necessary care. OBSERVATION 2: 7/17/23 R65 was observed at 7:26 AM fully dressed seated in her wheelchair in the dining area. From 7:26 AM - 8:25 AM, no staff approached to offer or attempt repositioning. At 8:25 AM, Activities Aide O (AA) placed R65 at a table for her meal and handed her a bowl of pureed French toast. From 8:25 AM - 8:35 AM, R65 ate and completed her meal. At 9:03 AM, Licensed Practical Nurse G (LPN) approached R65 with medications. At 9:22 AM, R65 began to wander around the room in her wheelchair, moving between other residents and the dining room tables. R65 continued to do this until 9:35 AM, at which time she positioned herself at a table. At 10:37 AM, staff moved R65 to her room. Surveyor entered the room and noted CNA I and CNA R were assisting R65 with the mechanical lift and placement on the toilet. Again, Surveyor was informed that R65 was assisted by the night shift between 5:00 AM - 6:00 AM and that they had not done any cares for R65 yet this day. This is an observation of 3 hours 11 minutes in which R65 was not offered or attempts made for toileting. OBSERVATION 3: 7/18/23 At 7:17 AM, Surveyor noted R65 was seated in her wheelchair at the table in the dining area of the second floor unit. R65 was fully dressed, head down chin to chest with hands folded as if in prayer, on the table. R65's eyes were closed. There was an empty coffee cup in front of her. At 7:32 AM, R65 woke up and took the cup in her hand by handle, looks around the room and sips the empty contents. She placed the cup back on the table and puts her head down again. R65 closed her eyes. At 8:09 AM, R65 was moved to an over bed table in the corner of an internal wall in the dining area in preparation for the morning meal. R65 was served one bowl of her meal at 8:14 AM, which consisted of pureed scrambled eggs in one bowl and 4 ounces of orange juice. R65 finished eating all of her tray contents at 8:42 AM, at which time Registered Nurse M (RN) approached her with an additional cup of coffee. R65 completed this coffee at 8:47 AM. From 8:47 AM- 9:36 AM, R65 moved repeatedly around the room in her wheelchair, going between table, approached additional residents and approached and left other tables, until finally she rested at one of them and appeared to have fallen asleep. At 9:55 AM, an activity started of painting in which R65 participated. This activity ended at 11:19 AM and residents were positioned at tables for the noon meal. R65 began to maneuver herself around the room, once again propelling herself between tables and additional residents, until 11:35 AM, when Surveyor ceased the observation, approached RN M and asked what the expectations for toileting R65 were. RN M stated R65 should be repositioned and toileted at least every two hours. Surveyor explained the observation made. RN M stated, Yeah, she should have been taken to the bathroom. At 11:34 AM, Surveyor approached CNA R, who was responsible for R65 on this day, and again, explained the observation made and asked CNA R what happened to prevent R65 from being assisted. CNA R stated, Yeah, I know. I just didn't get to her yet because of the call lights going off and doing cares. I will take her before she eats lunch. This observation began at 7:17 AM and ended at 11:35 AM (4 hours 18 minutes) when Surveyor went to talk to Director of Nursing B (DON) regarding the observations made over the course of the survey. At 11:36 AM, Surveyor approached DON B in her office. Also present was Nursing Home Administrator A (NHA) and Social Services Director T (SSD). Surveyor asked DON B what the expectations were for repositioning and toileting regarding residents at risk for development of pressure injury or skin impairments DON B stated the expectations depend on the resident and their comorbidities, and indicated residents are individually assessed and evaluated by therapy for cushion use in wheelchairs. She further stated that her expectation for residents at risk would be at least every two hours. The observations conducted were explained to all staff present in the room. DON B again stated her expectation for R65 was to be repositioned and toileted every two hours. 44863 Example 2 Centers for Disease Control and Prevention (CDC), Guidelines for Prevention of Catheter-Associated Urinary Tract Infections (CAUTI) recommends changing catheters and drainage bags based on clinical indications such as infection, obstruction, or when the system is compromised. Facility policy, Urinary Tract Infections-Guidelines for Preventing, reads in part .1. Insert catheters only for indications deemed appropriate for urinary catheter insertions. 2. Leave catheters in place only as long as needed. Document the following information: a. The continued need for indwelling catheter. R37 was admitted to facility on 1/29/20. Diagnoses include retention of urine unspecified, other obstructive and reflux uropathy, urinary tract infection, right side paralysis after stroke, type 2 diabetes with insulin use, and dehydration. Minimum Data Set (MDS) confirmed that R37 was admitted with indwelling Foley catheter, no trial of toileting program, and 2-person assistance with toileting/catheter care, which is consistent since admission. Physician Orders: change indwelling Foley catheter one time per month pattern: administer on the 16th. Reason for Indwelling Foley: obstructive uropathy monthly. Change Foley bag one timer per month pattern, administer on the 16th. Care Plan, 6/15/23: Self-care deficit. Toileting: refer to resident care card. Resident care card: continent foley catheter. Urinary Retention: assure standards of care are followed, monitor intake and output, catheter care per policy. On 07/16/23, Surveyor observed that R37 had a Foley catheter. Record review confirmed that R37 has had five UTIs in the last three months. Record review indicated R37 was not followed by urology. On 07/18/23 at 11:13 AM, Surveyor interviewed DONB. DON B reported that R37 was seen by urology at one time but R37 no longer wanted to attend any outside appointments. DON B stated that urology did trial removal of catheter that was not successful but was unsure of when this occurred. DON B stated, It was a while ago. DON B stated that facility providers order catheters to be changed routinely. DON B stated she has been unsuccessful in attempts to educate providers that this is not standard practice. Surveyor was unable to find documentation that R37 no longer wanted to attend any outside appointments. Surveyor was unable to locate any documentation that R37 was seen by urologist or that trial removal of catheter was attempted and unsuccessful. Surveyor was unable to locate documentation to support order for routine catheter care. 47657 Example 3 The facility policy, entitled Continence Assessment and Management, dated 04/30/23, states: If a resident does not respond and does not try to toilet, or for those with such severe cognitive impairment that they cannot either point to an object or say their own name, staff will use a check and change strategy. A check and change strategy involved checking the resident's continence status at regular intervals and using incontinence devices or garments. The primary goals are to maintain dignity and comfort to protect the skin. R15 was admitted to facility on 10/31/22 and has diagnosis that include dementia with behavior disturbances and Parkinson's disease. R15's current physician orders dated 7/13/23, indicated R15 was placed on an antibiotic for treatment of a urinary tract infection with last dose to be given on 07/23/23 at 8:00 am. R15's most recent quarterly MDS, dated [DATE], indicated problem with both short term and long-term memory, and severely impaired cognitive skills for daily decision-making regarding tasks of daily life. R15's most recent quarterly MDS, dated [DATE], indicated frequently incontinent (7 or more episodes of urinary incontinence). R15's quarterly MDS, dated [DATE], indicated extensive assistance with two-person for toilet use, and extensive assist with 1-person for personal hygiene. R15's care plan, dated 05/16/23, states R15 is incontinent of bladder and bowel but does become more restless when he needs to use the bathroom, toilet before and after meals, at bedtime and upon rising, monitor for incontinence episodes. On 07/17/23 at 7:06 am, Surveyor observed R15 in lounge in a Broda chair. Surveyor conducted continuous visual observation. On 07/17/23 at 10:46 am, Surveyor observed R15 taken to his room for toileting. On 07/18/23 at 7:50 am, Surveyor observed R15 brought to lounge. On 07/18/23 at 10:09 am, Surveyor observed R15 taken to room for toileting. Note: This observation was a time frame of 3 hours 3 minutes in which R15 was not offered or attempts made by staff to reposition or toilet. On 07/18/23 at 9:25 am, Surveyor interviewed DON B regarding standard of practice for incontinence and toileting care. DON B stated that a bladder and bowel incontinence assessment is completed upon admission, and with each MDSor any change in continence status. DON B stated that based on the assessment a restorative program would be developed. If a resident is not appropriate for a restorative bowel and bladder program the expectation would be based on resident assessment, resident request, or at least every 2 hours.

Based on interview and record review, the facility did not ensure each resident's drug regimen was free from unnecessary drugs for 1 of 5 residents (R37) reviewed for antibiotic medications. R37 had five urinary tract infections (UTIs) in three months. R37 did not meet criteria to determine infection. R37 was prescribed antibiotic therapy prior to laboratory test results. R37 was treated with an antibiotic that laboratory tests confirmed was resistant. This is evidenced by: The facility's Antibiotic Stewardship Policy and Procedure, documents, in part: Antibiotic Stewardship Program (ASP) is established to ensure that a resident who needs an antibiotic receives the appropriate antibiotic and to reduce the risk of antibiotic resistance. Nursing staff will use established methods to communicate with physician when an infection is suspected. Our nurses will incorporate diagnostic criteria from McGeer's 2012 revised definitions to frame their resident assessment for change in condition when infection is suspected. The ASP will promote nursing procedure to ensure antibiotic time-out to reconcile empirically chosen antibiotic with laboratory test results and susceptibility testing as well as with resident clinical progress. Physician antibiotic orders will be monitored for appropriateness based on documented clinical signs and symptoms, clinical culture results, and resident progress The facility policy, Criteria for Determining the Presence of Infection, states in part, .If an indwelling catheter is present both criteria 1 and 2 must be present: 1. At least one of the following sign or symptom sub-criteria a. Fever, rigors, or new onset hypotension, with no alternate sire of infection. b. Either acute change in mental status or acute functional decline. c. New onset flank or suprapubic pain or tenderness. d. Purulent discharge from around the catheter or acute pain, swelling, tenderness of the testes, epididymis or prostate. 2. Urinary catheter specimen culture with at least 100,000 cfu/ml of any organism. According to revised McGeer Criteria for Urinary Tract Infection Surveillance, a symptomatic UTI must meet the following criteria for a resident with an indwelling catheter, at least two of the following symptoms: fever or chills, new flank/suprapubic pain or tenderness, changes in character of urine, and worsening of mental or functional status. R37 was admitted to facility on 01/29/20. Diagnoses include retention of urine unspecified, other obstructive and reflux uropathy, urinary tract infection, right side paralysis after stroke, type 2 diabetes with insulin use, and dehydration. Minimum Data Set (MDS) confirmed that R37 scored 15 during Brief Interview for Mental Status (BIMS), indicating intact cognition. R37 was admitted with indwelling Foley catheter, no trial of toileting program, and 2-person assistance with toileting/catheter care, which is consistent since admission. Physician Orders: change indwelling Foley catheter one time per month pattern: administer on the 16th. Reason for Indwelling Foley: obstructive uropathy monthly. Change Foley bag one timer per month pattern, administer on the 16th. Record review confirmed that R37 has had five UTIs in three months. Surveyor was unable to locate documentation that R37 was seen by urology. Surveyor reviewed record regarding R37's UTIs, and noted that record did not indicate a clear timeline of events, such as R37's symptoms or actual date of onset. On 07/18/23 at 11:13 AM, Surveyor interviewed Director of Nursing (DON) B. DON B reported facility uses McGeers criteria prior to obtaining U/A. DON B stated that many urinalysis (U/A) did not meet criteria. DON B stated that it is difficult with agency staff as she will train and then agency staff leave, or agency staff do not follow facility policy. DON B stated long term staff are trained and educated. DON B reported that antibiotic stewardship training has not been completed in the last 8-10 months. Surveyor requested clarification regarding R37's UTIs. DON B stated that she just created a document for R37's physician outlining the last five UTIs. DON B provided document, dated 6/27/23 confirming R37's history of U/A and urine cultures for the previous three months. Five U/As were collected; all required new catheters to be inserted and treated with antibiotics. -4/7/23, symptoms were rusty colored urine with sediment present, culture came back with mixed flora and treated with nitrofurantoin for 7 days; on 4/12/23 R37 had blood and mucous in urine and ciprofloxacin was prescribed for 7 days. -4/22/23, DON B wrote, I am not sure why this was done as there are no symptoms documented. U/A obtained, culture and sensitivity (C&S) positive for E. Coli >50,000 colony count. C&S was resistive to ampicillin, cipro, and Bactrim. Treated with doxycycline for 7 days. -5/20/23, R37 was seen in the ER and positive for UTI. UTI was discovered as part of a work-up, as there were no urinary symptoms. UTI was treated with nitrofurantoin. C&S positive for proteus mirabilis >50,000, resistive to cipro, Levaquin, tetracycline, and nitrofurantoin. Antibiotic was changed to Bactrim. -6/11/23, catheter irrigation was not successful, scant amount of blood noted, no odor, no blood, urine was golden yellow. Provider ordered lab test with U/A and C&S. DON B wrote, I am truly not sure why there was even a call placed, as when staff changed the catheter it was working. C&S positive for E. Coli resistive to ampicillin, cipro, Levaquin, and Bactrim. 2nd bacteria positive for proteus mirabilis resistive to cipro, Levaquin, tetracycline, and nitrofurantoin. Treated with nitrofurantoin for 7 days. -6/22/23, follow up U/A with C&S ordered by R37's provider on 6/11/23. C&S positive for proteus mirabilis >100,000, resistive to cipro, Levaquin, tetracycline, and nitrofurantoin. Treated with Bactrim for 7 days. On 07/18/23 at 11:43 AM, Surveyor interviewed Licensed Practical Nurse (LPN) L. LPN L stated that staff are to call provider if a resident has two or more signs and symptoms of infection, such as fever, behaviors, or disorientation. LPN L stated that when a resident tests positive for UTI, licensed nurses must observe certified nursing assistants provide catheter care over 4-6 shifts. On 07/18/23 at 11:59 AM, Surveyor interviewed Registered Nurse (RN) M. RN M confirmed facility uses McGeer's criteria, and a resident must have three signs and symptoms of infection before calling provider to obtain a U/A. Signs and symptoms can include fever, discomfort, dysuria, and behaviors. RN M reported sometimes providers will call before C&S is back and prescribe an antibiotic. RN M stated that staff try to educate providers to wait until C&S is back but are not always successful in doing that.

Based on interview and record review, the facility must ensure that a resident is free of any significant medication errors for 1 of 1 resident (R60) reviewed. The facility did not ensure R60 was administered insulin on three separate occasions as ordered from physician. This is evidenced by: The facility policy, entitled Medication Administration, dated 04/03/23, states: Medications are administered in accordance with prescriber orders, including any required time frame. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering should mark the reason in the MAR when signing out medications. R60 was readmitted to the facility on [DATE] and has diagnoses of diabetes mellitus. R60 has physician orders for insulin aspart 18 units three times a day at 7:30 am 11:30 am, and 4:30 pm for type 2 diabetes mellitus. Administration Instructions: Hold if Fasting Blood Sugar is <100. R60's care plan, dated 05/26/23, with a target date of 3 months, states: Potential for ineffective disease management and fluctuating blood glucose. Interventions include blood glucose remain within normal limits. On 07/17/23, Surveyor reviewed Medication Administration Record (MAR) which indicated the following: 06/28/23 at 4:30 pm blood glucose level was 258. Administration of insulin record was blank, 07/01/23 at 11:30 am blood glucose level check and administration of insulin record was blank 07/07/23 at 1130 am blood glucose level check and administration of insulin record was blank On 07/18/23, at 9:37 am, Surveyor interviewed Director of Nursing (DON) B regarding the missing documentation noted on R60's MAR for June 2023 and July 2023. DON B stated that she checks MAR monthly for concerns and will discuss with specific nurse and have them document accordingly and her expectations would be that there are no blanks in MAR without any documentation to support as to why it is blank. On 07/18/23 at 11:28 am, DON B stated that was unable to locate any documentation to support why the missing blanks on his MAR.

Based on interview and record review, the facility did not ensure each resident (R) is offered a pneumococcal immunization for 1 (R11) of 5 residents reviewed for immunizations. R11's medical record did not contain documentation of R11 being screened and offered pneumococcal vaccine. Findings include: The facility policy, entitled Pneumococcal Vaccination, dated 04/30/2023, states: 1. Residents are assessed upon admission for eligibility to receive the pneumococcal vaccination, and when indicated, are offered the vaccination within thirty (30) days of admission to the facility. R11 was admitted on [DATE] and has diagnoses that include cerebral infarction (cerebral infarction, or stroke, is a brain lesion in which a cluster of brain cells die when they don't get enough blood) and Chronic Obstructive Pulmonary Disease (COPD refers to a group of diseases that cause airflow blockage and breathing-related problems). Review of R11's medical record did not document an assessment upon admission for eligibility to receive pneumococcal vaccination and was not offered the vaccine. On 07/17/23 at 3:15 PM, Surveyor asked Director of Nursing (DON) B for R11's immunization documentation for pneumococcal vaccine. On 07/17/23 at 9:08 AM, Surveyor reviewed immunizations history for R11. R11's record indicates that R11 received Prevnar 23 in December of 2007 which is not current. On 07/18/23 at 9:57 AM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding missing vaccinations on R11. NHA A replied on 03/22/23 the facility realized that some of our residents' vaccinations were not up to date, so we started a Performance Improvement Plan (PIP) and put this in our Quality Committee meetings. NHA A indicated that the pneumococcal screening process was first attempted on 07/05/23 by calling R11's Power of Attorney (POA) who has not returned any of our calls about this. On 07/18/23 at 10:50 AM, the facility attempted another call to the POA and there was no answer. Surveyor reviewed the facility's PIP dated 03/22/23. The facility did not follow the PIP when R11 was admitted to the facility on [DATE] and was not screened on admission for eligibility to receive pneumococcal vaccination and was not offered the vaccine. The first attempt to contact R11's POA was 07/05/23 with no response and did not follow up until 07/18/23.

