Every finding on record at Parsons Presbyterian Manor

Based on observation, interview, and record review, the facility failed to obtain a stop date for an as needed (PRN) antianxiety medication for Resident (R)2 and R5's lorazepam (an antianxiety medication). Findings included:- R2's Electronic Medical Record (EMR) documented a diagnosis of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R2's Significant Change Minimum Data Set (MDS), dated [DATE], documented R2 had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. She received antianxiety medication (a class of medications that calm and relax people) during the assessment period. R2's Psychotropic Drug Use Care Area Assessment (CAA), dated 03/02/2026, documented she had a diagnosis of anxiety and took antianxiety medication. R2's Quarterly MDS, dated [DATE], documented she had a BIMS score of 14, indicating intact cognition. She received antianxiety medication during the assessment period. R2's Care Plan, revised 03/15/2026, instructed staff to monitor the resident for side effects of her antianxiety medication. R2's EMR under the Orders tab, revealed the following physician's order: Lorazepam 0.5 milligrams, by mouth, every four hours, PRN, for a diagnosis of anxiety, ordered 04/08/2026. The order lacked a stop date. On 06/03/2026 at 08:30 AM, Administrative Nurse D confirmed R2's order for PRN lorazepam lacked a stop date, as required. The facility policy for Psychoactive Psychopharmacological Medications, revised 04/15/2025, included: PRN psychotropic medications shall be limited to no more than 14 days, unless the attending physician or prescribing practitioner believes it is appropriate to extend the order beyond the 14 days. The medical record should include documentation from the physician or prescriber for the rationale for the extended time period and indicate a specific duration. - R5's EMR documented a diagnosis of anxiety. R5's Significant Change MDS, dated [DATE], documented she had a BIMS score of six, indicating severe cognitive impairment. She did not receive antianxiety medication (a class of medications that calm and relax people) during the assessment period. R5's Psychotropic Drug Use Care Area Assessment (CAA), dated 04/16/2026, documented she took psychotropic medications. R5's Quarterly MDS, dated [DATE], documented she had a BIMS score of 11, indicating moderately impaired cognition. She did not receive antianxiety medication during the assessment period. R5's Care Plan, revised 04/26/2026, instructed staff to monitor the resident for side effects of her antianxiety medication. R5's EMR under the Orders tab, revealed the following physician's order: Lorazepam 0.5 milligrams, by mouth, every four hours, PRN, for a diagnosis of anxiety, ordered 10/19/2025. The order lacked a stop date. On 06/03/2026 at 08:30 AM, Administrative Nurse D confirmed R2 and R5's order for PRN lorazepam lacked a stop date, as required. The facility policy for Psychoactive Psychopharmacological Medications, revised 04/15/2025, included: PRN psychotropic medications shall be limited to no more than 14 days, unless the attending physician or prescribing practitioner believes it is appropriate to extend the order beyond the 14 days. The medical record should include documentation from the physician or prescriber for the rationale for the extended time period and indicate a specific duration.

Based on interview and record review, the facility failed to provide Resident (R) 31 with a written notification of transfer to the resident and/or his representative as soon as practicable and failed to send a copy of that notification to the ombudsman. Findings included:- R31's Electronic Medical Record (EMR) revealed a diagnosis of left femur fracture and cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). R31's admission Minimum Data Set (MDS), dated [DATE], documented R31 had a BIMS of 15, indicating intact cognition. R31's Discharge MDS, dated 03/18/2026, documented R31 had an unplanned discharge on [DATE]. R31's Health Status Note, dated 03/17/2026 at 04:07 PM, documented R31's daughter requested to have R31's medications and laundry ready to discharge the next day. R31's Health Status Note, dated 03/18/2026 at 01:17 PM, documented R31's family took R31 home with her medications and belongings. R31's EMR lacked documentation of a written notification to the residents and/or the representative, which explained the reason for the transfer to the hospital, or that the ombudsman was notified of the transfer. During an interview on 06/02/2026 at 12:51 PM, Administrative Staff A did not find where the letter to the family was for R31's discharge on [DATE] or the ombudsman notification was for this discharge. Another staff member was supposed to take over the ombudsman notifications for March and April and that staff member did not do it. The facility's policy Discharge Policy documented the facility shall notify the resident or representative of the transfer or discharge in writing and must send that notification to the ombudsman.

Based on observation, interview, and record review, the facility failed to perform restorative care for Resident (R) 6 who had a contracture (abnormal permanent fixation of a joint or muscle) to her right hand. Findings included: - R6's Electronic Medical Record (EMR) documented a diagnosis of hemiparesis/hemiplegia (weakness and paralysis on one side of the body). R6's Annual Minimum Data Set (MDS), dated [DATE], documented she had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. She had a limitation in range of motion (ROM) on one side of her upper and lower extremities. R6 did not receive restorative nursing care (care provided to maintain a person's highest level of physical, mental, and psychosocial function in order to prevent declines that impact quality of life) during the assessment period. R6's Activities of Daily Living (ADL) Care Area Assessment (CAA), dated 04/14/2026, documented the resident required staff assistance with ADLs due to left sided hemiplegia and limited mobility. R6's Quarterly MDS, dated [DATE], documented she had a BIMS score of 10, indicating moderately impaired cognition. She had limited ROM one side of her upper and lower extremities. R6 did not receive restorative nursing care during the assessment period. R6's Care Plan, revised 04/14/2026, instructed staff to perform passive ROM (PROM-when staff manipulate the joint rather than the resident) restorative care to R6's left upper extremity daily; staff instructed to open and close R6's left hand, perform elbow extension (the straightening of a limb), and assist with shoulder raises for 15 minutes, up to seven days per week. R6's EMR from 05/04/2026 through 06/01/2026 (30 days), lacked documentation of PROM taking place with R6. On 06/01/2026 at 09:09 AM, R6 sat at the dining room table feeding herself breakfast with her right hand. R6's left hand rested in her lap with her fingers curled inward into a fist. On 06/03/2026 at 09:45 AM, Certified Nurse Aides (CNA) O and CNA P transferred R6 from her wheelchair to her bed with the use of a full body lift. R6's left hand remained with her fingers curled inward into a fist. On 06/02/2026 at 08:57 AM, CNA O stated she would open the resident's left hand enough to clean her fingers and palm but R6 was not able to fully open her hand and move her fingers. CNA O stated she was unsure if R6 received restorative care. On 06/02/2026 at 01:27 PM, CNA M stated she did restorative care with the residents. CNA M stated R6 did not receive restorative care. On 06/02/2026 at 01:30 PM, Administrative Nurse E confirmed R6 should receive PROM to her left hand but had not been receiving the care. Administrative Nurse E was unsure why R6 was not receiving restorative care, as care planned, for her left-hand contracture. On 06/03/2026 at 08:30 AM, Administrative Nurse D confirmed R6 had not received restorative nursing cares, as care planned. The facility policy for Nursing Restorative Care Program, revised 02/03/2025, included: The facility shall provide restorative nursing care to residents in order to maintain their optimal physical function and to prevent further impairment.

Based on observation, interviews, and record review, the facility failed to provide grooming opportunities related to shaving of facial hair to maintain good personal hygiene and dignity for Resident (R)3. Findings included:- Review of R3's Physician Orders (POS), dated 05/01/2026, included diagnoses of vascular dementia (progressive mental deterioration characterized by confusion and memory failure), self-care care deficit, and major depressive disorder (MDD-major mood disorder which causes persistent feelings of sadness). R3's Significant Change Minimum Data Set (MDS), dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of eight, indicating moderate cognition impairment. She reported choosing her type of bath was very important. The resident was dependent on staff for bathing and personal hygiene. She did not exhibit behaviors of rejection of care. The Functional Abilities (Self Care and mobility) Care Area Assessment, (CAA), dated 03/11/2026, documented the resident had diagnoses that included vascular dementia, MDD, self-care care deficit due to periods of unsteadiness, impaired mobility, weakness, episodes of unsteady balance, poor safety, and cognitive impairment. The staff provided this dependent resident with bathing that included set-up assistance with hygiene/grooming tasks. She received Dressing/Grooming Restorative Nursing Program. R3's Care Plan, dated 05/29/2026, directed staff that the resident was able to perform hygiene/grooming task with set up assistance, initiated 01/29/2025. Her cognition and poor safety awareness deficit limited her ability to be independent. She required staff assistance for safety, initiated 04/11/2025. Staff should explain each procedure to R3 so she can participate in her activities of daily living (ADL) and maximize her abilities. Staff were to provide showers on Wednesday and Sunday evenings. She received restorative nursing program for dressing and grooming. A Restorative Nursing Assistant/Certified Nurse Aide (RNA/CNA) would encourage or involve the resident's active participation with dressing/grooming tasks for 15 minutes while providing daily assistance in the morning and evening up to seven day a week Date, initiated 05/20/2025. Review of Electronic Medical Record (EMR) Bathing Tasks dated 05/01/2026 through 06/02/2026 and Bath Sheets revealed they lacked evidence that the staff offered or provided shaves with bathing and/or grooming on scheduled bath/shower days or as needed. On 06/01/2026 at 11:33 AM, R3 sat in lobby in a chair. She had chin hair approximately one-quarter inch present. On inquiry, R3 stated she would like staff assistance with removal of her facial hair. She inquired if the facial hair was visible. On 06/02/2026 at 11:18 AM, R3 sat in common area/lobby. Certified Nurse Aide (CNA ) N applied a gait belt and positioned R3's walker then ambulated with R3 down the length of hall to her room. CNA N confirmed R3 had chin hair and needed shaving. CNA N stated the residents should be offered assistance with shaving as part of their bath and as needed. She reported that the resident refused her bath sometimes, but the staff should offer help with shaving when needed. CNA N asked the resident if she wanted her to shave her chin hair, R3 said Yes. On 06/03/2026 at 08:49 AM, Administrative Nurse D reported that when residents were observed with chin hair, staff should offer to shave the residents when needed and when bathed as a part of grooming. She verified the lack of evidence that the resident had been offered an opportunity to have staff assist her with shaving. Administrative Nurse D reported the facility lacked a policy to address shaving as a part of ADL care. The facility did not provide a policy to address shaving as part of ADL care.

The facility reported a census of 29 residents. The sample included three residents reviewed for medications. Based on observation, interview, and record review, the facility failed to prevent the significant medication error of cognitively impaired Resident (R) 1. On 09/12/24 Certified Medication Aide (CMA) R incorrectly administered another resident's (R2's) medications to R1, which included Crestor (anti-hyperlipidemic) 20 milligram (mg) and Coreg (anti-hypertensive) 25 mg, as well as R1's scheduled mirtazapine (anti-depressant) 15 mg. The health care provider advised (HCP) to transport the resident to the Emergency Department (ED) via Emergency Medical Services (EMS) due to R1's life-threatening hypotension (low blood pressure) which occurred within an hour and a half hour of the medication error. While waiting for the facility van to arrive at the front of the facility to take R1 to the ED, R1 began to tremor (shaking or trembling movement), and her eyes rolled in different directions. The nursing staff assisted the resident to the floor from the wheelchair and called EMS. The resident had very shallow breathes and did not respond to her name when called for a short period. She eventually began to speak with nursing staff. EMS arrived to transport the resident to the ED at 08:20 PM. Findings included: - R1's Physician Order sheet (POS), dated 10/01/24, revealed R1 admitted on [DATE] with the following diagnoses: hypertension (elevated blood pressure) and edema (swelling resulting from an excessive accumulation of fluid in the body tissues). The 04/12/24 Admission Minimum Data Set (MDS), documented the resident had a severely impaired cognition, with a Brief Interview for Mental Status score of nine. R1 required a manual wheelchair, propelled by staff, for mobility device due to weakness and reduce mobility. The resident required substantial assistance by nursing staff for Activities of Daily Living (ADL). The resident was able to feed herself with supervision. The ADL [Activities of Daily Living] Functional/Rehabilitation Protentional Care Area Assessment (CAA) dated 04/26/24 revealed the resident required substantial to maximum assistance for dressing, bathing, grooming/hygiene, and bed mobility. The resident required total assistance from two staff during transfers, toileting, and shower transfers. Mobility was maintained through use of a wheelchair with total assistance from staff. The resident was non ambulatory, and she was afraid of standing and bearing weight. Resident was able to feed herself with supervision provided. The 10/12/24 Quarterly MDS, documented the resident had severely impaired cognition, with a BIMS score of five. The resident was dependent on nursing for ADLs. The resident was able to feed herself with supervision. Mobility was maintained through use of a wheelchair with total assistance from staff. R1's Care Plan, dated 10/22/24, instructed staff that R1 had short-term memory problems, impaired decision making due to natural aging process, consult with primary care provider (PCP) due to cognitive deficits. R1 required total assistance with her wheelchair and touch assistance with ADLs. The resident was able to feed herself with supervision. A Nursing Note dated 09/12/24, revealed nursing staff monitored R1's vital signs and condition due to a staff member passing medications which resulted in a medication error, as a precautionary measure for the resident. R1 received the following medications on 09/12/24: R1's Electronic Medication Administration Records (EMAR) included Mirtazapine (antidepressant), start 6/28/24, Mirtazapine 15 mg tablet administer one tablet by mouth once daily for appetite stimulation. This medication was schedule at 05:01 PM - 09:00 PM. and R2's Electronic Medication Administration Records (EMAR) reflects the following orders: Coreg 25 mg tablet [Carvedilol] (anti-hypertensive) start date 8/30/24, administer by mouth one table twice a day for atherosclerotic heart disease; hold for BP less than 100/60 or Pulse less than 60. This medication was schedule at 05:01 PM - 09:00 PM. Crestor 20 mg tablet [Rosuvastatin], (ant-hyperlipidemic) start date 3/22/23, administer between 05:01 - 09:00 pm, administer one tablet by mouth on time daily for hyperlipidemia. This medication was schedule at 05:01 PM - 09:00 PM. Reviewed R1's systolic average pressure, from 09/01/24 - 09/11/24; documented 109-142 mmHg. Reviewed R1's diastolic average pressure, from 09/01/24 - 09/11/24; documented 55-73 mmHg. Review of License Nurse (LN) H witness statement, dated 09/12/24, documented she obtained R1's vital signs at approximately 09:30 PM. R1's blood pressure was 82/45 mmHg. LN H verified using a different cuff and the resident's blood pressure was 75/37 mmHg. The health care provider was notified and advised to send the resident to the ED. Observed that the resident was limp in the transportation wheelchair and not responding. The resident was transferred to the floor, with shallow breathing. She began to respond by saying her name and rubbing her. Staff called 911 and she was transported to ED by EMS. Review of a Nursing Note dated 09/12/24 at 06:01 PM documented the medication error occurred at the supper meal when CMA R administered R2's medications to R1. The medications were: Crestor 20 mg and Coreg 25 mg. R1's vital signs were stable at time of the medication error. R1's blood pressure was 158/74 mmHg, and her heart rate was 87 (beats per minute). The staff notified R1's HCP and her Durable Power of Attorney (DPOA). The HCP advised staff to monitor R1's vital signs every two hours for 12 hours. Review of Nursing Note dated 09/12/24 at 09:49 PM documented R1's blood pressure had decreased in one and a half hours, dropping from 158/74 mmHg to 82/45 mmHg, to 72/37 mmHg. The staff notified the resident's HCP who advised LN G to send the resident to the ED by EMS due to life threatening hypotension. Nursing staff transferred the resident into her wheelchair to transport her to the ED. While waiting for the facility van to move around to the front of the facility, nursing staff advised LN G that R1 was shaking, and her eyes went in different directions. LN G immediately assisted nursing staff to lower R1 to the floor and called 911. The resident had very shallow breathing and was not responding when staff called her name for a short period of time. The resident began to respond to her name as EMS arrived. EMS transported her to the ED at 08:20 PM. During an interview on 10/29/24 at 11:27 AM, R2 reported she was doing well and had received her medications without concern. During an interview on 10/29/24 at 12:09 PM Certified Medication Aide (CMA) R reported on 09/12/24 she was working the medication cart from 03:00 PM to 07:00 PM on the second floor. CMA R reported she should not have passed medication that shift due to excessive fatigue and needed to splash water in her eyes during the shift due to fatigue. During the 05:00 PM to 07:00 PM medication pass, CMA R reported she reviewed R2's medications and prepared to administer the medications. R1 and R2 sat together at the dining table on the second floor. At approximately 05:45 PM, CMA R reported she administered R2's medications to R1. CMA R reported she realized the medication error and immediately obtained R1's vital signs and immediately advised LN G of the medication error after obtaining R1's vital signs and CMA R continued to pass medications until her shift ended at 07:00 PM. During an interview on 10/29/24 at 03:34 PM Licensed Nurse (LN) G reported that she had not had concerns previously related to CMA R passing mediations. LN G reported she had not noticed on 09/12/24 that CMA R appeared to be very exhausted. She did not report to me after the incident that she was tired, and splashed water in her eyes. LN G said CMA R appeared very upset about the incident. At approximately 05:45 PM, CMA R advised she had administered R2's Crestor 20 mg and Coreg 25 mg medication to R1, along with R1's scheduled mirtazapine 15 mg. LN G reported she immediately notified R1's health care provider of the medication error and R1's vital signs were stable. The HCP wanted R1's vital signs monitored every two hours. R1 had an adverse event at approximately 07:30 PM in which her blood began to decrease to 82/45 mmHg and then to 75/37 mmHg. R1's HCP was advised of the adverse event and gave the order to transport the resident to the ED via EMS due to the substantial decrease in blood pressure within an hour and a half. LN G requested the nursing staff to transfer the resident into the wheelchair to transport to the ED. While waiting for a nursing staff member to drive the facility van to the front of the facility, R1 began to tremor (shaking or trembling movement) and her eyes rolled in different directions. The nursing staff assisted the resident to the floor from the wheelchair and called 911. The resident had very shallow breaths and did not respond to her name when called, for a short period. She eventually began to speak with nursing staff. EMS arrived to transport the resident to the ED at 08:20 PM. During an interview on 10/29/24 at 11:00 AM, CMA S reported a residents' medication must be verified with the residents EMAR and Physician Order Sheet (POS) and following the medications seven rights of administration. CMA S reported that if staff were unable to verify who the resident was, the staff should verify with the resident's picture as well as with another staff member who worked closely with the residents. She reported she did receive education related to Administration of Medication and Competency Skills Checklist prior to the following shift she worked. During an interview on 10/29/24 at 02:12 PM Certified Nurse Aide (CNA) R reported she was advised the residents eyes had rolled to back of her head and nursing staff needed assistance. She reported she then assisted the nursing staff to transfer R1 to the floor and laid R1 on her side. LN G advised CNA R to call 911 and EMS arrived shortly after. During an interview on 10/29/24 at 02:22 PM Certified Nurse Aide (CNA) N reported while she sat with R1, she observed the residents' eyes roll and R1 went limp in the transportation wheelchair. The staff transferred R1 to the floor and called 911. During an interview on 10/29/24 at 04:32 PM CNA M reported she noticed the nursing staff assisted the resident to the floor, and she begun to assist the nursing staff due to the resident was in distress. EMS did show up during that time and transferred the resident to the ED. During an interview on 10/29/24 at 05:10 PM Administrative Staff A reported she arrived at the facility at approximately 07:00 PM to begin the investigation. CMA R had been checked off on passing medications previously. Administrative Staff A had not heard concerns with CMA R that she was fatigued or that she was covering for another staff member. Administrative Staff A reported she was advised by LN G that CMA R had administered R2's medications to R1, and R1 had an adverse effected and was transferred to the ED by EMS per HCP orders. The resident admitted with hypotension. CMA R was immediately removed from the medication cart and suspended at 07:00 PM. During an interview on 10/29/24 at 05:20 PM, Administrative Nurse D confirmed she expected the nursing staff to always advise Administrative Staff if a nursing staff member was covering a shift for another nursing staff member for Administrative Staff approval. Administrative Nurse D also reported if the LN, CMA, or CNA were too tired to work a shift, he/she should always advise the administrative staff prior to working the shift and should not work the shift. Administrative Nurse D stated CMA R had not reported she was very tired and needed to splash water on her face during her shift. Administrative Nurse D said had she or any other staff reported those concerns or witnessed it, the facility expected staff to report the behaviors and CMA R would not have passed medications. The facility failed to prevent the significant medication error of dependent and cognitively impaired R1 on 09/12/24 when Certified Medication Aide (CMA) R incorrectly administered another resident's (R2's) medications which included the following: Crestor 20 mg and Coreg mg 25 MG, as well as R1's scheduled mirtazapine 15 mg. R1 suffered life threatening hypotension and required EMS transfer to the ED. The immediate jeopardy was determined to first exist on 09/12/24 at 05:50 PM, when Certified Medication Aide (CMA) R incorrectly administered another resident's medications to R1. The surveyor verified the facility identified and implemented corrective actions completed on 09/16/24 when the facility completed the following: 1. On 09/12/24 at 07:00 PM, the facility suspended CMA R. 2. Licensed Nurses (LN) and Certified Medication Aides (CMA) were provided education on 09/12/24 at 07:00 PM through 09/16/24 at 09:16 AM related to Medication Administration. 3. Licensed Nurse (LN) and Certified Medication Aides (CMA) completed a Medication Administration check-off observed by Administrative Nurse A on 09/12/24 at 07:00 PM through 09/16/24 at 09:16 AM. Due to corrective actions the facility completed prior to the onsite visit, the deficient practice was deemed past non-compliance and exited at a J scope and severity.