Based on observation, interview and record review, the facility did not ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident. This occurred for 1 of 3 residents, R11. RN C left R11's 8:00 am medications on his bed side table. R11 was not cognitively able to ensure administration of medications. Findings Include: On 07/18/23 10:10 a.m., Surveyor observed R11 in bed with his bedside table in front of his bed. On the table was a medication cup with 7 pills in the cup. Surveyor asked R11 about the medications and R11 responded, I don't know what the hell they are. Surveyor reported to nurses station and spoke with Registered Nurse (RN) C about the observation. RN C indicated she had left the pills on R11's bedside table at approximately 8:45 a.m. Surveyor asked if it is normal practice to leave R11's pills on his bedside table. RN C responded R11 beats to his own drum and sometimes takes his pills and sometimes waits to take his pills thus she leaves the pills on his bedside table for him when he does not want to take them. Surveyor asked RN C if R11 is a candidate for self administration of medications. RN C and Surveyor reviewed R11's medical record which notes on 6/02/23 and 7/16/23 R11 is not his own decision maker and is not a candidate for self administration of medications. Surveyor asked RN C if there is a physician order indicating medications could be left at R11's bedside. RN C and Surveyor reviewed R11's orders and there was no order for R11 to self administer his medications. Surveyor reviewed R11's care plan and it does not address R11's ability to self administer medications. Surveyor reviewed R11's admission Minimum Data Set (MDS) dated [DATE] which notes R11 is severely impaired in cognition and has impairment in his range of motion on one side of upper extremities. On 07/18/23 at 10:50 a.m., Surveyor spoke with Director of Nursing (DON) B regarding the observation and her expectation related to resident safe self administration of medications. DON B indicated R11 is not a candidate due to his cognitive impairment thus it would not be on his care plan or an order would not be obtained. Staff should not have left the medications at R11's bedside. Surveyor requested a list of medications that were left at R11's bedside. The medications included: Amlodipine 10 mg Aspirin 81 mg Metformin 1000mg Sertraline 100 mg Glipizide 10 mg Magnesium 400 mg Tramadol 50 mg Surveyor requested R11's physician's orders and compared to the medications left at bedside. The orders confirm the medications found at R11's bedside at 10:10 am were ordered for 8:00 am administration. DON B confirmed R11 did not have medications administered in a safe manner as R11 is not a candidate to do so safely.

Based on observations, interviews and record review, the facility did not ensure nurse staffing information postings were displayed daily in a clear and readable format and in a prominent place readily accessible to residents and visitors. This had the opportunity to affect all 75 of 75 residents at the facility. The facility did not post nurse staffing information daily and the postings were not posted in a way that would be accessible to all residents and visitors. The facility did not create a nurse staffing information post that was clear and readable. This is evidenced by: On 07/17/23 at 9:19 AM, Surveyor observed that the nurse staffing information posting on the bulletin board down the 300 wing is dated July 10, 2023. The nurse staffing information posting is located approximately six feet from the floor. Surveyor observed that the font of the posting is small and hard to read. Surveyor located the nurse staffing information posting on the second-floor bulletin board next to the nurse's station; it was also located approximately six feet from the floor, and the font size made it hard to read. The nurse staffing information posting on the second floor was dated July 10, 2023. On 07/18/23 at 10:37 AM, Surveyor interviewed Human Resources Coordinator (HRC) F, who is responsible for posting the nurse staffing information. HRC F stated that they post the nurse staffing information between 1:00 PM and 2:00 PM and have tried posting the information in other areas of the building. On 07/18/23 at 2:01 PM, Surveyor interviewed HRC F regarding nurse staffing information posting frequency. HRC F Stated they only update the posting when there is a change in the census or if the number of nurses available changes. Surveyor requested and received the nurse staffing information postings that were completed in the last month. Nurse staffing information postings were completed on the dates of 07/17/23, 07/10/23, 06/26/23, 06/23/23, 06/20/23, 06/19/23. On 07/18/23 at 11:20 AM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding expectations of nurse staffing information postings. NHA A stated they would expect nurse staffing information postings to be posted daily. Surveyor asked NHA A what they believed the font size on the nurse staffing information posting to be. NHA A stated a twelve-point font and that it is difficult to read. Surveyor then asked for any policies regarding nurse staffing information. At the time of exit, no policies were received.

Based on record review, policy review and interviews, the facility failed to update and implement policies to ensure all staff are fully vaccinated for Covid 19. This has the potential to affect all 59 residents. Certified Nursing Assistant (CNA) C was Covid positive and without symptoms on 12/14/21. CNA C was eligible to receive the Covid vaccine as of 12/29/21. CNA C was instructed to schedule the Covid vaccine on 3/14/22. The facility definition of temporarily delayed was 90 days post Covid recovery. CNA D was Covid positive with symptoms on 11/22/21. CNA D was eligible to receive the Covid vaccine as of 12/16/21. CNA D was instructed by the facility to schedule the Covid vaccine on 2/21/22 in accordance with the policy to temporarily delay Covid vaccines for 90 days post Covid recovery. This is evidenced by: According to the CDC (Centers for Disease Control and Prevention), Covid positive staff are eligible to receive the Covid vaccine once medically well. This information was published in the Frequently Asked Questions document last updated on 02/04/2022. Review of the facility policy titled Covid 19 Vaccine Policy and Procedure reads: Medical exemption/extension will be automatically granted for any staff member who has tested positive for Covid 19 in the last 90 days. Upon expiration of the 90 days, the staff member will either obtain the first in the series of an accepted vaccine, or request an exemption . On 02/22/2022 at 2:30 p.m., Surveyor interviewed Director of Nurses (DON) B regarding vaccination status for CNA C. DON B stated CNA C was in her 90 day post Covid recovery and was not eligible to receive the Covid vaccine until 03/14/2022. Surveyor informed DON B the CDC had recently changed the vaccine guidance and directed DON B to obtain updated information. DON B stated she was unaware of the changes and just missed this change. On 02/23/2022, DON B provided Surveyor with an updated policy that read Medical Exemption/extension will be automatically granted for any staff member who has tested positive for Covid 19. They will be required to obtain the first dose in the series of an accepted vaccine upon recovery from their illness. In the case of a positive test result without symptoms of illness, the expectation is they will be vaccinated within 14 days from positive test . Surveyor reviewed the facility's Covid positive cases for staff and residents along with vaccination status of staff and residents. In the last four weeks, R5 and R8 tested positive for Covid 19. R5 tested positive on 02/07/2022 during contact tracing from a possible exposure from a Covid positive staff. R5 was given the monoclonal antibodies via infusion on the same day. R8 also tested positive on 02/07/2022 from the same Covid positive staff exposure. Neither R5 or R8 were hospitalized or had Covid symptoms. R5 and R8 have recovered and have been removed from transmission based precautions as of 02/17/2022. CNA C was hired on 08/18/2016. CNA C was offered and declined Covid vaccines on 01/08/2021. CNA C had not received any Covid vaccinations or requested an exemption. CNA C tested positive on 12/14/2021 during contact tracing testing following exposure from a Covid positive staff. CNA C had no symptoms and was able to return to work under the contingency staffing guidance on 01/10/2022. On 02/09/2022, CNA C was given a letter from the facility that read Because you are in your 90 day recovery period, you will not need to receive a vaccine . until 03/14/2022. Surveyor reviewed CNA C's past schedule and noted CNA C worked 24 full or partial shifts since 12/29/2021, the date CNA C was eligible for the Covid vaccine. CNA D was hired 09/12/1988. CNA D was offered and declined Covid vaccines on 01/08/2021 and again on 02/09/2021. CNA D had not received any Covid vaccinations or requested an exemption. CNA D tested positive on 11/22/2021 and had symptoms of Covid 19. CNA D returned to work on 12/02/2021 under the contingency staffing guidelines. On 02/09/2022, CNA D received a letter from the facility that read Your 90 day covid recovery period ends on 02/21/2022. You will either need to receive your first dose of a covid vaccine . Surveyor reviewed CNA D's past schedule and noted CNA D worked 44 full or partial shifts since 12/16/2021, the date CNA D was eligible for the Covid vaccine. CNA D did receive the first Covid 19 vaccine on 02/21/2022. Review of the facility's vaccination data noted a total of 136 staff with 135 staff partially, fully, temporarily delayed, or exempted from vaccinations. This calculates to 99.26% staff vaccination rates. CNA C was listed as a temporary delay and CNA D was listed as partially vaccinated.

Based on observation, record review, and interview the facility did not prevent pressure ulcers from developing for 2 out of 3 residents reviewed for pressure ulcers. Resident #3 developed multiple pressure ulcers on the right heel, calf, and lateral toe from a hard splint that was worn for approximately 8 weeks. The facility never removed the hard splint to assess daily for skin integrity. There were no physician orders to care for Resident #3's medical device during that 8 week time frame. Resident #3 had been identified as high risk for pressure ulcer development and there was no daily skin assessment to include the right lower leg that was covered with a new hard plastic splint. Resident #6 was admitted to the facility without a pressure ulcer. Shortly after admission, Resident #6 began to complain of significant and on-going left heel pain. Heel pain is a significant precursor to the development of a pressure ulcer. Despite this the facility did not implement any type of pressure reduction modalities to off-load Resident #6's left heel. Resident #6 subsequently developed a fluid filled blister to the left heel. Once the pressure ulcer to Resident #6's left heel had been identified the facility implemented modalities to off-load the pressure ulcer. The facility however did not assess nor document timely the status of Resident #6's pressure ulcer. The pressure ulcer subsequently deteriorated to a DTI (Deep Tissue Injury) suspicious of infection. This is evidenced by: During the initial facility tour which was conducted on 01/04/16 beginning at 8:55 a.m., Surveyor # was informed by RN-P (Registered Nurse) that Resident #3 was admitted to the facility following a fall at home. RN-P stated Resident #3 had developed pressure ulcers on the right foot from the orthotic boot. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the hospital admission history noted Resident #3 had a fall at home which resulted in a [MEDICAL CONDITION] tibia. The fracture was just below an artificial knee joint. The fracture required surgical repair including a plate and screws to stabilize the fractured bone. The right lower leg was covered with dressing material and an Ace wrap from the toes to just below the knee. The right leg was placed in a hard plastic splint called a night splint. The physician had ordered toe touch weight bearing on the right foot. Review of the hospital discharge summary and orders noted there were no physician orders on how to care for Resident #3's splint or surgical incision. The facility did not call the physician to obtain orders on how to care for Resident #3's surgical incision or skin under the splint. The facility completed an admission MDS (Minimum Data Set) assessment for Resident #3 on 11/16/15 with the following data noted: ~required extensive staff assistance for bed mobility and transfers; ~required total staff assist for locomotion on and off the unit; ~was at risk for pressure ulcers, but had no pressure ulcers; ~was provided with pressure reducing bed mattress and wheelchair cushion. The facility did not identify Resident #3 had a non-removable dressing or device in place. The facility completed Skin risk assessments for Resident #3: ~11/03/15 high risk for skin breakdown. Interventions include pressure reducing mattress, improve nutrition/hydration, pillows for comfort/positioning, and monitor skin daily for changes. ~11/10/15 high risk for skin breakdown. interventions as above plus gel cushion to wheel chair. Currently has no skin breakdown. ~11/17/15 high risk for breakdown. Same as above. Resident #3 saw the physician assistant on 11/17/15. The progress notes dated from that visit did not identify any open skin areas for Resident #3. The progress note read The patient is currently in a night splint-type splint. Underneath this, she has an Ace wrap with some dressings over her incisions. She reports that these have not been removed. The incisions are evaluated, and she shows that she has some nicely healing incisions. There is no evidence of inflammation or irritation. She does have some swelling about her lower leg where her Ace wrap is slightly loose .She may bathe with showering but not soaking the wound. The facility did not request any orders for the care of Resident #3's medical device. Resident #3 continued to have dressing materials and Ace wrap covering the right leg from the toes to just below the knee and to wear a hard plastic splint at all times. The facility developed an initial care plan for Resident #3 dated 11/22/15. The care plan identified Resident #3 to be at high risk for skin breakdown due to limited mobility and urinary incontinence. The interventions were to assess skin daily, pressure reducing bed mattress and wheelchair cushion, assure placement of medical device after transfers, and reposition every two hours. Resident #3 was hosptalized on [DATE] through 11/25/15 due to an elevated clotting level. Resident #3 returned to the facility on [DATE] again with no orders to care for the medical device on the right foot. Resident #3 continued to have dressing material and Ace wrap covering the right foot from the toes to just below the knee and a hard plastic splint in place. Resident #3's Skin Risk Assessments indicated: ~11/26/15 high risk for skin breakdown. Interventions same as above except to bridge areas to off load pressure. Currently has no skin breakdown. ~12/02/15 high risk for skin breakdown. Same as above. ~12/09/15 same as above. ~12/16/15 same as above. Interventions same as above except brace is on right foot at all times. The facility completed a Medicare MDS assessment for Resident #3 on 12/16/15. Again, the facility did not identify Resident #3 with a non-removable dressing or device in place. The facility kept the dressing material, Ace wrap, and splint on until Resident #3 was seen by the physician on 12/23/15. Upon Resident #3's return from the physician appointment, Resident #3 was wearing a shoe and sock on the right foot and was weight bearing as tolerated. Review of Resident #3's orthopaedic progress notes dated 12/23/15 does not identify any open skin areas following the removal of the dressing material and Ace wrap. Review of the facility nurses notes from 12/23/15 through 12/24/15 identified only a skin tear on Resident #3's left arm and toenails are scabbed and dry from nail clipping done Sunday . The nurses notes did not include the pressure ulcers noted on Resident #3's right heel, right posterior calf, or right lateral foot. Review of the supplemental care plan dated 12/25/15 noted Resident #3 had a stage I pressure ulcer on the right lateral foot near the 5th toe. There are multiple interventions written in by multiple staff, but the interventions are not dated or signed. On 12/25/15 the nurses notes describe an open area on Resident #3's lateral aspect of the 5th toe on the right foot that was likely caused by pressure from shoes. The area measured 1 cm (centimeter) by 0.7 cm and was superficial with granulation tissue present. The facility changed the care plan to include leaving the wound open to air and removing Resident #3's shoe. On 12/27/15 the nurses notes describe an open area on Resident #3's right heel that measured 1.5 cm by 1.5 cm and was superficial with beefy red granulation tissue present. The facility covered the ulcer with a [MEDICATION NAME] dressing and changed daily. The care plan changes included Ace wrap to right lower leg to manage [MEDICAL CONDITION] and to bridge heels when in bed. Bridge heels includes pressure relief to heels when in bed. On 12/27/15 another supplemental care plan was started for Resident #3 due to pressure ulcer on the right heel. There are multiple interventions listed; however there are no dates by the interventions and the writing indicated multiple staff changing the care plan and not signing the changes. The care plan does add an alternating air mattress to Resident #3, but the date is unknown. The care plan was adjusted on 01/05/16 to add a heel suspension boot when in bed and a walking heel suspension boot for ambulation. On 12/28/15, the treatment for [REDACTED]. On 12/28/15 RN-C (Registered Nurse), who is the facility wound nurse, assessed Resident #3's skin problems. The notes read .she was admitted following a fracture of right tibia, she had a soft cast that covered from foot to just below the knee with ACE WRAP applied, instructions were to not remove from ortho and a [MEDICATION NAME] boot to be woren at all times . RN-C noted an ulcer on Resident #3's middle posterior calf that measured 0.7 cm by 1.5 cm that was superficial with 100% granulation present in the wound bed. The right heel ulcer measured 2 cm by 1.5 cm and was superficial with a beefy red wound bed and granulation tissue present. RN-C noted a change of treatment to the right heel to a thin [MEDICATION NAME] dressing. RN-C noted the lateral right foot near the 5th toe had a 2.5 cm by 1.5 cm necrotic area present. The treatment recommendations were [MEDICATION NAME] to the necrotic area and cover with a gauze and wrap with kerlix and then an Ace wrap. The note further reads The complexity of the resident's condition may limit responsiveness to treatment or tolerance for certain treatment modalities: the fact that resident has had leg/foot in a non-removable cast since admission area make take some time to heal. Skin problem is unavoidable due to: non-removable cast and unable to visualize area since admission . On 01/01/16 the right lateral foot near the 5th toe now measured 2.5 cm by 2 cm with necrotic eschar present. The right heel measured 3 cm by 2 cm with maceration present. The facility continued with the same treatment for [REDACTED]. On 01/05/16 beginning at 9:45 a.m., Surveyor # observed wound care of Resident #3's multiple skin problems. RN-C and RN-L completed the dressing changes. ~The right heel ulcer measured 3.5 cm by 2 cm with a black soft necrotic center that measured 1.5 cm by 1.4 cm. The wound bed was pink with granulation present; however there was maceration from 9 o'clock to 3 o'clock with an unhealthy periwound. ~The right lateral ulcer near the 5th toe measured 2.4 cm by 2 cm. The wound bed had moist yellow slough in the center with some granulation present on the outer wound bed. ~There were 4 right posterior mid calf wounds: The first wound (closest to the knee) measured 1.3 cm by 1 cm. The next wound measured 0.4 cm by 1.2 cm. The third wound measured 2 cm by 1 cm. The fourth wound (closest to the ankle) measured 0.5 cm by 0.7 cm. The calf wounds were partially covered with eschar with pink healing wound beds. On 01/05/16 at 5:10 p.m., Surveyor # interviewed Resident #3 regarding her pressure ulcers. Resident #3 stated the facility left the Ace wrap and splint on until her physician appointment on 12/23/15. Resident #3 stated the ulcers on her right heel and foot has delayed her ability to return home. Resident #3 stated there is little pain from the ulcers even when the dressings are changed. On 01/05/16 at 5:20 p.m., Surveyor # interviewed the DON (Director of Nursing) regarding the facility's pressure ulcer prevention program. The DON stated the facility completes a skin risk assessment which includes the Braden scale along with a physical inspection of the resident's skin upon admission and weekly for 4 weeks. The DON stated a physical inspection of the skin would include removing any dressings in place and documenting the skin condition. The DON stated residents on the rehab wing all have high end foam pressure reducing bed mattress. (Resident #3 resided on the rehab wing.) The DON stated she was unable to find any evidence of a physician order to leave Resident #3's dressing, Ace, and splint in place. The DON stated the facility did not pursue clarification orders on the care of Resident #3's medical device. The DON stated Resident #3's pressure ulcers were caused from the splint, but there is no evidence to support that theory. The DON stated the first skin problem notation was dated 12/25/15 which was 2 days after Resident #3 returned from the physician appointment wearing only a sock and shoe. On 01/06/16 at 1:00 p.m., Surveyor # interviewed RN-C and the DON. RN-C stated she was the wound nurse and she had assessed Resident #3's wounds on 12/28/15. RN-C stated Resident #3's pressure ulcers developed due to the splint that was worn continuously from 11/03/15 through 12/23/15. RN-C was unable to provide evidence to support this theory. There is no evidence to support the ulcers were present during the physician assistant visit on 11/17/15, the orthopaedic visit on 12/23/15, or the nurses progress notes dated 12/23/15 through 12/25/15. The first progress note identifying a pressure ulcer was on 12/25/15 and identified only 1 ulcer on Resident #3's right lateral foot near the toe. RN-C stated the facility was sure the dressings, Ace, and splint were not removed because of a physician order; however RN-C was unable to provide evidence of such a physician order for [REDACTED].#3 returned from the orthopaedic appointment on 12/23/15, the physician ordered weight bearing as tolerated. The DON stated Resident #3 was walking on the right heel even though there was a pressure ulcer present. The DON stated she thought the [MEDICATION NAME] would provide enough support and protection of the heel ulcer to allow for ambulation. The DON stated the heel ulcer deteriorated due to weight bearing and as of 01/06/16 Resident #3 has a walking suspension boot when ambulating and bilateral heel suspension boots when in bed. The DON was unable to determine when the facility placed an alternating air mattress on Resident #3's bed. The DON confirmed multiple staff had changed Resident #3's supplemental care plan but did not date or sign the changes. On 01/06/16 at 1:40 p.m., Surveyor # interviewed CNA-F (Certified Nursing Assistant) who stated she had cared for Resident #3 full time since her admission. CNA-F stated Resident #3 was completely immobile upon admission and required total care for repositioning, bed mobility, transfers, toilet use, hygiene, and dressing. CNA-F stated Resident #3 had improved significantly with bed mobility, transfers, dressing, hygiene, and toilet use and currently required only extensive staff assist with cares. CNA-F stated pillows were placed under Resident #3's feet to bridge her heels off of the bed. CNA-F stated Resident #3 had a hard splint in place at all times except when staff were unable to don slacks. CNA-F stated she would remove the splint, don slacks, and reapply the splint once slacks were on. CNA-F stated the splint had a hard metal piece in the back of the calf that went half way up the calf. CNA-F stated the splint was held in place with Velcro straps. On 01/06/16 at 1:45 p.m., Surveyor # interviewed PTA-M (Physical Therapy Assistant) who stated she had provided care to Resident #3. PTA-M stated she worked with Resident #3 on 12/23/15 and was unaware of any skin problems. PTA-M stated she became aware of Resident #3 open areas on her right foot when Resident #3's family took pictures of the wounds and gave a copy to the therapy department. PTA-M stated Resident #3 was not able to walk heel to toe yet because she was too weak. PTA-M stated Resident #3 would stand and transfer, but little pressure was applied to her heel. PTA-M offered to show Surveyor # Resident #3's wound pictures; however there was no date stamped on the pictures. Example #2 Resident #6 was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. Resident #6's admission MDS (Minimum Data Set) dated 12/18/15. The MDS indicated Resident #6, ~ Had a BIMS (Brief Interview for Mental Status) score of 11 indicating a moderate cognitive impairment; ~ Was able to walk, dress, eat, and go to the bathroom independently; ~ Was at risk for the development of a pressure ulcer; and ~ Had no pressure ulcers. Resident #6's comprehensive care plan was undated. The care plan contained no problems identifying nor managing skin problems. A facility form titled, Open Area Supplemental Care Plan dated 12/31/15 indicated, .Friction .clear fluid filled blister .etiology rubbing foot against foot .Also wheeling self with feet in w/c (wheel chair) .bridge heel when in bed .Heel suspension boots . Surveyor # completed a review of Resident #6's nursing notes and noted the following. ~ On 12/7/15 on admission to the facility a nursing note indicated Resident #6's skin was intact including Resident #6's feet. A skin risk assessment indicated Resident #6 was at moderate risk for the development of a pressure ulcer. ~ 12/9/15, .Pain Assessment .denies any pain .does not take anything for pain at the present time . ~ 12/11/15, .did complain this am of being weak when standing .observed using his W/C a lot . ~ 12/14/15, .Skin Risk Assessment .currently without any skin breakdown . ~ 12/15/15, .had a critical Na (sodium) level .today. MD (Medical Doctor) ordered sodium (salt) tablets . ~ 12/16/15, .Digestive Findings: Vomitus: moderate amount .stomach upset . By 12/16/15 the facility identified Resident #6 had complaints of weakness, was using the wheel chair more often, had a low sodium level, and nausea and vomiting. There were no changes made to Resident #6's plan of care. Nursing notes continue. ~ 12/17/15, .Location Of Pain: left heel .states it usually starts at 10 PM .sharp like a tac (sic) in his heel .usually lasts 1 hour .Described as 'terrible.' This was the first indication Resident #6 was experiencing left heel pain since admission to the facility. Heel pain is a significant precursor to the development of a pressure ulcer. There were no changes made to Resident #6's plan of care. Nursing notes continue. ~ 12/17/15, .asked if his heel is hurting .responded no. He said that it usually hurts late at night for the past 2 or 3 months .checked both heel and noted no redness nor tenderness . ~ 12/20/15, .[MEDICATION NAME] (Tylenol) .2 tablet .given at 01:00AM (1:00 a.m.) pain .Total Pain Score: 8 .left heel . ~ 12/22/15, .[MEDICATION NAME] .2 tablet .given at 05:30AM (5:30 a.m.) .Pain Level .9 .left heel .Result .Improved but still present . ~ 12/23/15, .Care plan for pain R (right) heel chronic .no significant change .Is an exacerbation of an existing problem . Pain rated at 8 and 9 is significant pain. Resident #6's pain was also new pain since admission to the facility. While the facility contended the pain was chronic in nature there was no indication the facility completed a comprehensive assessment including a physical assessment to determine the potential causes of the new and significant left heel pain. The nursing note dated 12/23/15 indicated Resident #6's pain was in the right heel when in fact pain was noted in Resident #6's left heel. Nursing notes continue. ~ 12/24/15, .has intermittent c/o (complaints of) left heel .pain since his admission. Resident reports that this had previously been an issue only during the night .Today, he is reporting significant pain in the left heel that has not improved with PRN (as needed) .Tylenol. He describes pain as severe, sharp and shooting. He does indicate some tenderness with firm palpation of the heel .He has refused all meals today, has refused to get out of bed because of this discomfort . Resident #6's left heel pain was so severe Resident #6 refused to eat and refused to get out of bed. The physician also ordered [MEDICATION NAME] a pain medication to treat Resident #6's pain. Despite the significance of the left heel pain there were no modalities implement to off-load Resident #6's left heel. Nursing notes continue. ~ 12/27/15, .is being monitored for c/o left heel pain. At the time of this assessment res. (resident) has no c/o left heel pain. He does report that it seems to have occurred more often during the night. When the pain occurs he says he braces his foot against the blankets to stretch the foot, pointing his toes toward his body, this helps relieve the discomfort . Resident #6 identified by pulling his foot towards his body he is able to relieve some of left heel pain. The act of pulling the foot towards the body may have offered some off-loading properties relieving pressure thus relieving pain. Still there were no new approaches added to Resident #6's plan of care to off-load Resident #6's left heel. Nursing notes continue. ~ 12/29/15, .[MEDICATION NAME] .given for complaint of pain in left heel. States pain is severe .[MEDICATION NAME] .given for severe heel pain, radiating up into the calf and around the ankle .Result: minimal change in discomfort .Change in behavior noted today .resistive .of getting up in his chair, to get dressed, or eat meals .has been reporting pain in his left heel .He seemed to feel discomfort with light palpation . ~ 12/30/15, .Care plan for behavior change .related to L (left) heel and leg pain .Indicates need to no significant change .is an exacerbation of an existing problem . Resident #6 had significant new and on-going pain since 12/17/15. The physician also ordered additional pain medication to treat the pain as Tylenol was not effective in controlling the pain. Resident #6 also had complaints of pain with palpation of the left heel. Despite this the facility continued to identify the pain as an exacerbation of an existing problem. There were no new approaches added to Resident #6's plan of care to off-load Resident #6's left heel. Nursing notes continue. ~ 12/31/15, .[MEDICATION NAME] .given .for pain in left heel. Noted a blue/purple area on his left heel, soft, surrounding tissue is very dry. Muscle rub applied . Blue and purple discoloration is indicative of a DTI (deep tissue injury). DTI's are caused from prolonged pressure to an area resulting in damage to underlying soft tissue. There were no new approaches added to Resident #6's plan of care to off-load Resident #6's left heel. Additionally muscle rub would not be considered an appropriate treatment for [REDACTED]. Nursing notes continue. ~ 12/31/15, .Weekly Skin Assessment .left heel Etiology: rubbing foot against foot, friction Size: 2cm x 2cm (2.0 centimeters by 2.0 centimeters) fluid filled blister .area is not open .Interventions: heel suspensions boot, area is bridged to off load pressure .would expect area to regain skin integrity and heel (sic) . Resident #6 now developed a fluid filled blister. The nursing note above did not identify the purple/blue discoloration as noted in the previous nursing noted. New interventions to off-load Resident #6's left heel were implemented after the development of the DTI. Nursing notes continue. ~ 1/2/15, .had a blister on his left heel, there is no fluid visible today, area is flat .let heel .2x2cm (2.0 cm x 2.0 cm) .area is a light purple/pink color .slight [DIAGNOSES REDACTED] noted around the blister area .has intermittent pain . From 1/2/15 through 1/5/15 there was no indication the facility assessed Resident #6's left heel. Nursing notes indicated Resident #6 continued to have significant pain in the left heel which required [MEDICATION NAME]. On 1/5/16 at the request of Surveyor # , RN-C and the DON observed Resident #6's left heel. Surveyor # noted a purple DTI on Resident #6's left heel measuring 2.0 cm x 1.8 cm as measured by RN-C. The purple blister was almost flat indicating most of the fluid within the blister had been expelled. The edges of the wound were loosened and moist in appearance. Redness surrounded the entire wound with an area of prominent redness noted from 2 o'clock to 6 o'clock. RN-C palpated the skin surrounding the wound at which point Resident #6 complained of significant pain and flinched. Surveyor # spoke with RN-C and the DON following the observation. RN-C indicated Resident #6's left heel blister had deteriorated since she last saw it on 12/31/15. RN-C indicated the wound was an unstageable DTI. The facility contacted the physician obtained new orders and implemented new off-loading modalities to relieve the pressure to Resident #6's left heel. On 1/5/16 at 11:10 a.m. Surveyor # spoke with CNA-B (Certified Nursing Assistant) about Resident #6's left heel pressure ulcer. CNA-B indicated she was not sure why or how Resident #6 developed the pressure ulcer. On 1/5/16 at 11:15 a.m. Surveyor # spoke with Resident #6. Resident #6 related he was having significant pain in his left heel. Resident #6 stated he did not know why he developed a pressure ulcer on the left heel. On 1/6/16 at 7:25 a.m. Surveyor # spoke with LPN-A (Licensed Practical Nurse). LPN-A indicated she was the full time nurse working on the unit in which Resident #6 resided. LPN-A indicated she did not recall Resident #6 having a lot of pain when he was first admitted . LPN-A indicated she went on vacation and when she returned Resident #6 was having significant pain in the left heel. LPN-A indicated the pain was not noted during the day but had been reported from the night shift. LPN-A indicated the floor nurses looked at wounds every day to every other day depending on the severity of the wounds. LPN-A indicated the floor nurses were at times directed by the wound team as to how often they needed to assess and/or document on a wound. LPN-A stated they did look at wounds with a dressing every day to make sure the dressing was still intact. Surveyor # asked LPN-A why Resident #6 developed a pressure ulcer. LPN-A was unsure. On 1/5/16 at 2:50 p.m. Surveyor # spoke with RN-C and the DON about the pressure ulcer to Resident #6's left heel. RN-C indicated when she initially saw Resident #6's left heel on 12/31/15 Resident #6 had a clear fluid filled blister with no purple discoloration. RN-C indicated she determined the blister was not pressure related as she felt it had been caused by friction from Resident #6 rubbing his feet together as well as using his feet to propel the wheel chair. RN-C indicated she implemented the heel suspension boot once the blister had been identified. Surveyor # asked what the facility practice was for monitoring pressure ulcers. RN-C indicated wounds were assessed and measured by the wound team one to two times a week depending on the severity of the wound. RN-C indicated assessment and documentation by the nurses on the floor was also dependent on the severity of the wound. The DON indicated the wound team would attach a slip of paper to a residents temporary care plan which directed staff on how often they needed to assess and document that status of a wound. The DON indicated the attached piece of paper was not saved. The DON indicated it was not their practice to observe and/or document wounds on a daily basis unless there was a dressing in place.