The facility reported a census of 28 residents. Based on interview and record review, the facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) with complete and accurate direct staffing information, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e. Payroll Base Journal (PBJ), related to licensed nursing staffing information, when the facility failed to accurately report 24 hour per day Licensed Nurse coverage on 12 dates between 07/01/23 and 09/30/23 and 10 dates between 01/01/24 and 03/31/24. Findings Included: - Review of the Payroll Base Journal (PBJ) Staffing Data Report for Fiscal year (FY), Quarter 4, 2023 (07/01/23 and 09/30/23) revealed a lack of License Nurse (LN) for 24 hours/seven days a week 24 hour/day on the following dates: On 07/01/23 , Saturday (SA), On 07/02/23, Sunday (SU), On 07/15/23, SA, On 07/22/23, SA, On 07/23/23, SU, On 08/12/23, SA, On 08/13/23, SU, On 08/19/23, SA, On 08/20/23, SU, On 09/03/23, SU On 09/23/23, SA, and On 09/24/23, SU. Review of the Payroll Base Journal (PBJ) Staffing Data Report for Fiscal year (FY), Quarter 2, 2024 (01/01/24 and 03/31/24) revealed a lack of License Nurse (LN) for 24 hours/seven days a week 24 hour/day on the following dates: On 02/17/24, SA, On 02/18/24, SU, On 02/24/24, SA, On 02/25/24, SU, On 03/02/24, SA, On 03/03/24 SU, On 03/09/24, SA, On 03/10/24, SU, On 03/16/24, SA, and On 03/17/24, SU. On 09/12/24 at 01:41 PM, interview with Administrative Staff A revealed as far as she knew, the PBJ was submitted correctly and stated the licensed nursed that worked on weekend do not leave the facility or take a lunch break and the facility had 24-hour licensed nurse coverage. The facility policy for PBJ Reporting Procedure, undated, instructed staff report to PBJ hours to CMS on a quarterly basis and must include the download from Time Tracker (an electronic method to record time worked by staff) to include agency staff. The facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) with complete and accurate direct staffing information, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e., Payroll Base Journal (PBJ), related to licensed nursing staffing information when the facility failed to accurately report 24 hour per day Licensed Nurse coverage on 12 dates between 07/01/23 and 09/30/23 and 10 dates between 01/01/24 and 03/31/24.

The facility reported a census of 28 residents. Based on observation, interview, and record review, the facility failed to maintain and/or dispose of garbage and refuse properly in a sanitary condition to prevent the harborage and feeding of pests. Findings included: - On 09/10/24 at 10:13 AM, initial tour with Dietary Staff BB revealed two of four compartments dumpster open with exposed trash and garbage. Additionally, discarded building supplies surrounded the dumpster with grass grown over the edges. Dietary Staff BB confirmed the above findings. She reported the facility staff should dispose of garbage and trash in a closed container to prevent harboring of pests and rodents from nesting around the facility. Dietary Staff BB stated the staff facility used the dumpsters and they should keep all compartment lid closed to contain the garbage and trash when placed in the dumpster. On 09/12/24 at 11:15 AM, during environmental tour with Housekeeping and Maintenance Director U and Consultant GG, revealed the trash dumpster lacked one lid which exposed trash and garbage. The building materials and overgrown grass that surrounded the dumpster remained as noted above. He reported the trash company replaced the dumpster approximately two weeks ago and agreed the dumpster compartment lids should be closed to maintain and/or dispose of garbage and refuse in a sanitary condition. The facility lacked a policy to address garbage and refuse disposal and containment. The facility failed to maintain and/or dispose of garbage and refuse properly in a sanitary condition to prevent the harborage and feeding of pests.

The facility reported a census of 28 residents, with 13 residents sampled which included three residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to complete a safe transfer for dependent (R)18 using a sit to stand lift related to the lack of use of the sling's safety belt to ensure the resident's safe transfer. Finding included: - Review of Resident (R)18's Physician Orders, dated 08/01/24, documentation included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) with psychotic disturbances (gross impairment in reality perception), dizziness, and hypertension (high blood pressure). The Significant Change in Status Minimum Data Set, (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of two, indicating severe cognitive impairment. He exhibited continuous altered level of consciousness and fluctuating disorganized thinking. The resident had no functional limitation in range of motion in his upper or lower extremities. He required maximum/substantial assistance of staff for transfers, toilet use, and personal hygiene. The Falls Care Area Assessments (CAA) dated 06/13/24, documented the resident at risk for falls but he would call and wait on staff to arrive. He required assistance of two staff members for transfers using a sit to stand lift. The Care Plan, (CP) dated 6/20/24, directed the staff the resident had self-care deficit. He required total assistance with repositioning and transfers. The resident had poor safety awareness, was impulsive, would attempt to get up on his own, and became easily annoyed and agitated if staff attempted to assist him if he did not want to be assisted. Two staff should use a sit to stand lift for all transfers. At times staff should use a full body lift when he was not feeling well. On 09/11/24 at 09:25 AM, Administrative Nurse D propelled the resident in his wheelchair to his room. She requested Certified Nurse Aide (CNA) Q and CNA P to check the resident for incontinence and to provide care if needed. Staff reported the resident required the use of the sit to stand lift and two direct care staff to transfer the resident. They positioned the sling beneath the residents back and hooked it to the lift. Staff failed to secure the safety belt prior to lifting the resident from the chair with the lift. Upon inquiry, they reported the safety belt was broken and was not able to secure the Velcro around the resident. Staff reported the lift was broken for over a week, but they continued to use it. Furthermore, they stated they had not reported the safety belt as broken. On 09/11/24 at 09:47 AM, Licensed Nurse (LN) E, reported staff should report any equipment that needed repair to the maintenance department prior to using the equipment. She confirmed the safety belt should be used to ensure the safety of the resident. On 09/11/24 11:25 AM, Administrative Nurse D stated the safety belt should be used when transferring residents using the sit to stand lift for transfers to prevent injury of the resident and confirmed the lift for the resident had not been reported as broken by the staff until today. The facility policy titled Equipment -Maintenance, Repair, and Cleaning, dated 10/11/21, documentation included equipment in need of repair is communicated to environmental services department. The facility policy Lifting & Transferring Residents, dated 10/25/23, documentation included the facility will provide a safe work environment for resident care by providing the use of safety materials, equipment, and training designed to prevent injury. The facility failed complete a safe transfer for dependent (R)18 using a sit to stand lift related to the lack of use of the sling's safety belt to ensure the resident's safe transfer.