Based on observation, record review, and interviews, the facility did not ensure that 2 out of 6 sampled residents reviewed for pressure ulcers, received the necessary treatment and services needed to promote healing and prevent new sores from developing. Resident #9 has recurrent open wounds on buttock area despite placement of an indwelling urinary catheter to prevent moisture related skin damage. Four days after removal of the urinary catheter, Resident #9 developed a pressure ulcer to the scrotum. The size and shape were consistent with that of a urinal. The facility did not update Resident #9's care plan to prevent redevelopment of the pressure ulcer to the scrotum. Resident #9 subsequently redeveloped a pressure ulcer on the same area of the scrotum. Despite Resident #9's high risk for pressure ulcer development and facility identified non-compliance with repositioning, there were no approaches implemented to prevent development of new pressure ulcers. Resident #9 developed unstageable pressure ulcers on the coccyx and on the left heel. When decline or lack of improvement were noted, there were no changes to the treatment and/or care plan to promote the healing of the pressure ulcers. Resident #8 has bilateral open areas on the buttocks. The right buttock is to have a [MEDICATION NAME] dressing over the wound. On 12/1/14 at 2:30 p.m., surveyor observed no [MEDICATION NAME] in place and the wound bed was dry. The goal of the dressing is to keep the wound bed moist for proper healing. Resident #8 [MEDICAL CONDITION] ([MEDICAL CONDITION] Resistant Staph Aureus) in the wounds. The Registered Nurse measured the wounds using the same measuring tool for two different open wounds on each buttock area, thus causing cross contamination. This is evidenced by: On 12/2/14 at 8:10 a.m., Surveyor # spoke with RN-F (Registered Nurse) who stated she is right now responsible for the infection control, pharmacy issues and skin. RN-F stated the nurses on the floor do the wound measurements and she will oversee them and/or do them herself. RN-F stated she is not wound care certified but a nurse on afternoon shift, recently became wound care certified and is currently working with the Director of Nurses on real life experiences with wounds. The Director of Nurses is also wound care certified and currently out of the building. Example #1: Resident #9 was admitted to the facility with a [DIAGNOSES REDACTED]. During tour on 12/1/14, Resident #9 was in bed eating breakfast, lying on an air overlay mattress, wearing bilateral boots on his feet. RN-E stated Resident #9 previously had sores and the indwelling catheter was recently removed. Review of Resident #9's initial MDS (Minimum Data Set) assessment, dated 3/14/14, indicates: ~Cognitive status is moderately impaired: ~Requires use of a device for transfers, extensive assist of 2 staff for bed mobility, dressing and toilet use; ~Eating is extensive assistance with one staff; ~Always incontinent of bowel and bladder, on no toileting program; ~Frequent moderate pain; ~Risk for pressure ulcers; and ~Receiving antidepressants, anticoagulants and diuretics. The CAAs (Care Area Assessment) indicated no pressure ulcers but does have moisture issues with superficial open areas on buttocks. He requires staff assistance to move sufficiently to relieve pressure over any one site and has a low air loss mattress. Friction and Shear: Slides down in the bed. Maceration: Persistently wet skin due to incontinence....Will develop a care plan. Skin and Ulcer Treatments being utilized are pressure reducing device for chair and bed. Turning/repositioning program and Nutrition or hydration intervention to manage skin problems are checked. Review of admission Braden Scale indicates a score of 13 (high risk for skin breakdown). Resident #9's care plan, dated 5/29/14, includes a problem of "Impaired skin integrity...Res (resident) has skin breakdown chronic intermittent... Approaches include, Weekly skin assessment note...Educate resident/family/staff regarding treatment and preventative measures. Reduce pressure and friction. Develop and monitor repositioning schedule based on status and support surfaces provided Pressure relieving device(s) for chair. Pressure relieving device(s) for bed...Assist with hygiene and general skin care. Avoid hot water for cleansing. Reposition every two hours while in bed...Heel protectors, bridge heels with pillows so there isn't any pressure on the heels. Apply A&D oint (ointment) to scrotum and penis area to keep skin to skin and skin to bedding without friction. Use a soft cloth around res scrotum...to keep skin to skin contact a minimum. Alternating air mattress on bed and cushion in chair. Reposition every 2 hours. Do not use Allegro (a moisture proof bed pad that does not wick moisture/fluids away from the skin) on bed, use flat sheet folded as a lift sheet..." According to NHA-G (Nursing Home Administrator) the dates on the care plan indicate when the care plan was reviewed. Individual approaches should coincide with the review date and are not dated individually. On 3/20/14, Resident #9 developed open areas on the buttocks which was not confined to an area over a bony prominence. On 4/23/14, the facility implemented an indwelling catheter related to incontinence and skin issues. Resident #9 continued to have recurrent open areas on the buttocks despite the catheter insertion. ~On 5/31/14, "Assessment of Wound: Location: coccyx area - midline and to the left, Size 1.2 cm x 2.0 cm, Depth; unknown, Drainage: moderate serous drainage, Wound Bed: greenish-yellow slough Odor: foul, Surrounding Tissue: clean and dry... Interventions: alternating air mattress, repositioning schedule, gel cushion pillows used for comfort and positioning." All of these interventions were implemented upon admission. There was no evidence of any new interventions in the care plan. There was no change in treatment. The facility did not identify the wound as a stage III or unstageable pressure ulcer even though slough was identified. ~6/2/14,"Assessment of a wound with dressing change: Location: Coccyx Size: 1.2 cm x 2 cm Depth: unable to determine due to slough Drainage: moderate serous Color: greenish-yellow Wound Bed: slough, firm Odor: foul...Wound Care: Cleanse with NS, Wound team assessed. [MEDICATION NAME] (debridement) will be applied to wound and covered with dry dressing, secured with tape. To be changed daily." There was no staging of the pressure ulcer. Assessment of wound: Location: right buttock, Size: 1 cm x 0.5 cm Depth: superficial Drainage: moderate sanguineous Wound Bed: granulation tissue Odor: none Surrounding Tissue: Area of induration approximately 5 cm x 6 cm around. Surrounding Tissue: clean and dry Healing Progress: tenderness present, induration new. Wound Care: cleansed with NS (normal saline) WMC (warm moist cloth) applied and wound covered with ABD (abd pad). WMC to be applied BID and covered with ABD. Skin Interventions: alternating air mattress roho cushion repositioning schedule pillows used for comfort and position. Induration is a sign of skin deterioration. The use of a wet-to-dry dressing is not an appropriate treatment for [REDACTED]. ~6/9/14, "...Location: coccyx-just to left midline, Size: 1.0 cm x 2.0 cm, Depth: unknown, Drainage: small amount of serous drainage, Wound Bed: 100% yellow slough, well attached, Odor: mildly odorous. Surrounding Tissue: mildly macerated at immediate perimeter, distant perimeter healing [MEDICATION NAME] tissue, Healing Progress: becoming smaller sloughing occurring..." The assessment did not include a staging. The length had decreased only 0.2 cm. There is no indication that the treatment or the care plan approaches were updated in order to promote healing of the existing pressure ulcer. ~6/11/14, "He has mattress overlay as the low air loss mattress was not effective due to his size and unsafe with the repositioning." ~6/16/14, "Skin Condition: coccyx Area 1: Size: 0.9 cm x 2.0 cm Depth: unknown due to slough in wound. Wound bed: slough Color: yellow Surrounding Tissue: clean and dry. Healing progress: per medicare nurse who has seen wound prior stated it is becoming smaller. Wound Care: ...dressing will be changed to a thick [MEDICATION NAME] dressing and secured with [MEDICATION NAME] tape. dressing will be changed q (every) 3 days and prn (as needed)." The documentation does not include staging of the pressure ulcer. The is the first wound assessment since 6/2/14, 14 days prior. According to current standards of practice, a wound covered with slough in which the wound base is not clearly visible is considered an unstageable pressure ulcer. It is critical to stage pressure ulcers correctly as the stage determines treatment. ~6/19/14, "Skin Condition: open area to coccyx...measures 1.8 x 1 cm in overall size. The middle is a creamy-yellow slough area that measures 1.2 x 0.7 cm. Where the slough recedes, depth is at least 0.3 cm. This area is surrounded by 0.4 cm of light pink granulation..." The pressure ulcer has increased in size. The documentation does not indicate the stage of the pressure ulcer. There is no indication that the treatment was changed or that the care plan approaches were updated to promote healing of the coccyx pressure ulcer. ~6/22/14, "Skin Condition: open area to coccyx. Size 1.2 cm x 0.6 cm. Center contains light colored slough. Depth: unable to determine due to slough. Drainage: none present scant Color: pink around immediate edges Surrounding Tissue: slight area of macerated tissue surrounding. healing Progress: no s/s (signs and symptoms) of infection..." Macerated tissue is a sign of too much moisture. Even though maceration is now identified, there was no change in treatment in order to better manage moisture levels of the pressure ulcer. Again, the documentation did not include a stage of the pressure ulcer. ~6/26/14, "Late Entry for: 6/25/14 Skin Condition: open area to coccyx measures 1.0 cm x 0.5 cm, slough is present though is loosening and pulling away from wound. Wound Bed: slough Surrounding Tissue: clean and dry. Healing Progress: becoming smaller appears more clean Depth: unable to measure due to slough ..." ~6/28/14, "Skin condition: open area Size: to the left of the coccyx Depth: unknown due to slough Wound Bed: slough Odor: none color yellow beefy red. Surrounding Tissue: clean and dry healing progress: becoming smaller. The documentation does indicate this pressure ulcer is to the left of the coccyx while previous documentation indicates coccyx. There are no measurements and no staging of the pressure ulcer. ~7/1/14, "Skin Condition: Assessment of an open area: Size: 0.9 cm x 0.4 cm noted to have slough in base of wound bed, though is loose and started to separate from base of wound...Wound Bed: slough Drainage: scant Color: yellow Surrounding Tissue: clean and dry Healing Progress: becoming smaller Wound Care: [MEDICATION NAME] dressing Skin Interventions: pressure reducing mattress gel cushion repositioning schedule." ~7/6/14, "Skin Condition: Size 0.8 cm x 0.4 cm continues to have slough in the wound bed, slough is loosely attached, to base of wound, area cleansed with saline and duoderm applied." Neither of the above notes identify the location of the pressure ulcer being assessed and no staging. 7/7/14, "Assessment of A Wound with Dressing Change: Location: Area 1: just to the left of the coccyx areas noted lower area, very superficial area measures 1 cm x 0.5 cm ...Area to right buttock measures 1 cm x 0.5 cm..." The size of the coccyx pressure ulcer has increased. There is no indication that the treatment or care plan approaches were changed to promote the healing of the pressure ulcer. This is the first documentation of the right buttock pressure ulcer since 6/2/14. At that time, the right buttock pressure area measured 1.2 cm x 2.0 cm. ~7/16/14, "Skin Condition: Location: Area 1: Assessment of Wound: ...Size: 0.6 cm x 0.5 cm at this time is noted to have light yellow/tan slough noted, this is only part of wound that remains open...Wound Bed: slough Odor: none... Skin Interventions: ...though is noncompliant with repositioning..." It is presumed that Area 1 is the pressure ulcer located on the coccyx. The assessment indicates Resident # 9 is "non-compliant" with repositioning, however, there was no evidence that the facility explored reasons why Resident #9 didn't want to be repositioned. There were no changes to the care plan to promote the healing of the pressure ulcer. ~7/31/14, Coccyx pressure ulcer is healed. Buttock wounds continue to open and close. Review of the documentation indicates Resident #9's pressure ulcer to the right buttock: 1. Redeveloped 9/5/14 and healed on 9/30/14. There was no assessment of the pressure ulcer from 9/5/14 to 9/16/14. 2. Redeveloped 10/7/14, measuring 0.7 cm x 2 cm. On 10/22/14, Resident #9 developed a pressure ulcer to the left buttock 2 cm x 1 cm superficial. During this time, Resident #9 had an indwelling urinary catheter. The urinary catheter was removed on 10/31/14. Also on 10/22/14, Resident #9 developed a pressure ulcer on the left inner heel, "Skin Condition: Location: inner left heel Size: round area 2.5 cm across. Area red with fragile skin. No open areas. Inside this area are 2 smaller areas. One area is 0.8 x 0.4 cm and another is 1 cm x 0.5 cm. These 2 areas have translucent skin and are grey in color...A&D applied, heel boot on, heel floated with pillow..." ~10/24/14, "Late entry for 10/23/14 Assessment of an open area: Location: inner left heel. Etiology: pressure Location: medial aspect lower heel Size 2 cm x 1.5 cm Wound Bed: red beefy tissue with some necrosis present Surrounding Tissue: Clean and dry Wound Care: podiatry did evaluate heel and ordered a sterile dressing to be changed M-W-F. Skin Interventions: alternating all mattress, heel suspension boot/s area is bridged to off load pressure." There was an addition to the 10/24/14 note dated 11/12/14 by RN-F: "Entry should read Skin Condition: Location: (214) left heel Size: 2 cm x 1.5 cm Wound Bed: eschar over wound bed Drainage: none present Etiology: pressure, unable to stage due to necrosis. Contributing Factors: resident is morbidly obese. He has weakness in bilateral lower legs. He has bilateral [MEDICAL CONDITIONS] with hemosisderous from feet to knees. Skin Interventions: will continue with alternating air mattress, heel suspension boot/s, area is bridged to off load pressure." ~10/29/14, "...inner left heel Etiology: pressure Size: necrotic area measures 2.2 cm x 2.2 cm, beefy red tissue to top of necrotic area measures 1.5 cm x 4 cm, fragile area around necrotic areas measures 1.5 cm x 4 cm...Wound Care: sterile dressing discontinued and staff will paint area with [MEDICATION NAME]." ~11/6/14, "...Location: left inner heel Size: 1.5 cm x 1.5 cm necrosis with no redness, warmth or drainage Etiology: unstageable pressure area. Resident has a tendency to lay with legs bent and laying to the right. Wound Care: open to air. Interventions:...he has the heel suspension boots on but is able to and does kick these off at times..." ~11/12/13, "Late entry for 11/11/14....left heel inner Etiology: pressure Size: 1.5 cm x 1.5 cm Wound Bed: necrosis present..." ~11/26/14, "area on left heel has a hard scabbed noted..." ~11/28/14, "...left heel inner aspect Size: 1.5 cm x 1/5 cm...necrosis Surrounding skin: dry skin around edges; peeling..." On 12/1/14 from 11:15 a.m. to 1:57 p.m., Surveyor # did a continuous observation on Resident #9 who was not repositioned or toileted (2 hrs. 32 min.). At 3:08 p.m., Resident #9 remained in his room sitting in the wheelchair. Resident #9 stated he was never toileted or repositioned. He stated he wanted to lay down after supper. Care plan indicates he is to be repositioned every 2 hours. On 12/2/14 at 9:00 a.m., Surveyor # observed CNA-I completing Resident #9 morning cares. Resident #9 was lying in bed with an overlay air mattress. CNA-I lowered the bed and Resident #9 stated, "Left shoulder is bad." CNA-I washed resident up using Nivia Men Cool Body Wash soap and a washcloth. Surveyor # observed Resident #9 was lying on a fitted sheet and an Allegro pad, both of which were saturated with urine. The care plan states not to use an Allegro pad but to use a full sheet folded in half for a lift sheet. There was no cloth around the scrotum. CNA-I stated she should have been in the room earlier but she had other cares to do. CNA-I stated she came in a 6 a.m. and did not reposition him until now. Resident #9 was not repositioned for 3 hours. When asked if he was on a toileting schedule, CNA-I stated he is suppose to be but she was caring for other residents. During cares, Surveyor # observed Resident #9's buttocks were very deep red in color, no open areas, but skin has previous scarring which is fragile and shiny. Resident #9's scrotum is [MEDICAL CONDITION]. CNA-I lifted the penis off of the scrotal area. There was no soft cloth in place to prevent skin-to-skin contact. Surveyor # observed an odd shaped open area with yellow slough in the middle. This would be considered an unstageable pressure ulcer. The shape of the open area matches the opening of the urinal if resting on the scrotum. Review of skin nurse's notes reveal the following: ~10/31/14, Indwelling catheter was discontinued. ~11/4/14, "...Has a superficial open area at the bottom of the scrotum noted, 0.5cm x 2cm, wound base is moist..." ~11/7/14, "No open areas noted on scrotum or buttocks at this time." ~11/28/14, "...Scrotum (left anterior) Size: 1.6 cm x 0.4 cm odd shaped...Staff instructed to monitor when resident using urinal and to ensure that is removed promptly after urinating complete." This was not added to Resident #9's care plan. ~12/1/14, "...on left side of scrotum Size: 2 cm x 1 cm. Depth: Superficial Drainage: none present Color pink/red Surrounding Tissue: some maceration to wound edges Wound Care: soap and water, open to air." The pressure ulcer to the scrotum has redeveloped and increased in size in 2 days time. There were no changes to the care plan to direct staff on promoting the healing of a pressure ulcer and preventing redevelopment. Example #2: Resident #8 was admitted with a [DIAGNOSES REDACTED]. Review of Resident #8's admission MDS assessment dated [DATE] indicates: ~Alert and oriented; ~Minimally depressed; ~Extensive assistance with bed mobility, dressing, hygiene and toilet use. Unable to ambulate. Eats independently. ~Has pressure ulcers. 5 stage 2 pressure ulcers, 1 stage 3 pressure ulcer, 1 stage 4 pressure ulcer, 1 Deep Tissue Injury and Moisture Associated Skin Damage (MASD). ~Has a [MEDICAL CONDITION] and straight catheter daily every 6 a.m. and as needed. Review of Resident #8's Care Area Assessments (CAAs) indicate that he stays in bed most of the time, is non compliant with repositioning and often tries to pull himself up in bed which causes shearing on the buttock area. He has been reminded not to do this. Resident is his own person. Care plan last updated on 11/5/14, indicates for nurse aides to report changes to the nurse. On 12/1/14 at 2:30 p.m., Surveyor # observed RN-H completing Resident #8's dressing change. There was no dressing on the right open buttock wound. The wound bed was dry. Resident stated the dressing came off yesterday (11/30/14) and didn't know if it was replaced. He stated there was "nothing on there last night." RN-H cleansed the wound and applied a thick [MEDICATION NAME] over the wound. RN-H stated no one told her the dressing was off. Physician orders, dated 12/1/14, indicate to cleanse wounds to right and left buttocks with normal saline. Apply thick [MEDICATION NAME]; Apply foam dressing and [MEDICATION NAME] border sacrum dressing 23 cm x 23 cm to left buttocks; Change every three days as needed, first date: 10/31/14. On 12/4/14, Surveyor # reviewed the November 2014 medication record which indicates that Resident #8's dressing was last changed on 11/29/14 (no nurse initial), 5 days prior. The December medication record indicates that nursing checked the dressing and it was found intact and drainage was less than 75% of outer covering on the night and day shift. RN-H initials were in the 12/1/14 a.m. box. RN-H was unable to be interviewed. There were no entries in the nurses notes related to the pressure ulcer. On 12/2/13 at 2:00 p.m., Resident #8 was seen by TeleHealth for his wounds by the surgeon. The physician changed the treatment to twice a day double strength damp to dry dressings, cover with ABD pad and have resident wear underwear; no tape. The facility documents all wound care assessments in the interdisciplinary notes. Review of all the notes since admission indicate: ~There is no consistent weekly assessments ranging from 5 times being 1-2 days beyond the 7 days to 18 times being 11-19 days beyond the 7 days. ~The weekly assessments did not consistently include wound classifications (staging) to aid in the description of the extent of skin and tissue damage presenting as a pressure ulcer. There was no consistent description of the wound. There was no evaluation if current treatment was effective or not and if the current care plan interventions were appropriate or not, such as repositioning schedule and/or refusals from the resident. On 12/2/14 at 9:38 a.m., Surveyor # observed RN-F don personal protective equipment (gown, gloves) and measure Resident #8's wounds using a clear plastic 6 inch ruler. RN-F used the same ruler for measuring each wound, therefore causing cross contamination. Resident #8 is on contact precautions for [MEDICAL CONDITION] Resistant Staph Aureus (MRSA) infection in a wound. Surveyor # asked if this was normal practice to use the same measuring tool to measure different wounds. RN-F stated no, that she should have used another ruler.