The facility reported a census of 28 residents with 13 selected for review, which included four residents reviewed for pressure ulcers. Based on observation, interview, and record review, the facility failed to ensure pressure relieving device was in working order for one Resident (R)21, of the four residents reviewed for pressure ulcers. Findings included: - Review of Resident (R)21's medical record revealed diagnoses that included diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), polyneuropathy (disorder of many of the nerves outside of the brain and spinal cord), venous ulcers (sores due to poor circulation), and stage two pressure ulcer (partial thickness skin loss into but no deeper than the dermis including intact or ruptured blisters). The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 15, which indicated normal cognitive function. The resident required partial/moderate assistance for transfers. The resident had no impairment in range of motion in his upper or lower extremities. The resident had no pressure ulcers. The Pressure Ulcer Care Area Assessment (CAA), dated 03/12/24, assessed the resident not at risk for pressure ulcer development. The Five Day Admission MDS dated [DATE], assessed the resident with a BIMS of 14, which indicated normal cognitive function. R21 had no impairment of upper or lower extremities. The resident assessed as not at risk for pressure ulcer development and had no pressure ulcers. The resident had two venous ulcers (wounds caused by poor circulation). The Quarterly MDS dated [DATE], assessed the resident with a BIMS score of 14, with one stage two pressure ulcer, and two venous stasis ulcers. The resident had a pressure reducing device for his chair and bed and received pressure ulcer care. The resident required supervision for standing and transfers. The Care Plan updated 06/20/24 instructed staff to ensure a low air loss mattress was on the resident's bed and a cushion in his chair. An update to the care plan dated 07/12/24, instructed staff to cleanse the open area to R21's right and left buttocks with wound cleanser and apply a foam dressing every three days. Staff instructed to encourage and assist the resident to reposition every two hours. The Additional Orders from wound care, dated 09/05/24, instructed the facility to provide a roho (a type of pressure relieving cushion that utilizes flowing air cubes that adjust to meet individual contouring needs to decrease pressure) type of cushion to any surface the resident sat on. Staff were to cleanse the sacral pressure ulcer with wound cleanser and apply a sacral (large triangular bone between the two hip bones) dressing every three days. Observation, on 09/10/24 at 10:34 AM, revealed the resident seated in his recliner. The resident sat on two cushions. The resident stated he has a sore area on his bottom, and the two cushions help relieve the discomfort of the sore area. Observation, on 09/11/24 at 01:48 PM, revealed Administrative Nurse E prepared to provide a dressing change to R21's sacral pressure ulcer. The resident sat in his recliner and stood up as requested. The cushion in the recliner contained multiple areas of malfunctioning air cells and were deflated. Administrative Nurse E stated staff did not report the deflated cushion to her and proceeded to remove the cushion for reinflation and placed a foam cushion in the resident's recliner. Administrative Nurse E removed the foam dressing and noted the wound as pink in color and measured the area as 0.3 by 1.2 centimeter (cm) and 0.4 by 0.3 cm. Administrative Nurse E cleansed the resident's sacral wounds with wound cleanser and applied a foam dressing to the resident's sacrum. Administrative Nurse E stated the wound care provider managed the resident's vascular and this pressure ulcer. The facility policy Therapeutic Support Surface revise 09/05/24, instructed staff positioning techniques, devised and chair seat cushions should be considered for resident who are in the sitting position. The facility failed to monitor the status of R21's roho cushion to ensure optimal functioning to provide pressure reduction for this resident's stage two sacral pressure ulcer.

The facility reported a census of 28 residents, with 13 residents sampled which included three residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to complete a thorough investigation to determine causes and contributing factors related to a skin tear and failed to implement appropriate immediate interventions to prevent further skin tear for Resident (R)18. Findings included: - Review of Resident (R)18's Physician Orders, dated 08/01/24, documentation included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) with psychotic disturbances (gross impairment in reality perception), dizziness, and hypertension (high blood pressure). The Significant Change in Status Minimum Data Set, (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of two, indicating severe cognitive impairment. He exhibited continuous altered level of consciousness and fluctuating disorganized thinking. The resident had no functional limitation in range of motion in his upper or lower extremities. He required maximum/substantial assistance of staff for transfers, toilet use, and personal hygiene. The Falls Care Area Assessments (CAA) dated 06/13/24, documented the resident at risk for falls but he would call and wait on staff to arrive. The Care Plan, (CP) dated 6/20/24, directed the staff the resident had self-care deficit. He required total assistance with repositioning and transfers. The resident had poor safety awareness, was impulsive, would attempt to get up on his own, and became easily annoyed and agitated if staff attempted to assist him if he did not want to be assisted. R18 was at risk for skin impairment such as skin tears and staff should apply long sleeves and pants to protect his extremities. Review of the Interdisciplinary Team Notes,(IDT) dated 09/07/24 at 11:48 AM, documentation included the staff discovered a C shaped skin tear with dried blood on the back of the resident's right hand between the thumb and his forefinger. The administered treatment included cleaning the area with wound cleanser, applied skin prep, applied seven steri-strips (wound closures), applied folded and secured with paper tape for protection. The documentation lacked identification of cause or contributing factors related to the skin tear or an immediate intervention to prevent further injury. On 09/10/24 at 10:49 AM, the resident sat in a high back reclining chair. His left arm was bent at his elbow with his left hand cupped beneath his right elbow. The top of his right-hand had a bordered foam dressing in place, dated 9/10/24, On inquiry, R18 stated he did not know what happened to his hand. On 09/11/24 at 09:00 AM, the resident sat in a high back reclining chair rubbing his right shoulder with his left hand. The back of his right hand had seven steri-strips visible without a covering for protection. Observation revealed there was dried blood on top of his hand. There was no bordered foam dressing in place. On 09/11/24 at 09:47 AM, Licensed Nurse (LN) E reported the resident wheeled himself down the hall and would hit his hand against the wall and the doorway. She stated the skin tear happened over the weekend. LN E reviewed the resident's electronic medical record and confirmed the lack of an order related to R18's right hand skin tear. She stated the facility had standing orders for skin tears. LN cleaned the skin tear with wound cleaner an verified the placement of seven steri-strips, and the wound measured 3.7 centimeters (cm) by 0.5 cm by 0.1 cm. R18's right hand had a blue-black discolored area around the approximated wound edges. LN E stated she did not know the immediate intervention implemented by the facility to prevent further skin tears. On 09/11/24 11:25 AM, Administrative Nurse D confirmed the resident's hand skin tear lacked a thorough investigation to determine the cause or contributing factors as well as lacked an immediate intervention to prevent further injuries for dependent R 18. The facility lacked a policy to address the root cause analysis for skin tears to determine the causes and contributing factors and implementation of an immediate intervention to prevent further injury. The facility failed to complete a thorough investigation to determine causes and contributing factors related to a skin tear and failed to implement appropriate immediate interventions to prevent further skin tear for Resident (R)18.

The facility reported a census of 28 residents with 13 residents sampled, which included one resident sampled for abuse. Based on observation, interview, and record review, the facility staff failed to report an allegation of staff to resident, verbal abuse (the use of oral, language that willfully includes disparaging and derogatory terms to residents or within their hearing distance regardless of their age ability to comprehend, or disability) related to calling Resident (R)4 lazy in the presence of another resident. Findings included: - Review of Resident (R)4's Physician Orders, dated 08/01/24, documentation included diagnoses of diabetes (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), heart failure, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), morbid obesity (severely overweight), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and supplemental oxygen dependence. The Annual Minimum Data Set (MDS)dated 03/09/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact. He did not demonstrate any behaviors, mood indicators, nor depression indicators. He required staff assistance and supervision for activities of daily living (ADLs) which included transfers and wheeling his wheelchair. He was 69 inches (five foot nine inches tall) and weighed 353 pounds (lb). The resident received as needed (prn) pain medication and reported almost constant pain rated 08/10. He received medications which included anti-anxiety (medications used to treat mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), antidepressants (medications used to treat depression), opioids (medication/controlled substance used to treat pain), and diuretics, (medications to promote the formation and excretion of urine). The resident received restorative nursing program for active range of motion and walking for two days of the look back period. The Quarterly MDS dated [DATE], documented change from the above assessment included the resident weight as 372 lbs. The Care Plan (CP) dated 06/20/24, directed staff the resident had left knee pain and received pain medication twice a day. R4 had a new wheelchair with foot pedals. He was pleasant, cooperative , and participated in exercise, activities, and restorative nursing program and required staff assistance with his ADLs. Review of the facility self-report to the State agency dated 07/08/24, revealed on 06/29/24, Certified Medication Aide (CMA) R and Certified Nurse's aide (CNA) N witnessed CNA O verbally insult R4 while in the dining room in the presence of other residents. The event described included CNA O propelled R4 to his room, CNA O was yelling at him, calling him names, such as lazy and telling him he could do it himself. CNA O exclaimed she did not care if she got wrote up again. The investigation documentation revealed CNA N did not report the incident to facility staff until she gave the facility her resignation on 07/08/24. She identified CMA R as a witness to the event. The facility suspended CNA O pending investigation upon having knowledge of the event. The administration interviewed CMA R who confirmed the above findings. All facility staff completed training regarding Abuse Neglect, and Exploitation as of 07/11/24. CNA O was terminated related to failure to respond to previous counseling by the facility. CMA R's witness statement, dated 07/08/24, documented R4 wanted staff assistance to his room. CMA R asked CNA O to take R4 to his room. CNA O responded that R4 could push himself to his room. CNA O approached R4, yelling and calling him names such as lazy and told R4 he could do it himself. CNA O assisted R4 out of the dining room. CNA O's witness statement, dated 08/08/24, documented I do not recall that weekend. Sorry. On 09/10/24 at 11:10 AM, R 4 stated he had been a resident for three years. He reported he felt safe, and he had no worries about his care. The resident stated he did not recall ever being abused or mistreated and had not seen any other resident abused or mistreated. On 09/10/24 at 11:56 AM, Certified Nurse Aide (CNA) M provided the resident with incontinence care which included peri-care, applied a new incontinence brief, and changed his wet clothes. On 09/11/24 at 08:33 AM, R4 sat in a wheelchair while CNA M propelled the resident to his room. He thanked CMA M for her help and stated the staff sometime tell him he should roll his own wheelchair, but he would get tired. On 09/12/24 at 01:24 PM, CMA R confirmed the above findings with the exception of the date of the event. She stated the event described occurred on 06/29/24 verses 06/23/24. She stated on the morning of 06/29/24, she was passing her medications and R4 asked for assistance to return to his room. CMA R reported she was holding medications and she saw that CNA O was available to assist R4. CNA O verbally insulted R4 in the dining room in the presence of other residents. The event described included CNA O yelled the resident was lazy and she did not care if she got written up again. He could push himself to his room. Additionally, CNA O continued to call the resident names such as lazy when she assisted the resident in the wheelchair to his room. Approximately 10 other residents were in the dining area at the time, and they appeared to be shocked and were talking amongst themselves. CNA N heard what happened and talked to her about it and CMA R thought CNA N reported the event to the facility management. CMA R stated she should have stopped CNA O and reported the event to her charge nurse at the time. On 09/12/24 at 02:24 PM, Administrative Staff A confirmed the above findings and agreed facility staff failed to report the allegation of verbal abuse at the time it occurred as they should have. She reported when she was informed, CNA O was immediately suspended pending investigation. Administrative Staff A was told about the verbal abuse on 07/08/24, nine days afterwards. Staff should have reported the event at the time it occurred so immediate action could have been taken to protect the residents. The facility policy ANE: Abuse Prevention, intervention, Reporting and Investigation-Staff Treatment of Residents, dated 03/04/24, documentation included it is the responsibility of employees to promptly report to community management any occurrence or suspected occurrence of neglect or resident abuse. Verbal/Written abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging a derogatory term to residents within their hearing distance regardless of their age ability to comprehend, or disability. The facility staff failed to report an allegation of staff to resident, verbal abuse to this resident. The deficient practice was deemed past non -compliance when the facility completed the following: On 07/08/24, the facility conducted staff interviews with the identified staff present during the alleged verbal abuse. (CNA O, CMA R, and CNA N). On 07/08/24, the facility staff notified R 4's Durable Power of Attorney (DPOA)/representative of the allegation of verbal abuse. On 07/08/24, upon notification of allegation of verbal abuse, the facility suspended the alleged perpetrator, CNA O, pending investigation. CNA N resigned. CMA R received Teachable Moment training regarding reporting abuse immediately, as the first step of disciplinary action due to her failure to report an allegation of verbal abuse immediately. On 07/08/24, the facility interviewed R 4 who had no recall of the above event of verbal abuse on 06/29/24. On 07/08/24, the facility interviewed three additional residents that reported they felt safe at the facility and got the help they needed when they asked the staff for help. On 07/08/24, the facility initiated all staff education/training regarding abuse neglect and exploitation, which included immediate reporting of allegations of abuse, and completed the re-education and training for all staff on 07/11/24. On 07/11/24, the facility terminated CNA O following the investigation, related to her lack of response to prior counseling regarding her tone of voice. The facility plans for monitoring effectiveness of corrective action plan through Quality Assurance Performance Improvement (QAPI) Risk Committee quarterly meeting. The onsite surveyor verified the implementation of the above actions on 09/12/24 and the deficient practice remained at a D scope and severity.