Based on observation, interview, and record review, the facility did not ensure 2 of 9 residents reviewed for falls, had an environment as free from accident hazards as possible. Resident #1 had a history of [REDACTED]. Since 1/9/14, Resident #1 had 33 falls. Multiple falls resulted in injury including head trauma. Of the 33 falls, one required Resident #1 to be transferred to the emergency room for sutures to the head. Despite the numerous falls including falls leading to injury, the facility did not determine the root cause of the fall and initiate interventions following each fall to prevent further falls based on the cause of the fall. Additionally, the facility utilized multiple alarms for Resident #1 despite the fact that the alarms had previously been proven ineffective. Resident #5 had 18 falls over a 4-month period. The evaluation of each fall lacks root cause analysis and care plan interventions to address the root cause. The care plan approaches are not appropriate for Resident #5 due to advanced dementia. Resident #5 currently has a physical restraint to prevent falls. This is evidenced by: Example #1: Surveyor # completed a review of Resident #1's clinical record and noted the following. Resident #1 had current [DIAGNOSES REDACTED]. Resident #1's most current MDS (Minimum Data Set) was dated 11/19/14. The MDS indicated Resident #1: ~Had both short and long-term memory problems; ~Required assistance of 1 staff person for all aspects of care including bed mobility, transfers, and walking; ~Was occasionally incontinent of bladder; and ~Had 2 non-injury and 2 minor injury falls. Surveyor # requested and received Resident #1's most current CAA (Care Area Assessment) summary for falls. The CAA was not dated. The CAA indicated, "...location of the fall...room and hallway doing usual/unusual activity standing still while walking reaching root cause of prior fall...impulsive...impaired balance during transitions difficulty (sic) maintaining standing position gait problem even with mobility aid or personal assistance...impulsivity...poor safety awareness..." Resident #1's fall care plan was dated 10/30/13. The care plan had the following approaches in which none were dated: ~15-minute safety checks; ~Reminders when doing an unsafe activity; ~Reminders to call for help; ~Keep room clutter free; ~Keep personal items within reach; and ~Locate near staff when out of bed. Surveyor # completed a review of Resident #1's CNA (Certified Nursing Assistant) care plan. The care plan was undated. The CNA care plan had the following approaches in which only 1 of the 3 was dated: ~Musical mat on the floor next to Resident #1's bed; ~A pressure alarm on both Resident #1's bed and chair; and ~11/16/14 a pull apart alarm when Resident #1 was in bed. Surveyor # completed a review of Resident #1's nursing notes and noted the following: ~On 1/14/14 Resident #1 was found on the floor in the hallway next to his room on his hands and knees. Resident #1 sustained a 4.0 cm (centimeter) by 2.5 cm bruise with a 1.0 cm laceration in the center of the bruise to the right outer eye. The nursing note indicated, "...Causal Factors: poor body mechanics balance deficit gait instability cognitive impairment impulsive unaware of safety unaware of physical limitation...We are currently doing every 15 minute checks, we will continue with these..." ~On 1/15/14 a nursing note indicated, "...Incident Investigation/Root Cause Analysis...Incident was an accident and apparently related to...res (resident) was attempting to get soiled laundry to care...without walker and either lost his balance or fell forward...Res was in the process of arranging, rearranging his clothes, removing soiled laundry to cart...Staff have increased monitoring in response to moon phase..." ~ On 1/17/14 a nursing note indicated, "...History of Incident/Root Cause Analysis...has unsteady gait at times, impulsive, unsafe chances...poor postural control, poor body mechanics balance deficit gait instability...unaware of safety issues unaware of physical limitation...Current status and interventions balance the benefits of greater independence and freedome (sic) of movement with the desire to minimize falling and prevent future injuries. Risk: Resident is at high risk: frequent fall..." The facility identified Resident #1 was rearranging clothing and was attempting to bring dirty clothing to the laundry cart. The facility also identified multiple fall risk factors for Resident #1. Despite this, there were no new interventions put into place to prevent Resident #1 from further falls. Nursing notes continue. ~On 1/31/14 a nursing note indicated Resident #1 fell in his room while putting something in his dresser. The nursing note indicated Resident #1 sustained no new injuries related to the fall. The nursing note indicated, "...Causal Factors: weakness poor body mechanics balance deficit gait instability, cognitive impairment impulsive unaware of safety unaware of physical limitations...will continue with the every 15 min (minute) checks, we do remind res. to turn slowly, make sure he has his balance before starting to walk...instruct resident on safe use of assistive device safe transfer techniques..." Resident #1 had both short and long-term memory problems and would not have the ability to recall instructions or reminders. Nursing notes continue. ~On 2/2/14 Resident #1 fell in his room while attempting to put on a pair of pants. Resident #1 sustained a small skin tear on the left elbow. The nursing note indicated, "...Causal Factors: weakness balance deficit gait instability cognitive impairment impulsive unaware of safety unaware of physical limitation improper footwear...instructed resident on safety..." ~On 2/3/14 a nursing note indicated, "...Incident Investigation/Root Cause Analysis: This is a conclusion of two incidents which occurred on 1/31/14...and 2/2/14...In each incident resident was in his room after the evening meal and lost his balance...Incident was an accident and apparently related to: Resident losing his balance while in his drawer and changing his pants...Resident indicated to writer that he was just...fell over backwards..." ~On 2/5/14 a nursing note indicated, "...History Of Incident/Root Cause Analysis: Res lost his balance when at his dresser...Date Of Incident: 1/31/14...does have a history of falls in the late afternoon, often will fall when turning. loses balance...balance deficit gait instability impulsive unaware of safety issues unaware of physical limitation...We continue with every 15 minute checks and we remind res to take his time, turn slowly, make sure he always uses his walker...Date of incident 2/2/14...Contributing Factors: weakness gait instability cognitive impairment impulsive unaware of safety issues unaware of physical limitation...Current status and interventions balance the benefits of greater independence and freedome (sic) of movement with the desire to minimize falling and prevent future injuries. Continue with safety checks. Supper tray will be served last in the DR (dining room)..." The facility again identified what Resident #1 was doing at the time of the falls. The facility also identified many fall risk factors for Resident #1. Despite this, there were no new interventions put into place based on the cause of Resident #1's falls to prevent Resident #1 from further falls. There was also no indication the approach of making sure Resident #1 got his tray last was added to Resident #1's plan of care. Nursing notes continue. ~A nursing note dated 2/18/14 indicated Resident #1 had a fall in his room and was found in front of his dresser. The nursing note indicated reminders were given to Resident #1 to use his call light and to keep his walker near. ~A nursing notes dated 2/19/14 indicated Resident #1 had two falls in his room. Resident #1 sustained skin tears to the right arm, and bruising to the left arm. The nursing note also indicated Resident #1 hit his head. ~A nursing note dated 2/19/14 indicated, "...Incident Investigation/Root Cause Analysis: This is a conclusion for three incidents occurring on 2/18/14...2/19/14...Res was found on the floor all three times...Incident was an accident...GI (gastrointestinal) illness..." While the facility identified Resident #1 had a GI illness, the facility put no new interventions into place to prevent further falls. Resident #1 subsequently had three falls including injury falls during the GI illness. The facility indicated on 2/19/14 a pull apart clip alarm was implemented. Nursing notes continue. ~On 2/20/14 a nursing note indicated Resident #1 had a fall in his room. The nursing note indicated Resident #1 sustained an abrasion on the back. According to the nursing note Resident #1 had been utilizing an alarm attached to Resident #1's call light and not a pull apart alarm. The alarm had been removed prior to the fall. According to the nursing note the facility implemented a pull apart alarm. ~On 2/21/14 a nursing note indicated, "...Incident Investigation/Root Cause Analysis...Res was observed...to start to lose his balance and sit backwards; res could not be reached in time to intervene...Incident was an accident and apparently related to...Res lost his balance...developed GI s/s (signs and symptoms) 2/19 (2/19/14) and has been weak...recently has been very focused on opening/closing his window, walking forward and then backwards...had a pull apart alarm...2/19/14; frequent alarm sounding and staff response seemed to be both confusing res and making him more anxious. Shortly before...incident alarms were discontinued....now they have been reinstitued (sic)..." Nursing notes continue. ~On 2/21/14 Resident #1 had a fall in his room. According to the nursing notes there was no injury. The facility implemented a motion sensor alarm. ~A nursing note dated 2/23/14 indicated, "History Of Incident/Root Cause Analysis: Date Of Incident: 2/19/14...Contributing Factors: weakness acute illness...cognitive impairment impulsive unaware of safety issues unaware of physical limitation Incident Analysis: Current status and interventions balance the benefits of greater independence and freedome (sic) of movement with the desire to minimize falling and prevent future injuries...Resident is at high risk..." ~A nursing note dated 2/24/14 indicated,"...Incident Investigation/Root Cause Analysis...Incident occurred: 2/21/14...observed to be sitting on the floor next to his bed. Alarm device clip had been removed from res clothing, apparently by res...Staff adjusted alarms in response to res incident, adding a sentinal device and pressure alarm in hopes of alerting staff..." Nursing notes continue. ~On 3/1/14 a nursing note indicated Resident #1 had a non-injury fall in his room. The nursing note again reiterated Resident #1 had weakness, a cognitive impairment, was impulsive, was unaware of limitations and had gait and balance problems. The nursing note also indicated, "...resident refuses to ask for help or wait for assistance...numerous falls with same pattern...resident does into his room and moves his garbage bucket or chair, bends down and falls...devices were implemented, pressure alarm in bed and chair at all times..." There was no investigation of the fall on 3/1/14. The facility implemented a pressure alarm. According to the nursing note dated 2/24/14, a pressure alarm had already been implemented. The facility had also identified Resident #1 had a history of [REDACTED]. Despite this there were no new interventions added to Resident #1's plan of care to prevent further falls. Nursing notes continue. ~On 3/5/14 Resident #1 had a fall in his room. Resident #1 sustained three small bruises to the right hand. A nursing note dated 3/5/14 indicated, "...poor postural control, poor body mechanics balance deficit gait instability cognitive impairment impulsive unaware of safety...instructed resident on safe use of assistive device safe transfer techniques use of call light resident also educated on asking/waiting for assistance..." ~A nursing note dated 3/6/14 indicated, "...Incident Investigation/Root Cause Analysis...Incident occurred: 3/5/14...staff responded to sound of alarms...Incident was an accident...res...lost his balance...had a haircut ...the same afternoon and this was a change in routine...recovering from GI illness...pressure alarm has been utilized and effective in alerting staff to res movements...Therapy will be contacted..." The facility continued to identify multiple fall risk factors and patterns of Resident #1's falls. Despite this, there were no new interventions added to Resident #1's care plan to prevent further falls. Additionally, the facility continued to educate and/or remind Resident #1 on safety, use of the call light, and to ask for assistance when Resident #1 did not have the ability to recall the information. Nursing notes continue. ~On 3/10/14 Resident #1 had a fall in his room. Resident #1 sustained bruising on the back. The nursing note indicated the alarm on Resident #1's bed was not working and a new alarm was placed. The nursing note indicated Resident #1 was walking with an armful of clothing without the walker. The nursing note indicated staff instructed Resident #1 on the use of the walker and use of the call light. ~A nursing note dated 3/11/14 indicated, "...Incident Investigation/Root Cause Analysis...Pressure alarm...very successful in alerting staff to res...frequent movements and independent transfers, ambulation...Alarm was not functioning at time of incident - perhaps due to wear and tear...also possible that res may have manipulated or tampered with alarms...Staff will continue to monitor res and alarms..." The information again indicated Resident #1's fall was associated with carrying clothing. Despite this knowledge there were no new interventions put into place. Nursing notes continue. ~On 3/14/14 Resident #1 had a non-injury fall in his room. Resident #1 indicated he was attempting to open a window. The nursing note indicated, "...he does have a recliner in his room next to his window...did speak to him about this recliner, he never uses it and we did remove it so the path to his window is now open...instructed resident on not getting up alone...Incident Investigation/Root Cause Analysis...Incident was an accident...Res...was in the process of adjusting the window...Res had been observed by staff responding to the alarms to be opening and closing the window throughout the night...he often adjust the window...Staff had observed res on frequent checks doing so...unused recliner removed from room to give res a clearer path..." According to the nursing note, Resident #1 had been up several times to open or close the window prior to the fall. It was not until after Resident #1 fell , that the facility removed a recliner which obstructed Resident #1's path. Nursing notes continue. ~On 3/16/14 a nursing note indicated Resident #1 had a fall in his room. The fall was witnessed. The nursing note indicated, "...was walking backwards from windown (sic) lost balance and fell , res did strike his head...obsessed currently with his window, his clothes, the garbage can...he has been up repeatedly to check his window, to open the window, to close the window...will continue with every half hour checks and with the pressure alarm in bed and chair..." ~On 3/17/14 a nursing note indicated, "...Incident Investigation/Root Cause Analysis...Incident was an accident and apparently related to: Res losing his balance...has become focused on first opening and alternately closing his window...staff will attempt to involve res in more constructive activities in areas that are cooler..." There was no indication the approach to involve Resident #1 in activities in areas cooler was added to Resident #1's plan of care. Nursing notes continue. ~On 3/19/14 a nursing note indicated Resident #1 had a witness fall at the nursing station. The nursing note indicated Resident #1 had walked from a chair approximately 6 feet from the nursing station, place a cup of coffee on the counter of the nursing desk with his walker and then walked backwards to the chair Resident #1 had come from. The nursing note indicated Resident #1 started to turn to sit on the chair and lost his balance. Resident #1 sustained a skin tear on the right hand and right elbow with bruising surrounding, a laceration on the left thumb, and a bruise on the right buttock The nursing note indicated the pressure pad alarm was not sounding and a new one was placed. ~A nursing note dated 3/21/14 indicated, "...Incident Investigation/Root Cause Analysis...Incident occurred: 3/19/14...Incident was an accident and apparently related to: Res losing his balance while walking backwards...Alarm...did not sound when res got up to go to the desk...wear and tear were a factor in alarm not functioning..." This was the second incident in which an alarm was not functioning properly. There were no new interventions put into place. Nursing notes continue. ~A nursing note dated 3/25/14 indicated Resident #1 had a witnessed fall in his room. The nursing note indicated Resident #1's alarm was sounding and staff found Resident #1 walking with his walker with his pants down. The nursing note indicated Resident #1 lost his balance, and fell backwards striking his head on the corner of the bed frame. The nursing note indicated Resident #1 sustained a laceration to the back of the left side of the head and a bruise to the back of the right side of the head. The nursing note indicated the facility would continue with the interventions previously placed including the bed and chair alarms and frequent checks. Resident #1 was transported to the emergency room for an evaluation and treatment. The laceration required staples. Resident #1 returned to the facility. Nursing notes continue. ~A nursing note dated 3/26/14 indicated, "...Incident Investigation/Root Cause...Incident occurred: 3/25/14...CNA responded to sound of alarm and found res walking with walker towards the bathroom, pants down around his ankles. As CNA entered room...he started to lose his balance and fell backwards before CNA could get to him...Incident was an accident and apparently related to...he may have lowered his pants...when he felt toileting urgency..." The nursing note indicated Resident #1 may have been responding to a toileting need. There was no indication the facility completed a comprehensive bladder assessment to determine if Resident #1's toileting schedule required changes. There was no new interventions put into place to prevent further falls. According to the nursing notes, on 4/2/14 Resident #1 was transported to the emergency room due to a decline in overall condition including increasing confusion, lethargy, slowed responses, and increased ADL (activities of daily living) needs. Resident #1 returned to the facility with [DIAGNOSES REDACTED]. Nursing notes continue. ~A nursing note dated 4/9/14 indicated Resident #1 fell in his room. The nursing note indicated Resident #1 was found on his back with his head resting on the metal bar of the over-the-bed table. According to the nursing note Resident #1 prior to the fall had been sitting in a wheelchair. ~A nursing note dated 4/10/14 indicated, "...Incident Investigation/Root Cause Analysis...resident had been sitting in w/c (wheelchair) just prior to incident and staff responded to alarm and found him on the floor. Incident was an accident and apparently related to: resident apparently attempting to get up on his own and lost balance...is currently being treated for [REDACTED]. The root cause analysis reiterated the information regarding the fall itself. There were no new interventions put into place following the fall. Nursing notes continue. ~On 4/10/14 a nursing note indicated Resident #1 had a fall in his room. The nursing note indicated Resident #1 was walking without his walker and staff responded to an alarm. ~On 4/11/14 a nursing note indicated, "...Incident Investigation/Root Cause Analysis...staff responded to alarm and found resident on the floor...Incident was an accident and apparently related to: less then 5 minutes prior to incident staff had just seen resident in his w/c. He apparently attempted to get up on his own and fell ..." ~On 4/12/14 a nursing note indicated, "...History Of Incident/Root Cause Analysis: Date Of Incident: 4/10/14...Pattern shows: numerous incidents with same pattern...weakness poor postural control poor body mechanics balance deficit gait instability cognitive impairment impulsive unaware of safety issues..." The root cause analysis again reiterated the same information gathered during the fall. There were no new interventions put into place. Nursing notes continue. ~On 4/13/14 a nursing note indicated Resident #1 had a non-injury fall in his room. The nursing note indicated Resident #1 was found on the floor and his alarm was not sounding. ~On 4/15/14 a nursing note indicated, "...Incident occurred 4/13/14...Res was found sitting on the floor next to his bed...Incident was an accident and apparently related to...res indicated that he fell , without providing further details...At time of incident alarm was not functional and was subsequently replaced...reminded res that he may become dizzy or lightheaded when standing...re-education and reminding res of issues with his health..." This was the third time Resident #1's alarm was not functioning. The root cause analysis did not analyze the cause of the fall. There were no new interventions put into place. Nursing notes continue. ~On 4/15/14 a nursing note indicated Resident #1 had a fall in the dining room. The nursing note indicated when Resident #1 went to stand the wheel chair Resident #1 was in moved backwards and Resident #1 subsequently sat onto the floor. The new intervention put into place was to ensure Resident #1's wheel chair was locked. The nursing note indicated Resident #1 was able to lock and unlock the brakes on the wheelchair. This was the second time Resident #1 had a fall from the wheelchair when attempting to stand. Resident #1 did not have the cognitive ability to remember to lock the brakes of the wheelchair. Nursing notes continue. ~On 4/16/14 a nursing note indicated Resident #1 had a fall in his room. The nursing note indicated Resident #1 was sitting next to his bed and the battery from the alarm was found sitting next to him. The facility surmised Resident #1 removed the battery. ~On 4/16/14 a nursing note indicated, "...Incident Investigation/Root Cause Analysis...1st incident occurred: 4/15/14...Another res witnessed res leaning forward as if to stand, w/c wheeled back and res slid out of the chair...2nd incident occurred: 4/16/14...Res was found on the floor...sitting next to bed. Alarm device had been dismantled...Incident was an accident and apparently related to: Primarily to res actions of attempting to get up without summoning or waiting for needed assistance...It has been determined that res should be transferred to a stationary chair with walker in close proximity after either ambulating or moving to activity area...following the 2nd incident staff determined that a mat type alarm placed on floor next to bed may be more effective..." The alarming mat is designed to play a tune when it senses pressure being applied to it. Nursing notes continue. ~On 5/19/14 a nursing note indicated Resident #1 had a fall in the dining room while walking independently with his walker to another table in the dining room to obtain water. The nursing note indicated Resident #1's alarm was sounding when the fall occurred. The nursing note also indicated, "...instructed resident on not getting up without staff to assist him...also reminded him that he should not get up if he hears the alarm go off, he told writer to 'Shut up!'..." Resident #1 sustained a skin tear on the right shin and redness and swelling to the left wrist. ~On 5/21/15 a nursing note indicated, "...Incident Investigation/Root Cause Analysis...resident was in the dining room and went to another table to get water...witnessed by 3 other residents...Incident was an accident and apparently related to: resident getting up on his own and falling...Staff will assure his water pitcher is full on his table." Surveyor # completed a review of a facility form titled "Park Manor Nursing Home Supplemental Care Plan." The care plan identified Resident #1 had a decline in functioning, including increased weakness, decreased balance both sitting and walking, leaning to the right and leaning forward when walking. Nursing notes continue. ~On 6/30/14 a nursing note indicated Resident #1 had a fall in the dining room. The nursing note indicated Resident #1 stood up eliciting the alarm; however staff were unable to reach him before he fell . Resident #1 sustained three bruises and three skin tears on the right elbow. The nursing note indicated staff were to continue with the current alarms and alarming mat. ~On 7/1/14 a nursing note indicated the root cause analysis again reiterated the information contained in the fall nursing note. There were no new interventions put into place. Nursing notes continue. ~On 8/9/14 a nursing note indicated, "...lowered to sitting on edge of tub...staff...assisting him...to his bathroom...During the process of turning to sit on the toilet, he started loosing his balance and staff lowered him to the edge of the tub...He began to slid into the tub was repositioned back to sitting and assisted up onto the toilet..." There were no new interventions put into place following the fall. ~According to the nursing notes on 8/9/14 Resident #1 had a second fall. A nursing note dated 8/9/14 indicated Resident #1 was found on the floor laying on his right side while attempting to go to the bathroom. The nursing note also indicated the alarming mat by Resident #1's bed was found underneath Resident #1's bed and staff surmised that Resident #1 had pushed it under the bed to avoid it alarming. The nursing note indicated staff heard the bed alarm but enroute (sic) to Resident #1's room heard Resident #1 fall. The nursing note indicated staff put non-slip material under Resident #1's mat to keep it from sliding. ~On 8/11/14 a nursing note indicated, "...Incident Investigation/Root Cause Analysis...The incident...resulted from staff toileting resident...The second incident occurred...Resident stated he had to go to the bathroom...This was during the full moon and resident has a pattern of incidents during the full moon phase..." Both falls were related to Resident #1 needing to use the bathroom. There was no indication the facility completed a bladder assessment to determine if Resident #1's current toileting regimen required changes. There were no new interventions put into place based on the cause of the falls. There was no indication the use of non-slid material was placed on Resident #1's plan of care. Nursing notes continue. ~On 9/11/14 a nursing note indicated Resident #1 had a fall in his room. The nursing note indicated, "...kneeling on left knee and holding onto walker, behind door to room. Door has been left 1/4 open...after prior toileting...Doorway now closed, CNAs able to push open w/ (with) difficulty to reach res..." Resident #1 sustained bruising to the buttock and redness to the left knee. ~On 9/11/14 a nursing note indicated, "...Incident Investigation/Root Cause Analysis...Staff noted that res room door was closed as alarm began sounding...When staff...attempted to open room door it was discovered that res had fallen and was laying against doorway...Incident was an accident and apparently related to...appeared that res may have been looking in his closet or in that general area when he fell ...It was also noted that musical mat alarm...was under the bed instead of along side of the bed. Night staff had found res on two occasions moving mat with his feet under the bed...It is possible that res...is moving mat to avoid intervention...Res remain fiercely independent and motivated to do things for himself despite his complex medical conditions. He is not willing nor able to wait for assistance..." The facility had identified the alarming mat was not effective, yet it continued to be an intervention. Surveyor # could not determine if the non-slip material was under the mat. There were no new approaches added to Resident #1's plan of care to prevent further falls. On 9/16/14 a nursing note indicated Resident #1 had symptoms of a stroke including leaning to the right, right facial droop, and tongue deviation to the right. Per family wishes and physician orders, Resident #1 was not transported to the emergency room for an evaluation. Nursing notes continue. ~On 9/27/14 a nursing note indicated Resident #1 had a fall in the bathroom and was found sitting inside the tub. The nursing note indicated there were no alarms sounding and Resident #1 was responding to a toileting need. The nursing note indicated Resident #1 sustained a cut on the left side of his tongue. The nursing note indicated Resident #1 had been last seen sitting in a chair by the nursing station. The nursing note also indicated Resident #1 had a pressure alarm and pull apart alarm on both the bed and chair. Surveyor # was unable to determine when the pull apart alarm was implemented. The pull apart alarm however had been utilized in the past and proven ineffective as Resident #1 would remove it. ~On 9/29/14 a nursing note indicated, "...Late Entry for: 9/28/14...History Of Incident/Root Cause Analysis: Date Of Incident: 9/27/14...found sitting in tub with legs over the side...unable to safely ambulate or transfer alone. Continues to attempt even w/frequent reminders to wait for help, disables floor mat alarm at times...frequent falls despite interventions in place..." ~On 9/30/14 a nursing note indicated the alarm utilized on the chair by the nursing station was not sounding. Resident #1 was again responding to a toileting need. There were no new interventions put into place. Additionally Resident #1's alarm was again not sounding. Nursing notes continue. ~On 9/30/14 a nursing note indicated Resident #1 had a fall by the nursing station when attempting to get up from a chair. The nursing note indicated, "...trying to get up to go to the bathroom...but slid from the chair and onto the floor...incident occurred faster than staff could get to resident..." The nursing note indicated there were no new approaches added to Resident #1's care plan to prevent further falls. ~On 10/1/14 a nursing note indicated, "...Incident Investigation/Root Cause Analysis...heard sound of alarms, immediately turned and observed res sliding from his chair...Pressure alarm was noted to be sliding with res..." Resident #1 was again responding to a toileting need. There was no indication the facility completed a comprehensive bladder assessment. There were no new approaches added to Resident #1's plan of care to prevent further falls. Nursing notes continue. ~On 10/5/14 a nursing note indicated Resident #1 slid to the floor from a chair. On 10/6/14 the facility placed a non-skid mat on Resident #1's chair. This was implemented after Resident #1 had several slides

Based on observations, interviews, and record reviews, the facility did not ensure that 11 of 19 sampled residents received appropriate care and treatment related to urinary incontinence: ~1 of 4 residents reviewed for indwelling urinary catheters did not have medical justification for placement of a catheter, and experienced urethral damage and pressure ulcers as a result. (Resident #9) ~10 of 11 residents reviewed for urinary incontinence were not assessed and did not have an individualized toileting plan developed to assist them in improving and maintaining as much continence as possible. (Residents #3, 4, 5, 6, 7, 9, 10, 14, 15, 16) ~1 of 11 residents reviewed for incontinence did not receive care to prevent the development of a UTI. (Resident #5) *The facility implemented a 3-day voiding data collection for Resident #9 beginning 3/8/14. The data collection was incomplete and the facility did not develop a plan to assist Resident #9 to restore as much normal bladder function as possible. No toileting plan was developed even though Resident #9 demonstrated the ability to remain continent. Resident #9 developed open areas, believed to be associated with urinary incontinence. An indwelling catheter was inserted on 4/23/14 for urinary incontinence and skin breakdown. Despite placement of the catheter, Resident #9 continued to develop and redevelop open areas on his buttocks. This demonstrated that the skin breakdown was not related to urinary incontinence and therefore negated the reason for placement of the catheter. While the catheter was in place, Resident #9 experienced injury to the urethral opening and also developed pressure ulcers to the scrotum due to the catheter tubing. In addition. Resident #9's catheter was changed on a routine monthly basis without medical justification to do so. On 8/26/14, Resident #9 was admitted to the hospital with [REDACTED]. He was found to have a urinary tract infection and possible pneumonia. The catheter was removed on 10/31/14. The facility did not complete a comprehensive assessment and develop an individualized toileting plan to assist Resident #9 in improving his bladder continence status. *Resident #10 had a decline in bladder status. The facility did not complete a comprehensive assessment and did not update the care plan to assist her in regaining and maintaining as much bladder function as possible. *Resident #16 had a decline in bladder status identified on the 4/18/14 MDS assessment. The facility did not complete a comprehensive assessment and did not update the care plan to assist her in regaining and maintaining as much bladder function as possible. *Resident #3, #4, #14, and #15 all had functional incontinence. Despite this, the facility did not complete a comprehensive bladder assessments including critical data in order to implement individualized toileting schedules to maintain and/or improve incontinence. Residents #3, #4, #14, and #15 subsequently were never afforded the opportunity to improve incontinence. *For Resident #5, #6, and #7, the facility did not comprehensively assess the residents' usual voiding patterns, determine the types of incontinence, consider toileting schedules, develop care plans to improve bladder function with individualized approaches and measurable goals, and explore reversible causes of incontinence. *Resident #5 received improper perineal hygiene following an incontinence episode. This is evidenced by: Example #1: Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS (Minimum Data Set) assessment dated [DATE] indicates: ~Unable to ambulate, extensive assistance with bed mobility, dressing, toilet use with assistance of 2 staff. Transfers with a lift; ~Always incontinent of urine with no toileting plan. Occasionally incontinent of bowel; and ~High risk for pressure ulcers. BLADDER ASSESSMENT 1 A 3-day elimination trial was initiated for Resident #9 on 3/8/14 through 3/11/14. Review of that information reveals the following: ~ 3/8/14, the 3-day elimination form was incomplete. Toileting was not offered every 2 hours per the facility's protocol indicated on the form. There is no documentation from 7:30 p.m. to midnight. The trial indicates that resident was dry 7 out of 10 times, requested to be toileted/expressed urge to go 5 out of 10 times, and was continent upon toileting 4 out of 10 times the resident was continent upon toileting. ~ 3/9/14, the 3-day elimination form was incomplete. No toileting offered from 8:00 p.m. to midnight. The trial indicated Resident #9 was dry 9 out of 11 times, requested toileting/expressed urge 4 out of 11 times, and was continent upon being toileted 4 out of 11 times. ~ 3/10/14, the 3-day elimination form was incomplete. No toileting offered between 9:30 a.m. to 1:30 p.m. and from 7:30 p.m. to midnight. Resident was dry 6 out of 10 times. Requested 4 out of 10 times to be toileted or expressed the urge to go. Resident was continent 2 out of 10 times upon being toileted. On 3/11/14, the facility completed the continence assessment using the incomplete information. The assessment indicated: Awareness Toileting: Resident is rarely aware of toileting needs. Toilet Ability: Resident is not able to be toileted due to: resident is a Hoyer lift and dribbles almost all the time. Plan: Staff will provide good incontinence care as necessary. The assessment and plan did not reflect the information gathered during the 3-day voiding pattern. CATHETER PLACEMENT According to nursing notes: ~On 3/20/14, Resident #9 developed several open areas on the right and left buttocks. The left buttock was healed on 3/24/14, and the right healed on 4/1/14. ~On 4/22/14, staff requested to place Foley catheter due to urinary incontinence and skin breakdown r/t (related to) decreased mobility. Physician orders [REDACTED]. ~4/23/14, inserted Foley catheter #16 Fr.