The facility reported a census of 25 residents with 14 selected for review, which included two residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, interview, and record review, the facility failed to ensure Resident (R)76 and R4 received timely interventions for pressure ulcer prevention, which resulted in R76's development of an unstageable pressure ulcer (unable to determine depth of the ulcer due to overlying slough (dead tissue usually yellow or white) or eschar (dried dead tissue). Findings included: - Review of Resident (R)76's Physician Order Sheet, dated 12/09/22, included diagnoses of femur (thigh bone) fracture, Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), anxiety, and arteriosclerotic (blood vessel hardening and narrowing) heart disease. The resident admitted to the facility on [DATE]. The Admission Minimum Data Set (MDS,) dated 12/09/22, assessed the resident with severe cognitive deficits and noted R76 required extensive assistance of two staff for bed mobility and transfer. The resident had impairment in functional range of motion on one side of the lower extremity. The resident was at risk for pressure ulcer development and had one stage two pressure ulcer (a shallow ulceration with a red base) that were not present upon admission. The Pressure Ulcer Care Area Assessment (CAA), dated 12/14/22, assessed the resident had impaired skin integrity due to left hip surgery with surgical incision. The resident had a deep tissue pressure injury to his left heel that measured 5 by 5 centimeters (cm). The resident required off- loading of feet when in bed and required extensive assistance with repositioning. The Admission Nursing Screen and Care Plan, dated 12/02/22, instructed staff the resident required maximum assistance in bed for repositioning. This care plan documented the resident was at risk for pressure ulcers due to surgery. The resident had a left hip incision but lacked assessment of the resident's heels. This care plan lacked interventions for pressure relieving/reducing mattress, pressure relieving cushions to chair/wheelchair, heel protectors, or a repositioning program. The Care Plan, dated 12/16/22 (after the resident developed a pressure ulcer), instructed staff to provide the following measures: 1. 12/08/22, Off -load heels and apply KerraFoam (absorbent foam dressing) dressing to the left heel and change every third day and provide air mattress. 2. 12/15/22, Heel protectors to both heels and a multi-podus (pressure relieving device) boot to the left foot. 3. 12/16/22, The resident required extensive assistance to reposition and staff encouraged to reposition R76 routinely. Staff instructed to off-load his heels when he was in bed or in a chair. Staff instructed to monitor the heel pressure ulcer for signs of edema (swelling), erythema (redness), bogginess (sponge like soft tissue due to fluid), or drainage. A Physical Therapy Note, dated 12/08/22, documented during a therapy session the resident had dried blood on his bed and left foot sock. Therapy staff removed the sock and noted an open wound on the resident's left heel. A Nurse's Note dated 12/08/22 at 11:51 AM, documented the resident had a deep tissue pressure injury (DTPI) to his left heel which measured 5cm by 5cm, with minimal drainage noted. The staff applied KerraFoam and were to change the KerraFoam every three days and as needed for soiling, and to offload his feet while in bed. The Skin Evaluation Record dated 12/08/22, documented the resident had a DTPI to his left heel which measured 5 cm by 5 cm, with minimal drainage with a treatment of a KerraFoam dressing, every three days. The Skin Evaluation Record, dated 12/12/22, documented the left heel worsened and the treatment changed to apply the KerraFoam dressing daily until improvement and minimal drainage. The wound measurements recorded the area as 5 cm by 5 cm, with no exudate (drainage). The Skin Evaluation Record, dated 12/12/22, documented the left heel worsened and the treatment changed to apply the KerraFoam dressing daily until improvement and minimal drainage. The wound measurements recorded the area as 5 cm by 5 cm, with no exudate (drainage). A Physician's Order, dated 12/13/22, instructed staff to consult wound care. A Physician's Order, dated 12/15/22, instructed staff to administer Pro-Stat Advanced Wound Care (protein supplement formulated to promote wound healing) 17 gram-100 kilocalorie per 30 milliliter twice a day, and a multivitamin with minerals daily for wound healing. A Physician's Order, dated 12/15/22, instructed staff to cleanse the wound with normal saline, moisturize the surrounding skin and apply Santyl (ointment that removes dead skin and aides in wound healing) ointment 60 gram (gm), daily to the wound base and cover with non-adhesive dressing, and wrap with gauze. The Physician's Note faxed 12/15/22, described the wound as a 4.3 cm by 5 cm by 0.5 cm, unstageable pressure ulcer. A Physician's Order, dated 12/16/22, instructed staff to administer Zinc gluconate 50 milligrams (mg) daily and Vitamin C 500 mg, daily, for wound healing. The order further instructed the staff to monitor the heel pressure ulcer for signs of edema, erythema, bogginess, or drainage. The Skin Evaluation Record, dated 12/19/22, documented the left heel ulcer measurements as 5 cm by 5 cm, with small amount of yellow brown drainage. Observation on 12/15/22 at 08:00 AM, revealed the resident positioned in bed with the multi-podus boot on the floor beside the resident's bed. The resident had bilateral heel protectors on. The resident's wheelchair lacked a cushion. Observation on 12/20/22 at 07:52 AM, revealed Licensed Nurse (LN) H prepared to provide a dressing change to the resident's left foot. The resident's multi-podus boot was on the floor and Administrative Nurse F noted the boot lacked one of the straps to secure the boot. The resident wore blue heel protectors. LN H did not sanitize the surface of a table, used to place the dressing items on, before placing paper towels on the table surface. LN H removed the gauze wrap and non-adherent dressing. The wound bed contained black eschar(dead tissue), approximately 5 cm by 5cm, with yellow brown drainage noted on the removed dressing. LN H cleansed the wound with normal saline, applied Santyl to the wound bed, applied the non-adhesive dressing, applied gauze, and a protective foam heel protective cup, then wrapped the foot with gauze and applied the heel protector. The resident stated the area was tender. Interview on 12/15/22 at 02:46 PM, with LN G, revealed she did not know when the resident developed the heel pressure ulcer, but the resident went to wound care for treatment today. Interview on 12/20/22 at 09:37 AM with LN H, revealed she thought the resident had the pressure ulcer when he first admitted , but LN H did not remember. LN H stated the resident was cooperative with cares. Interview on 12/20/22 at 10:30 AM with Certified Medication Aide (CMA) R, revealed the staff were supposed to off load the resident's heels with a rolled blanket and blue heel protectors, CMA R but did not know when the interventions started. Interview on 12/20/22 at 11:58 AM with Administrative Nurse F, revealed she thought the resident had the left heel DTPI when he admitted to the facility, but the admission assessment lacked identification of the DTPI. Administrative Nurse F stated she noted the DTPI on 12/08/22 and instructed staff to off load the resident's heels and apply KerraFoam every three days and as needed. Administrative Nurse F stated the wound had worsened when she assessed it on 12/12/22 and at that time they consulted wound care. Interview on 12/20/22 at 12:02 PM, with Administrative Nurse E, revealed she expected the admitting nurse to put interventions in place on the Admission Nursing Screen and Care Plan, and confirmed the lack of pressure relieving interventions upon admission for R76. Interview on 12/20/22 at 12:09 PM, with Consulting Medical Staff HH, revealed she expected pressure relieving interventions in place upon admission to help prevent DTPI development. The facility policy Skin Integrity: Pressure Ulcer/Injury Prevention, Nursing Intervention and Wound Treatment, revised 08/30/22, instructed staff to evaluate skin integrity and tissue tolerance, implement preventative measures as indicated and treat skin breakdown. Risk factors should be reviewed along with possible causes and a determination made to what extent the factors can be modified. Staff instructed to use heel protectors, multi-podus boots or pillows to support heels and reduce shearing effect. Consider suspending or floating heals using lower extremity positioning devices. The facility failed to ensure pressure relieving interventions were in place for R76, a resident at risk for pressure ulcer development, who developed an unstageable pressure ulcer to his left heel.

The facility reported a census of 26 residents. Based on interview and record review the facility failed to complete an annual performance review at least once every 12 months for five of five Certified Nurse Aides (CNA) and Certified Medication Aides (CMA) reviewed, including CNA O, P and CNA Q and CMA T and RR. Findings included: - Review of these five employee personnel files, revealed the following concerns: 1. Certified Nurse Aide (CNA) O, hired 07/02/21, lacked an annual performance review in his personnel file. 2. CNA P, hired 07/28/21, lacked an annual performance review in her personnel file. 3. CNA Q, hired 08/02/21, lacked an annual performance review in her personnel file. 4. Certified Medication Aide (CMA) T, hired 02/14/17, lacked an annual performance review in her personnel file. 5. CMA RR, hired 07/27/21, lacked an annual performance review in her personnel file. The facility policy for Performance Evaluations, undated, included: Employees may receive performance evaluations annually based on the anniversary date. On 12/20/22 at 12:51 PM, Administrative Staff C stated the annual performance reviews were not completed in a timely manner. The facility failed to complete annual performance reviews for these three CNAs and two CMAs, who had been employed for over one year to ensure quality of cares to the residents.

The facility reported a census of 26 residents with 14 residents sampled, that included two residents sampled for urinary catheter care. Based on observations, interviews, and record review, the facility failed to provide appropriate and sufficient services, treatment, and care based upon current standards of practice to ensure that Resident (R) 176 received appropriate treatment and services to prevent urinary tract infections to the extent possible. Findings included: - Resident (R) 176 admitted to the facility on [DATE] with a diagnosis of urinary retention (lack of ability to urinate and empty the bladder). The entry tracking record for the Minimum Data Set, dated dated [DATE], documented the resident entered from an acute hospital. Review of the Admission Nursing Screen and Care Plan dated 12/12/22, revealed the resident was incontinent of urine and had an indwelling urinary catheter (a tube inserted into the bladder to drain urine into a collection bag) and required extensive assistance with perineal care. The physician's hospital discharge orders included follow-up in one to two weeks for urinary retention and catheter removal. On 12/15/22 at 08:50 AM, revealed the resident sat in his recliner. His urine collection bag hung uncovered from the side of a small trash can and the bottom of the collection bag touched the floor. On 12/15/22 at 02:53 PM, revealed the resident sat in his recliner. His urine collection bag hung uncovered from the side of a small trash can and the bottom of the collection bag touched the floor. On 12/19/22 at 12:40 PM, revealed the resident sat in his recliner. His urine collection bag was in a covered bag, however, the whole bag laid directly on the floor. On 12/15/22 at 09:09 AM, Licensed Nurse (LN) G reported staff should not store indwelling urinary catheter collection bags on the sides of the resident's trash can. Staff should not keep catheter bags directly on the floor. On 12/19/22 at 01:00 PM, Administrative Nurse D reported her expectation for indwelling urinary catheter collection bags is for staff to cover the collection bag with a dignity bag and the bag should not touch the floor. Review of the facility's policy titled Urinary Catheter Care revised on 10/08/21 revealed, The collection bag must be off the floor to prevent infection. The facility failed to provide appropriate and sufficient services, treatment, and care based upon current standards of practice to ensure that the resident received appropriate treatment and services to prevent urinary tract infections to the extent possible.