(French) 5 ml (milliliters). There is no valid medical justification for the Foley catheter as Resident #9 has no current open areas. In addition, there is no indication that the open areas experienced on 3/20/14 were a result of moisture/incontinence. Review of the nurse's notes reveal the following entries related to urethral injury: ~4/30/14, the head of Resident #9's penis is red and the catheter seems to be making meatus opening larger. ~5/1/14, staff reported resident has redness and blistered area to top of penis. Gauze wrapped around catheter tubing to protect area from irritation. ~5/2/14, the top of the penis is now open and appears to be from catheter rubbing to area. Measures: 0.5 cm x 0.5 cm, Depth: superficial. The tip of Resident #9's penis and the catheter insertion site is reddened. ~5/7/14, Resident #9 has a very small area approximately 0.2 cm that was a possible blister, although there was also swelling of the foreskin as it was not pulled back over head of penis. This has subsided since that time. No swelling of foreskin. The scrotum does appear to be more tender and swollen than last week seen by this nurse He has catheter in place and at times does have whitish discharge that comes out from around the catheter. res. (resident) has the leg strap that holds the tubing in place high up on leg to avoid pulling of the tubing. He has no open areas on buttocks. ~5/26/14, Meatus where catheter seems to rub is also pink and occasionally has bloody-like drainage, small amount. Attempting to keep area dry with use of cloth but no pad as the pad has plastic outside and this causes increased moisture on inner thighs. ~5/28/14, Meatus has 0.6 cm area that is like a slit opening. A soft cloth is placed under and up on sides of scrotum to prevent the skin to skin contact. He is also allowing repositioning. ~5/29/14, skin appears to be slowly improving i.e.: less moisture is present as soft cloths are placed to keep the skin-to-skin contact. ~6/1/14, blackened area to penis just below urinary meatus. Penis and scrotum are wrapped with soft cloth in a hammock-like manner for protection. ~6/2/14, urinary meatus approximately 1 cm x 1.5 cm slightly raised, no drainage, black in color. ~6/3/14, "Assessment of wound:...He has a Foley catheter to keep urine from skin, he is incontinent of bowel. He has been getting fluid filled areas that open and then heal the past few weeks. Nothing has been greater than 2 cm. Now he has an area on the left buttocks that is larger, firm and has purulent drainage. MD was notified and we are monitoring at this time. he was treated in Marsh (sic) and April with antibiotics for UTIs (urinary tract infection). He has an alternating air mattress on the bed. He is repositioned by staff and good incontinence care is given. Location: inner aspect of coccyx writer did recommend [MEDICATION NAME] to the wound to provide autolytic debridement to area. Will continue with above interventions. Etiology: of coccyx is moisture, obesity and skin to skin contact. Etiology: of left buttocks is unknown. Etiology: blackened area on penis is moisture, he is uncircumcised, has indwelling Foley catheter." ~6/10/14, "Skin Condition: Assessment of Wound: Location: tip of resident's penis, this area was previously documented as blackened. Size 1.5 cm x 0.8 cm Depth: superficial Drainage: non present Wound Bed: slough noted to upper portion of the wound that measures 1 cm x 0.4 cm, granulation tissue is noted to rest of wound bed. Color: Area of slough currently is yellowish/white, beefy red tissue is noted to the rest of wound. Surrounding Tissue: clean and dry Healing Progress: becoming smaller Wound Care: Area cleansed with soap and water, apply A & D to this area. Skin Interventions: Catheter tubing is wrapped with a soft cloth to prevent rubbing to resident's penis." (questionable location of the above description). ~6/11/14, "He has a mattress overlay as the low air loss mattress was not effective due to his size and unsafe with the repositioning. The tip of penis is not blackened colored, area is healing and there is some granulation tissue present already..." ~6/26/14, late entry for 6/25/14. "Resident is morbid obese and sweats profusely. Soft cloths are placed around scrotum. He has chronic skin breakdown to scrotum and buttocks R/T the moisture. He currently has a chronic indwelling catheter to keep the urine off his skin which would contribute to more moisture." ~10/24/14, late entry for 10/23/14. "Assessment of an open area: Location: head of penis Etiology: from catheter tubing being kinked. Size: 0.5 cm Wound Bed: pink meaty tissue. Surrounding Tissue: moist. Wound Care: will assure excellent peri care is being done. Skin Interventions: will wrap penis/scrotum with soft cloths and assure proper placement of tubing. Resident is prone to open areas here from the tubing..." "Will evaluate risks and benefits of the catheter vs no catheter and inform MD (medical doctor)." Penis and Scrotum pressure ulcers: ~8/20/14, open area on the right side of penis starting from under the foreskin and 3 cm towards the base of the penis 0.2 cm wide. Contributing factors: Foley catheter. Care plan and injury of unknown origin investigation started. ~8/22/14, "Assessment of Wound: This is a chronic area for this resident. He has an indwelling Foley catheter. He has a hx (history) of skin breakdown to penis tip, shaft and scrotum along with his buttocks and thighs. This is not an injury of unknown origin." ~10/7/14, Late entry for 10/3/14, 2 open areas remain on scrotum, they are superficial at this time. ~10/14/14, "scrotum have fragile skin and are healed over." ~10/19/14 "an abrasion 0.5 cm in diameter on the anterior side of his penis, it is superficially open." ~10/21/14, "Bottom of scrotum 1 cm x 1 cm and over shaft of the penis, ventral 2 cm x 1 cm." Pressure Ulcers: During the time that Resident #9 had the urinary catheter in place to prevent skin breakdown, he experienced the following: Coccyx - opened 5/31/14 and healed 7/31/14. Right buttocks - opened 5/2/14 and healed on 5/7/14. Left buttocks - opened 5/2/14 and healed on 5/7/14. Left buttocks - 2 areas reopened 5/12/14 no indication when healed. Right buttocks - reopened 8/18/14 and healed 9/30/14. Left buttocks - 2 areas reopened 8/18/14 and healed 9/30/14. A note on 10/29/14 states, "Catheter for protection to the skin mainly buttocks d/t (due to) frequent skin openings, had frequent episodes of skin irritation to the penis from catheter tubing. He has had openings to the buttocks also even with the indwelling Foley catheter. We have an order to remove when skin to buttocks is healed. At this time it is felt that the risks of contributing to more skin irritations specifically to the penis and his chronic pain in his penis and scrotum out way the benefits of the catheter in place to prevent skin breakdown as he has skin breakdown. Will remove catheter at this time and provide excellent incontinence care." ~10/31/14, the indwelling catheter was removed. ~11/4/14, "His scrotum is swollen, reddened and tender to the touch. Has a superficial open at the bottom of the scrotum noted, 0.5 cm x 2 cm, wound base moist." ~11/6/14, "tip of penis is healed at this time...The indwelling Foley catheter was recently removed and resident is able to know the need to void at times and at others he does not...C.N.A.s, (certified nurse assistants) he is incontinent of bowel and bladder even with toileting..." ~11/28/14, "Skin Condition: open lesion Location: Scrotum (left anterior) Size: 1.6 cm x 0.4 cm odd shape...Staff instructed to monitor when resident using urinal and to ensure that it is removed promptly after urinating complete." ~12/1/14, "Skin Condition: open lesion Location: Scrotum Size: 2 cm x 1 cm Depth: superficial Drainage: none present Color: pink/red Surrounding Tissue: some maceration to wound edges Wound Care: soap and water, open to air." Infection: On 8/26/14, Resident #9 had a temperature of 105 degrees F and is lethargic. Sent to the emergency room where he was diagnosed with [REDACTED]. Five days after removal of the catheter on 10/31/14, the facility initiated a 3-day bladder data collection starting 11/6/14. The following was noted: The last day was not complete. There was no offering of toilet from 2:00 p.m. until midnight. Nursing completed the continence assessment on 11/7/14 before the 3-day elimination trial was completed. The nurse documented that resident is usually aware of toileting needs. Toilet Ability: totally dependent on staff. Response to Incontinence: Resident expresses acceptance of incontinence or catheter. Plan: Continence Management - Resident wears incontinent product. Resident will be toileted upon request and as needed. There is no individualized plan. According to the 3-day elimination form, Day 1 = resident did not request toileting or express the urge to go. Day 2 = requested or expressed the urge to go 9 out of 12 times. Day 3 is incomplete but from 12 a.m. to 2 p.m., he requested or had the urge to go 4 out of 8 times. Review of Resident #9's care plan indicates no care plan for incontinence with individualized approaches or goals. The facility did not determine an accurate individualized toileting plan for Resident #9. Resident was dry more than incontinent if toileted. On 12/2/14 at 9:00 a.m., Surveyor # observed CNA-I completing Resident #9 morning cares. Resident #9 was in bed lying directly on an Allegro pad then a fitted sheet which both were soaked with urine. The care plan indicates that staff should not use an Allegro Pad. There was no soft cloths inbetween skin-to-skin of penis and scrotum. The care plan indicates to use a soft cloth to keep skin off skin. This was not followed. Surveyor # observed an open area with an odd shape anterior part of the scrotum. Slough was seen in the open wound which would indicate that this wound was a pressure ulcer. The odd shape of the wound indicates that pressure could be related to the shape of the opening of the urinal. The 11/28/14 note instructs staff to promptly remove the urinal after urinating is complete. This intervention is not on the care plan. Review of the nursing notes and treatment sheet indicates Resident #9's indwelling catheter was changed on a monthly basis: 5/22, 6/22, 7/22, 8/22,9/27, and 10/27. There was no individualized assessment to determine how often the indwelling catheter should be changed. With the already urethral trauma, frequent changes could prevent adequate healing to the area. Example #2: Resident #10 has [DIAGNOSES REDACTED]. Review of the MDS assessments finds the following related to bladder continence: ~1/9/14 Initial - Occasionally incontinent. ~6/19/14 Quarterly- Occasionally incontinent. ~9/15/14 Quarterly - Frequently incontinent. Review of the CAAs (Care Area Assessments) indicate Resident #10 is on a toileting plan. Review of Resident #10's care plan indicates: 1/17/14 "Problem: (Urinary Incontinence: Mixed incontinence...Occasional). Related To: Cognitive deficit (Dementia) Mobility deficit (Muscle weakness) Resident requires physical assistance with toileting. Manifested By: Incontinence (Primarily at Night). Approach: ...Toilet per scheduled toileting plan...Scheduled toileting..." There is no individualized toileting plan. Surveyor # reviewed Resident #10's continence assessments and noted the following entries: ~1/17/14: "Occasionally incontinent of urine...Functional Incontinence...Resident is able to be toileting with assist of: 1...Continence Management - toilet: every 2-3 hours, before and after activities and meals and as resident requests. Resident wears incontinent product..." ~6/13/14: "Occasionally incontinent of urine...Mixed Incontinence...Resident is able to be toileting with assist of:1...Continence Management - Staff will provide good incontinence care as necessary..." ~9/15/14: "Frequently incontinent of urine...Mixed Incontinence...Resident is able to be toileting with assist of: blank...Continence Management - Resident will be toileted upon request and prn (as needed)..." Resident #10 is moderately impaired for any decision making so being toileted upon request is not realistic. Surveyor # requested a 3-day voiding trial for the 9/15/14 assessment. No 3-day voiding trial was given to surveyor at end of survey. On 12/4/14 at 11:30 a.m., Surveyor spoke with RN-F regarding Resident #10's change in status. RN-F stated she should have completed a change in condition MDS which would include the decline in bladder status. Example #3: Resident #16 had [DIAGNOSES REDACTED]. Review of the MDS assessments finds the following related to bladder continence: ~12/13/13 Annual - Occasionally incontinent. ~3/11/14 Quarterly - Occasionally incontinent. ~4/18/14 Quarterly - Frequently incontinent. ~7/11/14 Quarterly - Frequently incontinent. Surveyor # reviewed Resident #16's continence assessments and noted the following entries: 3/10/14, "...Occasionally incontinent of urine...Functional incontinence...Symptoms (none listed)...Functional capabilities: decreased upper extremity strength decreased upper extremity strength (sic) pain with movement...Ambulation: Resident is unable to ambulate...Plan: toilet: Resident will be toileted upon request and prn (as needed)..." 4/3/14, "...Frequently incontinent...Functional incontinence...Symptoms: Resident experiencing increased frequency of urination...Resident experiencing dribbling or very slow interrupted urination stream...Functional capabilities: impaired mobility, decreased manual dexterity, decreased upper extremity strength decreased lower extremity strength...Ambulation: Resident is unable to ambulate...Plan: Continence Management-Resident wears incontinence product. Resident will be toileted upon request and prn..." During the 4/3/14 assessment, staff identified Resident #16 as having an increase in incontinence, an increase in symptoms and an increase in the number of functional impairments. However, there was no evidence that staff collected voiding data over several consecutive days. The purpose of doing so would be to identify voiding patterns and to develop a proactive plan to increase the likelihood of maintaining bladder continence. On 12/4/14, Surveyor # requested any voiding data collections completed for Resident #16. At 2:16 p.m., Surveyor # spoke with NHA-G. NHA-G indicated no data collection had been collected when the decline had been identified. Example #4: Resident #4 had [DIAGNOSES REDACTED]. Resident #4's most current MDS (Minimum Data Set) was dated 11/12/14. The MDS indicated Resident #4: ~ Had both short and long-term memory problems; ~ Required the assistance of one staff person for all aspects of care including using the bathroom; ~ A toileting program had not been attempted; and ~ Was frequently incontinent of bladder. Resident #4's care plan for urinary incontinence was dated 11/23/14. The care plan indicated Resident #4 had functional incontinence. The care plan had no approaches directing staff on how to manage Resident #4's bladder incontinence. Resident #4's CNA (Certified Nursing Assistant) care plan was undated. There were no directives to staff on how to manage Resident #4's bladder incontinence. Surveyor # completed a review of Resident #4's most current comprehensive bladder assessment dated [DATE]. The assessment indicated Resident #4 had functional incontinence. The assessment indicated, "...Plan: Continence Management - toilet: Resident wears incontinence product. Staff will provide good incontinence care as necessary." Surveyor # completed a review of Resident #4's most current bladder diary. On 9/4/14, 8 entries were noted in a 24 hours time frame indicating if Resident #4 was incontinent or requested to use the bathroom. On 9/5/14, 8 entries were also noted and on 9/6/14, 11 entries were noted. It would be impossible for the practitioner to determine a toileting schedule based on the limited information gathered. Surveyor # also received a form titled "Nursing Assessment/Evaluation of 3-Day Voiding Program." The assessment was undated. The assessment was not complete and did not indicate a plan for assisting Resident #4 to the bathroom to maintain continence to the extent possible. The assessment indicated, "...Res (Resident) sometimes is noted to try and toilet self...At times is aware of need to toilet..." On 12/2/14 at 10:20 a.m., Surveyor # observed Resident #4 hastily propelling her wheelchair stating "come on, come on" several times. Resident #4 then indicated "gotta pee." Resident #4 was assisted to the bathroom. On 12/3/14 at 12:10 p.m., Surveyor # spoke with CNA-T. CNA-T indicated all residents were on an every two hour toileting schedule. On 12/4/14 at 10:10 a.m., Surveyor # spoke with CNA-U about Resident #4. CNA-U indicated Resident #4 was incontinent and not able to hold her urine long. CNA-U also indicated Resident #4 never requested to use the bathroom, however will attempt to go to the bathroom independently. CNA-U indicated she assisted Resident #4 to the bathroom before and after breakfast and lunch. CNA-U indicated on that schedule Resident #4 does not maintain continence. On 12/4/14 at 10:20 a.m., Surveyor # spoke with RN-F (Registered Nurse). RN-F indicated the nurses on the floor completed routine bladder assessments and diaries including quarterly, annually, and with a change in condition. RN-F indicated staff were to look at the 3-day voiding diary and establish a toileting plan based on patterns noted. Surveyor # reviewed Resident #4's bladder diary with RN-F. RN-F indicated a toileting schedule could not be determined based on the limited information. Example #5: Resident #15 had [DIAGNOSES REDACTED]. Resident #15's most current MDS (Minimum Data Set) was dated 8/29/14. The MDS indicated Resident #15: ~ Had both short and long-term care memory problems; ~Required the assistance of 1 to 2 staff persons for all aspects of care; ~Did not have a toileting program attempted; and ~Was always incontinent of bladder. Resident #15's urinary incontinence care plan was dated 10/20/13. The care plan indicated Resident #15 had functional incontinence. There were no directives to staff on how to manage Resident #15's incontinence. Surveyor # completed a review of Resident #15's most current bladder assessment dated [DATE]. The bladder assessment indicated, "...Plan: Continence Management: Staff will provide good incontinence care as necessary..." There was no bladder diary associated with the bladder assessment dated [DATE]. Surveyor # also reviewed a bladder assessment dated [DATE]. The bladder assessment indicated, "...Functional incontinence...is sometimes aware of toileting needs...Plan: Continence Management - Resident wears incontinent product. Staff will provide good incontinence care as necessary..." Surveyor # completed a review of the bladder diary dated 8/13/14 through 8/15/14 and noted the following: ~For the 24-hour period on 8/13/14, there were 3 entries indicating whether was incontinent, or requested to use the bathroom. ~For the 24-hour period on 8/14/14, there were 3 entries. ~For the 24-hour period on 8/15/14, there were 3 entries. It would be impossible for the practitioner to determine a toileting schedule based on the limited information gathered. On 12/3/14 at 12:10 p.m., Surveyor # spoke with CNA-T. CNA-T indicated all residents were on an every two hour toileting schedule. On 12/4/14 at 10:20 a.m., Surveyor # spoke with RN-F (Registered Nurse). RN-F indicated the nurses on the floor completed routine bladder assessments and diaries including quarterly, annually, and with a change in condition. RN-F indicated staff were to look at the 3-day voiding diary and establish a toileting plan based on patterns noted. Surveyor # reviewed Resident #4's bladder diary with RN-F. RN-F indicated a toileting schedule could not be determined based on the limited information. Example #6: Resident #3 had current [DIAGNOSES REDACTED]. Resident #3's most current MDS (Minimum Data Set) was dated 9/24/14. The MDS indicated Resident #3 had both short and long-term memory problems, required the assistance of 1 to 2 staff persons for all aspects of care, had not had a toileting program attempted, and was frequently incontinent of bladder. Resident #3's comprehensive care plan was undated. The