The facility reported a census of 26 residents, with 14 residents sampled. Based on observations, interviews, and record review, the facility failed to ensure that one sampled Resident (81), received care and services in accordance with professional standards of practice, when the facility waited over 13 days to implement the physician ordered neurostimulator (an implanted device that sends low levels of electricity directly into the spinal cord to relieve pain), following surgery to the resident. Findings included: - Resident (R) 81 admitted to the facility on [DATE] with diagnoses that included surgery aftercare of the nervous system, adjustment of the neurostimulator (an implanted device that sends low levels of electricity directly into the spinal cord to relieve pain), and low back pain. The Admission Minimum Data Set (MDS), dated [DATE], revealed a brief interview of mental status (BIMS) of 14, that indicated intact cognition. The Pain Care Area Assessment (CAA), dated 12/14/22, revealed the resident had back pain and had prior neurological (involvement of nerves) surgeries for pain relief. The resident had a neurostimulator device placement for management of nerve pain. She recently had surgery for reversal/adjustment of a malfunctioned electrode. In addition, the CAA documented the resident had surgery of the nervous system and had mechanical complication of an implanted neurostimulator of the spinal cord electrical lead removal. She had impaired mobility related to unsteadiness, pain, fatigue, and decreased activity tolerance. Review of the Admission nursing screen and care plan dated 12/07/2022, revealed the resident's pain was lumbar/sacral spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities) and the resident's pain was constant and interfered with her sleep and Activity of daily living (ADL) participation. Furthermore, on 12/09/22, the baseline care plan indicated she returned from surgery related to her neurostimulator. The physician's orders included Physical therapy (PT) to address the pain stimulator, to advise on charging instructions and level progression, dated 12/07/22. Review of the Physical Therapy PT Evaluation and Plan of Treatment, dated 12/12/22, revealed the resident had a decline in functional strength, endurance, mobility, activity tolerance and balance due to issues with the implanted stimulator and chronic pain. The resident had placement of spinal cord stimulator on 11/30/22. She continued to experience lower left extremity pain and hospitalized for a revision of failed surgery with identified lead malfunction. The resident continued to experience pain and admitted to the facility due to loss of functional independence with increased need of assistant. Review of the Physical therapy Treatment Encounter notes from 12/08/22 thru 12/19/22, revealed on 12/14/2022 (eight days after the physician's order), staff discussed her pain stimulator. The resident was unsure if the device was turned on. PT staff consulted with nursing staff, and they were unaware if the resident's stimulator was turned on. The record revealed PT staff should obtain orders from the surgeon on specific parameters to begin resident education and to set the device (neurostimulator) up appropriately. The record revealed the plan for the PT next visit was to address the pain stimulator. On 12/15/2022 at 10:00 AM, the resident reported she admitted to the facility for strengthening so she could return home. She reported she had an implant for pain and had to have a lead repaired on 12/09/2022. She reported she had constant low back pain rated seven on a 1-10 pain scale. When asked what treatments were being done for pain, she indicated she had pain medication and the stimulator device for pain but stated, nobody knows how to use the stimulator. PT should check on it today. The resident indicated the battery/ remote of the stimulator stored on her dresser and nursing staff or therapy staff had not touched the remote. On 12/15/2022 at 02:30 PM, the resident sat in her recliner. She reported pain in her lower back at scale of six/ on a 1-10 scale. She reported physical therapy had not been in yet and no one still knows how to use the pain stimulator. On 12/19/22 at 09:08 AM, the resident sat in her recliner chair, and rested quietly with her eyes closed. On 12/15/2022 at 02:45 PM, licensed nurse (LN)G, reported PT should take care of the stimulator, however PT was not in the facility and PT was not going to be in on 12/15/22. On 12/19/2022 at 09:12 AM, LN H reported she was unaware if the pain neurostimulator device functioned properly and stated, she wanted to check on her chart to see what happened since she worked with her last week. She reported she was not familiar with the neurostimulator. On 12/19/2022 at 09:32 AM, consultant GG stated OT (occupational therapy) saw her on 12/07/22, and PT saw her the next day (12/08/22). She had a follow-up appointment with her orthopedic surgeon but lacked instructions to operate the stimulator or what settings to use. On 12/19/2022 at 12:31 PM, approximately three hours later, LN H reported she had not looked at the resident's chart and had not followed-up with the resident or the surgeon related to the neurostimulator. On 12/19/2022 at 01:08 PM, LN H reported she sent a fax communication to the resident's surgeon, to request perimeters for the neurostimulator device. (a total of 13 days after the physician's order date). On 12/19/2022 at 01:30 PM, administrative nurse D was aware the resident's neurostimulator was not being utilized. She thought nursing staff may have sent communication to the surgeon, however, she was unable to provide documentation for attempts to communicate with the surgeon related to the neurostimulator settings. On 12/20/2022 at 09:42 AM, the resident reported her pain level was on a scale of six (one to 10 scale). Staff informed the resident that the surgeon would send one of his staff members to the facility to instruct staff how to use the settings. The facility's policy for Pain management revised 10/12/22 included, optimal use of pain control measure depends on education and cooperation between members of the health care team and should consist of appropriate and individualized nonpharmacologic comfort measures with pain medication management in addition as needed. The facility failed to ensure this resident received care and services in accordance with professional standards of practice, when the facility waited over 13 days to implement the physician ordered neurostimulator (an implanted device that sends low levels of electricity directly into the spinal cord to relieve pain), following surgery to the resident.

The facility reported a census of 26 residents with 14 selected for review, which included five residents reviewed for unnecessary medications. Based on observation, interview and record review, the facility failed to ensure two of the five residents reviewed were monitored for extrapyramidal (abnormal involuntary body movements caused by medications) symptoms for Resident (R) 12 and R 76. Findings included: - Review of Resident (R)12's Physician Order Sheet, dated 12/01/22, revealed diagnoses included arteriosclerotic (hardening and thickening of the blood vessels) heart disease, depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness) and nausea. The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with severe cognitive impairment, and received one day of antipsychotics and seven days of antidepressant medications during the seven-day look-back period. The Psychotropic Drug Use Care Area Assessment (CAA), dated 09/22/22, assessed the resident was on end of life services through hospice due to continued decline. The resident received Haldol (an antipsychotic medication) gel to her inner wrist for nausea. The Care Plan, revised 12/17/22, assessed the resident received Ativan (an antianxiety medication) for seizures and Haldol topical gel for nausea and vomiting. The Physician's Order, dated 10/1/22, instructed staff to administer Haldol gel 0.5milliliter (ml) to the resident's inner wrist, daily at hour of sleep, for nausea/vomiting. The Physician's Order, dated 12/17/22, instructed staff to administer Haldol gel 0.5 ml, every four hours to her inner wrist as needed for nausea/vomiting for 14 days. The medical record lacked an assessment for extrapyramidal symptoms. Observation, on 12/20/22 at 10:30 AM, revealed the resident seated in her wheelchair in her room. The resident did not respond verbally to questions. No abnormal movements noted. Interview, on 12/20/22 at 11:30 AM, with Administrative Nurse D, confirmed lack of assessment for extrapyramidal symptoms. Administrative Nurse D stated the resident received Haldol gel for nausea/vomiting and did not realize she would need an assessment for the extrapyramidal movements. Administrative Nurse D stated the facility utilized an Abnormal Involuntary Movement Scale (AIMS) assessment. The facility policy Health Risk Screenings, revised 04/11/2019, instructed staff the health risk screening are tools which included AIMS, were used to develop an appropriate plan of care. The facility did not provide a policy for the frequency of the AIMS for residents administered antipsychotic medications. The facility failed to assess this resident receiving antipsychotic medications for extrapyramidal movements as required. - Review of Resident (R)76's Physician Order Sheet, dated 12/09/22, included diagnoses of femur (thigh bone) fracture, Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), anxiety, and arteriosclerotic (blood vessel hardening and narrowing) heart disease and major depressive disorder (major mood disorder). The resident admitted to the facility on [DATE]. The Admission Minimum Data Set (MDS,) dated 12/09/22, assessed the resident with severe cognitive deficits and noted R76 required extensive assistance of two staff for bed mobility and transfer. The resident received four days of antipsychotic medications during the seven-day look-back period. The Cognitive Loss Care Area Assessment (CAA), dated 12/14/22, assessed the resident cognitive loss and dementia but could make his needs known. The Admission Nursing Screen and Care Plan, dated 12/02/22, lacked documentation the resident received antipsychotic medications. The Care Plan, dated 12/16/22, instructed staff the resident could make his needs known, but had memory issues and could become agitated. The Physician's Order, dated 12/03/22, instructed staff to administer Ziprasidone (an antipsychotic medication), 20 milligrams (mg), daily for major depressive disorder. Review of the medical record revealed staff completed an Abnormal Involuntary Movement Scale (AIMS), on 12/19/22, 17 days after admission. Observation, on 12/19/22 at 08:12 AM, revealed Consulting therapy staff GG, assisted the resident to transfer from his bed to chair. The resident followed commands and did not display abnormal movements, although he displayed anxiousness with the transfer. Interview, on 12/20/22 at 11:30 AM, with Administrative Nurse D, confirmed staff completed the AIMS assessment 17 days after admission. Administrative Nurse D stated the facility utilized an Abnormal Involuntary Movement Scale (AIMS) assessment. The facility policy Health Risk Screenings, revised 04/11/2019, instructed staff the health risk screening are tools which included AIMS, were used to develop an appropriate plan of care. The facility did not provide a policy for the frequency of the AIMS for residents administered antipsychotic medications. The facility failed to assess this resident receiving antipsychotic medications for extrapyramidal movements as required.