care plan did not identify Resident #3's bladder incontinence. The care plan contained no directives to staff on how to manage Resident #3's bladder incontinence. Surveyor # completed a review of Resident #3's most current bladder assessment dated [DATE]. The bladder assessment indicated, "...Functional incontinence...is sometimes aware of toileting needs...Continence Management - toilet: Resident wears incontinence product. Resident will be toileted upon request and prn (as needed). Surveyor # did not receive a bladder diary which corresponded with the bladder assessment dated [DATE]. A bladder diary contains critical information necessary to develop an individualized toileting program. At would be necessary to review a bladder diary prior to completing a comprehensive bladder assessment in order to determine an appropriate continence management. On 12/2/14 at 8:00 a.m., Surveyor # observed CNA-R assist Resident #3 with morning cares. This included placing Resident #3 onto a commode. Resident #3 was noted to void when seated on the commode. On 12/3/14 at 12:10 p.m., Surveyor # spoke with CNA-T. CNA-T indicated all residents were on an every two hour toileting schedule. On 12/4/14 at 10:20 a.m., Surveyor # spoke with RN-F (Registered Nurse). RN-F indicated the nurses on the floor completed routine bladder assessments and diaries including quarterly, annually, and with a change in condition. RN-F indicated staff were to look at the 3-day voiding diary and establish a toileting plan based on patterns noted. Surveyor # reviewed Resident #4's bladder diary with RN-F. RN-F indicated a toileting schedule could not be determined based on the limited information. Example #7: Resident #14 had current [DIAGNOSES REDACTED]. Resident #14's most current MDS (Minimum Data Set) was dated 9/23/14. The MDS indicated Resident #14 had a severe cognitive impairment, required the assistance of 1 to 2 staff persons for all aspects of care, and was always incontinent. Resident #14's most current bladder assessment was dated 9/4/14. The assessment indicated, "...Frequently incontinent...Functional incontinence...sometimes aware of toileting needs...Continence Management - toilet: resident wears incontinence product. Staff will provide good incontinence care as necessary. There was no bladder diary associated with the bladder assessment dated [DATE]. A bladder diary contains critical information necessary to develop an individualized toileting program. At would be necessary to review a bladder diary prior to completing a comprehensive bladder assessment in order to determine an appropriate continence management. On 12/3/14 at 12:10 p.m., Surveyor # spoke with CNA-T. CNA-T indicated all residents were on an every two hour toileting schedule. On 12/4/14 at 10:20 a.m., Surveyor # spoke with RN-F (Registered Nurse). RN-F indicated the nurses on the floor completed routine bladder assessments and diaries including quarterly, annually, and with a change in condition. RN-F indicated staff were to look at the 3-day voiding diary and establish a toileting plan based on patterns noted. Surveyor # reviewed Resident #4's bladder diary with RN-F. RN-F indicated a toileting schedule could not be determined based on the limited information. Example #8: Resident #5 was admitted to the facility for long term care on 11/29/13 due to progressive dementia. The facility completed a significant change in status MDS (Minimum Data Set) assessment for Resident #5 on 11/05/14 with the following data noted: ~Makes self understood sometimes; ~Understands others sometimes; ~Has impaired short and long term memory; ~Moderately impaired daily decision making skills; ~Required extensive staff assist with hygiene, toilet use, eating, and dressing; ~Was on a bladder toileting program; and ~Was frequently incontinent of urine and occasionally incontinent of bowel. During the initial tour that began on 12/01/14 at 6:50 a.m., RN-L (Registered Nurse) informed Surveyor # that Resident #5 required total staff assist for all activities of daily living and was incontinent of bladder and bowel. The facility completed a 3-day elimination diary on 10/14/14 through 10/16/14. The diary revealed staff toileted Resident #5 approximately every 2 hours; however there were gaps in documentation where there was no toileting information was recorded. The facility completed a Continence Assessment for Resident #5 dated 10/15/14. The assessment was a computer-generated form that did not include the cause of Resident #5's incontinence. The assessment noted to toilet Resident #5 with morning and bedtime cares, before and after meals, and as needed. The facility then completed a Nursing Assessment/Evaluation of the 3-day voiding diary on 11/08/14 for Resident #5. The assessment noted there was no incontinence pattern identified and Resident #5 would be

Based on observation, interview, and record review, the facility did not ensure that staff honored 1 of 22 sampled residents rights to make choices about their schedules. Resident #6 has a [DIAGNOSES REDACTED].#6 adamantly refusing to get washed and dressed, repeatedly stating she was too cold, to let her sleep a little while longer, leave her alone, etc,. She cried and moaned during both observations. Staff did not respect Resident #6's right to refuse and continued to conduct the cares and assisted Resident #6 to the wheelchair for the day. This is evidenced by: Resident #6 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Since admission to the facility, Resident #6 has had 3 MDS (Minimum Data Set) assessments completed. Certain areas of interest are listed below for each assessment: Initial [DATE]: ~ Speech clear; ~ Sometimes makes self understood and sometimes understands others; ~ Short and long-term memory problems; ~ Moderately impaired daily decision-making; ~ Continuous inattention and disorganized thinking; ~ Fluctuating level of consciousness and psychomotor [MEDICAL CONDITION]; ~ Poor appetite nearly every day; ~ Trouble concentrating nearly every day; ~ Short-tempered or easily annoyed nearly every day; ~ [MEDICAL CONDITION]; ~ Physical behavioral symptoms ,[DATE] days; ~ Verbal behavioral symptoms ,[DATE] days; ~ Rejection of care daily; ~ Extensive assistance of two staff for bed mobility, transfers, ambulation, toileting, and personal hygiene; ~ Extensive assistance of one staff for bathing, dressing and eating; ~ Occasionally incontinent of bowel and frequently incontinent of bladder functions. Quarterly MDS dated [DATE] had the following changes: ~ BIMs score of ,[DATE], this indicates severely impaired cognitive function; ~ Fluctuating inattention and disorganized thinking; ~ No Mood or behavioral symptoms; ~ All ADLs were coded as extensive assistance of one staff. Quarterly MDS dated [DATE] had the following changes: ~ Feeling tired or having little energy ,[DATE] days; ~ Rejection of care ,[DATE] days. The MDS assessments demonstrate an overall improvement in Resident #6. Resident #6's undated CNA (Certified Nursing Assistant) Care Plan indicates staff are to feed Resident #6 her breakfast at 10:00 a.m. There were no individualized approaches or interventions listed for staff on how to react or respond to any behaviors of rejection of cares specific to this resident. No indications on what works well for Resident #6 to achieve a positive result that is effective for both resident and staff. The undated Comprehensive Care Plan included the following problems: ~ Self Care Deficit Need to maintain current level of functioning related to Dementia with behavioral disturbances, anxiety, DJD ([MEDICAL CONDITION] joint Disease). Current approaches include to assure safety, monitor for changes in functional status, assess for behavioral changes and depression, establish ADL program, calm and gentle approach, establish consistent routine. ~ Activities: "Need for activities that maximize strengths, promote maintenance of physical, cognitive, social, spiritual, and emotional health...related to as able- important that resident make own decisions. Historically resident is very independent...generally responds well to structured environment...Manifested by as able needs to make choices and control lifestyle and activities..." Approaches include, but not limited to, encourage resident to state preferences regarding activities, lifestyle, etc. as able. ~ "Adjustment/Social Services: Potential for ineffective Coping related to loss of independence, loss of health, vision deficits, cognitive impairment, depression and anxiety...changes in routine and environment, loss of spouse...manifested by cannot meet own needs, agitation, wandering, resistive to interventions, needs assist with ADLs, physical and verbal behavior toward staff, refusing medications/food/fluids/care, nocturnal restlessness..." Approaches include to use a calm and gentle approach, compromise, document behaviors, redirect when wandering, and reapproach. There were no individualized approaches listed for staff on how to react or respond to any behaviors of rejection of care. No indications on what works well for Resident #6 to achieve a positive result that is effective for both resident and staff. Observation #1: On [DATE] from 9:18 a.m. until 10:05 a.m., Surveyor # observed CNA-A assist Resident #6 with cares. CNA-A attempted to gently arouse Resident #6. Resident #6 responded by stating, "I'm cold, I'm so cold. I don't want to get up. Let me sleep, leave me alone." Resident #6 repeated this several times, and each time CNA-A stated, "It's time to get up." CNA-B entered to assist with transferring Resident #6 to the commode. The two staff sat Resident #6 on the side of the bed. Resident #6 responded by stating, "No, no, please leave me alone. Let me sleep. I'm cold." This was repeated by Resident #6 several times. CNA-A and CNA-B proceeded to place a gait belt around Resident #6's waist in preparation for the transfer. The staff then attempted to transfer Resident #6 to the commode in which she responded, "I'm froze, please. Why are you so mean to me? I'm so cold." At this time, Surveyor # asked CNA-A if this is normal for Resident #6. CNA-A stated, "Yeah, she's like this almost every morning. Her daughter wants her to be up by 9:30 to eat breakfast at 10:00. Once, when I let her (Resident #6) sleep until 11:00 a.m., she was so pleasant, she helped me with her cares and she stood up really nice. " CNA-A and CNA-B then proceeded to transfer Resident #6. Resident #6 would not stand, instead buckled her knees and the staff had to nearly drag the resident to the commode. CNA-B then left the room. CNA-C then entered the room to assist CNA-A. CNA-A washed Resident #6's face, hands, underarms, and back. During this entire process, Resident #6 stated, "I'm frozen. I'm so cold." She then began to cry. CNA-A placed underpants on Resident #6 while CNA-C placed a long-sleeved undershirt on her. Resident #6 continued to state, "I'm so cold. I'm frozen. Why? I don't do anything to you." CNA-A then put a sweatshirt and slacks on Resident #6 and Resident #6 stated, "Ohhh, ohhh. Why are you so mean? Ohhh. Ohhhh, please." She then began to cry and wiped her tears with the right sleeve of her shirt. CNA-A and CNA-C placed the walker in front of Resident #6. When they attempted to stand her, Resident #6 again buckled her knees. CNA-A washed the resident's front and back perineum, pulled up her clothing and nearly dragged her to the seat of the wheelchair, as she begins to fall, buckling her knees during the entire transfer. The staff then attach the clip alarm to the back of the resident's shirt. At this time, Surveyor # asked CNA-C if this was normal for Resident #6. CNA-C stated, "Yeah, normally it's a battle in the morning but once she's up, she's fine." CNA-C left the room and CNA-A cleaned up her supplies. Resident #6 placed her face into her hands and began to cry, stating, "Ohhh, ohhh so mean to me. I'm not to you." Resident #6 began to complain her pants were too tight. CNA-A assisted her to change them. During this process, Resident #6 stood very well. On [DATE] at 2:15 p.m., Surveyor # asked RN-D, who was Resident #6's nurse on this day, about Resident #6 not wishing to get up that morning. RN-D stated, "It was a family decision to get her up by 9:30 a.m. or she would sleep all day and night, as she did at home. The family wants her to get her lunch at lunch time and breakfast later in the morning." RN-D stated there are behaviors every morning during her cares, but stated, "She would do better letting her sleep until the afternoon." On [DATE] at 8:15 a.m., Surveyor # asked CNA-B about her knowledge regarding Resident #6's behaviors. CNA-B stated sometimes Resident #6 helps with her cares and she is able to stand and walk down the hall. CNA-B stated she does Resident #6's cares between 9:00 a.m. and 10:00 a.m. She further stated, "The way you saw her yesterday is the way she always is when we get her up." Observation #2: On [DATE], Surveyor # observed CNA-B provide morning cares for Resident #6 from 9:15 a.m. - 10:18 a.m. CNA-B approached Resident #6, who was laying in bed on her left side, fully covered, head to toe with a quilted blanket. CNA-B gently attempted to arouse Resident #6. CNA-B told Resident #6 what time it was and it was time to get up. Resident #6 stated, "No, not yet. It's too early." CNA-B continued to gently coax Resident #6 into getting up, for which Resident #6 replied, "No, it's too cold." CNA-B readied her supplies, then returned to the resident's side, rubbed her shoulder and asked her if she was ready to get up. Resident #6 replied, "No, it's too cold." CNA-B then informed the resident that she was going to sit her on the commode. The resident stated, "No, it's cold. Ohh, I'm cold. Why get up so early?" CNA-B again told Resident #6 the time. Resident #6 responded, "So what?" CNA-B asked Resident #6 if she could sit up for her. Resident #6 stated, "No." When CNA-B asked why she could not sit up, Resident #6 stated, "Ohh, it's cold. I don't want to get up yet." CNA-B stated, "I know" and proceeded to uncover the resident and put slippers on her feet. CNA-B asked Resident #6 to sit up as she was wet and needing to be changed. Resident #6 replied, "I'm cold. I don't want to get up." CNA-B stated to the Surveyor, "I know it's against her right but they told us we have to try." When asked by the Surveyor who told her that, CNA-B responded, "I think it was the family." CNA-B then went back to coaxing the resident to sit up on the side of the bed. Resident #6 continued to reply that she was cold and it was too early to get up. She further stated she wanted to sleep a little while longer. CNA-B then offered to wash Resident #6 up in bed. The resident agreed to this, but did state, "I don't know. Somebody else might get mad. You tell me what to do...If you don't get the bed all wet. I'm cold. Why such a rush to get me out of bed?' CNA-B then proceeded to wash Resident #6 up in the bed. Resident #6 was uncovered while CNA-B washed her hands and face. Resident #6 complained repeatedly that she was cold but allowed CNA-B to provide the bath. When CNA-B removed Resident #6's gown, the resident began to cry louder that she was cold. The resident remained uncovered for the remainder of the bath. She cried out, "Ohhh ohhh ohhh" and "It's so cold" repeatedly. Resident #6 then stated, "Please, why are you doing this to me? and again continued with "ohhh, ohhhh" repeatedly. CNA-B apologized to Resident #6 but continued with the bath. Resident #6 whined, "Let me wake up, ohhh, ohhh, ohhh. I don't do nothing to you. Now I'm sopping wet. Ohhh, ohhh, ohhh, ohhh, ohhh, ohhh I'm so cold. Why are you doing this to me." This dialogue continued throughout the care delivery. CNA-B then placed a shirt on Resident #6 and rolled her to the right and left sides to straighten it. The resident continued to complain she was cold, and made statements of, "why are you doing this to me," and "let me alone," etc., throughout the entire process. CNA-B then assisted the resident to sit on the side of the bed Resident #6 refused to sit and CNA-B layed her back down. Resident #6 stated, "Who the hell is doing this to me? I'm wet, the bed is wet. I never saw such crap in my life." CNA-B stated, "I know." Resident #6 responded, "Then why are you doing it if you know?" The dialogue again continued back and forth with Resident #6 stating to be left alone, that she was cold and wet and CNA-B agreeing with the resident and apologizing. However, CNA-B continued with the cares and got Resident #6 to sit on the side of the bed. She then called over her walkie-talkie for CNA-C to assist with a transfer. CNA-C entered the room and assisted with this task. CNA-B and CNA-C then proceeded with the transfer. As she had the day before, Resident #6 refused to stand to assist with the transfer, buckling her knees. CNA-C stated to the Surveyor, "It's always a struggle but she has some good days if we let her sleep in." At 10:18 a.m., Surveyor # exited the room as Resident #6 was seated safely on the commode. On [DATE] at 2:30 p.m., Surveyor # met with Family-N, Resident #6's HCA (Health Care Agent), who is also an employee of the facility. Family-N stated it is very difficult to have her mom in the facility because of her loss of independence as well as her being an employee here. She stated at home, her dad had been Resident #6's caregiver but in early July he passed away. Family-N stated the routine at home was to allow Resident #6 to sleep late. Family-N stated she expects cares to be delivered here as they were in her home. Family-N stated Resident #6 was never a morning person, always complained she was too cold and getting her up in the morning was always a big problem. Family-N stated she wants a routine for Resident #6 and desired the resident sleep at night without being awakened for toileting if she was sleeping. That was the custom at home even though she would be incontinent. Family-N stated there is a noticeable difference on how Resident #6 is in the morning and how she is in the afternoon. Again Family-N stated, "She was never a morning person. We have managed to get a later breakfast delivered to her so she can sleep until 9:00 a.m.- 9:30 a.m., but maybe that isn't good either. Maybe we should try later." Surveyor # shared the observations made on [DATE] and [DATE]. Family-N stated, "I guess we really should try getting her up later, maybe we can give her Ensure or Carnation Breakfast in the morning and just let her sleep." On [DATE] at 4:00 p.m., Surveyor # interviewed SS-M (Social Services) regarding Resident #6's care. The Surveyor asked SS-M what the expectation is regarding a resident's refusal of cares. SS-M stated, "Staff would adjust the care plan to accommodate the resident's wishes. We would talk to the staff and adjust the resident's schedule." Surveyor # described the care observations made on [DATE] and [DATE]. SS-M was unaware of the anxiety and distress care delivery caused in Resident #6 and stated, "I will have to talk with the Certified Social Worker regarding this."