The facility reported a census of 26 residents with 14 selected for review which included two residents reviewed for Activities of Daily Living (ADL). Based on observation, interview and record review, the facility failed to offer bathing and grooming opportunities to one of the two residents (R)76 reviewed for ADLs. Findings included: - Review of Resident (R)76's Physician Order Sheet, dated 12/09/22, included diagnoses of femur (thigh bone) fracture, Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), anxiety, and arteriosclerotic (blood vessel hardening and narrowing) heart disease. The resident admitted to the facility on [DATE]. The Admission Minimum Data Set (MDS,) dated 12/09/22, assessed the resident with severe cognitive deficits and noted R76 required extensive assistance of two staff for bed mobility and transfer. The resident had impairment in functional range of motion on one side of the lower e extremity. The resident required extensive assistance for bathing. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 12/14/22, assessed the resident had decreased physical functioning, weakness and required extensive assistance for bed mobility, transfers, grooming, toileting, and bathing. The Admission Nursing Screen and Care Plan, dated 12/02/22, instructed staff the resident required maximum assistance in bed for repositioning. This care plan documented the resident required extensive assistance of two staff for bed bath and one-person assistance for personal hygiene. The Care Plan, dated 12/16/22, instructed staff the required extensive assistance for bathing (showers) on Monday and Thursday daytime. The resident required extensive assistance with dressing and grooming. Observation, on 12/15/22 at 10:30 AM, revealed the resident positioned in his bed. The resident had several days' worth of facial hair. Observation, on 12/20/22 at 07:42 AM, revealed the resident seated in his wheelchair in his room. The resident continued with several days' worth of facial hair and felt his face and stated he was due for a shave. Interview, on 12/20/22 at 11:00 AM, with Certified Medication Aide R, revealed she thought the resident received showers on day turn but did not know what day. Interview, on 12/20/22 at 12:11 PM, with Administrative Nurse D, revealed the resident received a bath on 12/08/22, refused on 12/15/22 and was due on 12/19/22 but did not receive one. The facility policy Admission/Readmission updated 05/16/22, instructed staff to review the plan of care and discuss the resident's needs.

The facility reported a census of 26 residents with 14 residents sampled, including two residents reviewed for restorative services. Based on observation, interview, and record review, the facility failed to provide restorative services for one of the two sampled, Resident (R)14 to maintain or prevent decline in range of motion (ROM) ability. Findings included: - Review of Resident (R)14's electronic medical record (EMR) revealed a diagnosis of post-polio syndrome (a group of potentially disabling signs and symptoms that appear decades after the initial polio illness). The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. She required total assistance of one staff for locomotion on the unit with the use of her wheelchair. She received passive range of motion (ROM) one day and active ROM of the assessment period. The Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 06/11/22, documented the resident had limitation in ROM of her upper and lower extremities. The quarterly MDS, dated [DATE], documented the resident had a BIMS score of 15, indicating intact cognition. She required extensive assistance of one staff for locomotion on the unit with the use of her wheelchair. She received no restorative cares during the assessment period. The restorative care plan, revised 11/07/22, instructed staff to perform active ROM to both ankles, knee flexion (the action of bending) and extension (stretching), hip flexion and abductions (the movement of a limb or other part away from the midline of the body) for 2 sets of ten repetitions each. Review of the resident's EMR from 12/01/22 through 12/19/22, revealed no documented restorative cares. On 12/15/22 at 10:00 AM, the resident sat in her wheelchair in her room. The resident was unable to fully straighten her left leg. On 12/19/22 at 07:54 AM, Certified Medication Aide (CMA) R assisted the resident with getting her ready for the day. The resident was unable to fully straighten her left leg. On 12/15/22 at 10:00 AM, the resident stated she was unable to fully straighten her left leg. The resident stated the leg felt better when staff worked with her on stretching her muscles, but staff no longer did exercises with her. On 12/19/22 at 07:54 AM, CMA R stated staff no longer did restorative care with the resident. On 12/20/22 at 10:14 AM, Certified Nurse Aide (CNA) M stated she was responsible for doing restorative care with the resident. CNA M stated she had only done passive ROM with the resident a couple of times and restorative care was not done with the resident on a regular basis. On 12/20/22 at 09:45 AM, Administrative Nurse E stated restorative cares were to be done to residents on a daily basis. On 12/20/22 at 09:56 AM, Administrative Nurse D stated it was the expectation that staff do restorative cares for the resident on a daily basis. The facility policy for Nursing Restorative Care Program, revised 10/11/21, included: Through effective rehabilitation/restorative, the staff assists the resident to do for him/herself rather than doing everything for the resident. The resident is to be encouraged to use their abilities; no matter how limited they may be so that the resident can attain his or her maximum functional potential. The facility failed to complete restorative cares for this dependent resident on a routine basis.

The facility reported a census of 26 residents with 14 selected for review. Based on observation, interview and record review, the facility failed to ensure the development of a Baseline Care Plan for two of the 14 residents (R) R4 and 76 for pressure ulcer preventive interventions. Findings included: - Review of Resident (R)76's Physician Order Sheet, dated 12/09/22, included diagnoses of femur (thigh bone) fracture, Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), anxiety, and arteriosclerotic (blood vessel hardening and narrowing) heart disease. The resident admitted to the facility on [DATE]. The Admission Minimum Data Set (MDS,) dated 12/09/22, assessed the resident with severe cognitive deficits and noted R76 required extensive assistance of two staff for bed mobility and transfer. The resident had impairment in functional range of motion on one side of the lower extremity. The resident was at risk for pressure ulcer development and had one stage two pressure ulcer (a shallow ulceration with a red base) that were not present upon admission. The Pressure Ulcer Care Area Assessment (CAA), dated 12/14/22, assessed the resident had impaired skin integrity due to left hip surgery with surgical incision. The resident had a deep tissue pressure injury to his left heel that measured 5 by 5 centimeters (cm). The resident required off- loading of feet when in bed and required extensive assistance with repositioning. The Admission Nursing Screen and Care Plan, dated 12/02/22, instructed staff the resident required maximum assistance in bed for repositioning. This care plan documented the resident was at risk for pressure ulcers due to surgery. The resident had a left hip incision but lacked assessment of the resident's heels. This care plan lacked interventions for pressure relieving/reducing mattress, pressure relieving cushions to chair/wheelchair, heel protectors, or a repositioning program. The Care Plan, dated 12/16/22 (after the resident developed a pressure ulcer), instructed staff to provide the following measures: 1. 12/08/22, Off -load heels and apply Kerra Foam (absorbent foam dressing) dressing to the left heel and change every third day and provide air mattress. 2. 12/15/22, Heel protectors to both heels and a multi-podus (pressure relieving device) boot to the left foot. 3. 12/16/22, The resident required extensive assistance to reposition, and staff encouraged to reposition R76 routinely. Staff instructed to off-load his heels when he was in bed or in a chair. Staff instructed to monitor the heel pressure ulcer for signs of edema (swelling), erythema (redness), bogginess (sponge like soft tissue due to fluid), or drainage. A Physical Therapy Note, dated 12/08/22, documented during a therapy session the resident had dried blood on his bed and left foot sock. Therapy staff removed the sock and noted an open wound on the resident's left heel. Observation on 12/15/22 at 08:00 AM, revealed the resident positioned in bed with the multi-podus boot on the floor beside the resident's bed. The resident had bilateral heel protectors on. The resident's wheelchair lacked a cushion. Interview on 12/15/22 at 02:46 PM, with LN G, revealed she did not know when the resident developed the heel pressure ulcer, but the resident went to wound care for treatment today. Interview on 12/20/22 at 09:37 AM with LN H, revealed she thought the resident had the pressure ulcer when he first admitted , but LN H did not remember. LN H stated the resident was cooperative with cares. Interview on 12/20/22 at 10:30 AM with Certified Medication Aide (CMA) R, revealed the staff were supposed to off load the resident's heels with a rolled blanket and blue heel protectors, CMA R but did not know when the interventions started. Interview on 12/20/22 at 11:58 AM with Administrative Nurse F, revealed she thought the resident had the left heel DTPI when he admitted to the facility, but the admission assessment lacked identification of the DTPI. Administrative Nurse F stated she noted the DTPI on 12/08/22 and instructed staff to off load the resident's heels and apply Kerra Foam every three days and as needed. Administrative Nurse F stated the wound had worsened when she assessed it on 12/12/22 and at that time they consulted wound care. Interview, on 12/20/22 at 12:15 PM, with Administrative Nurse E, revealed the admitting nurse was responsible for initiating and completing the Admission Nursing Screen and Care Plan. The facility policy Admission/Readmission, dated 05/16/22, instructed staff that licensed staff initiated the Base Line Care Plan and discusses it with the nursing assistants and team leaders. To assure continuity, the charge nurse reviews the Base Line Care Plan, and serves as coordinator of the plan. Staff instructed to revise the Resident Plan of Care as needed. The facility failed to ensure the Base Line Care Plan,/ Admission Nursing Screen and Care Plan for this resident requiring extensive assistance for bed mobility included interventions for preventive measures for pressure ulcer development. - Review of Resident (R)4's Physician Order Sheet, dated 12/12/22, revealed diagnoses included fracture acetabulum (part of hip) and fractured pelvis. The resident admitted to the facility on [DATE]. The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with normal cognitive function. The resident required extensive assistance of two staff for bed mobility and had impairment in functional range of motion on one side of the lower extremity. The Pressure Ulcer Care Area Assessment (CAA), dated 11/28/22, assessed the resident was at high risk for pressure injuries and had an air mattress on his bed and a chair pad in his recliner to relieve pressure. Staff to elevate his heels with pillows. The Admission Nursing Screen and Care Plan, dated 11/22/22, assessed the resident at risk for pressure ulcer development due to hip surgery. This care plan lacked interventions for pressure relieving devices to the resident's bed, chair, wheelchair, repositioning, and other preventive measures. Staff added an intervention of a pressure relieving mattress on 11/28/22 and a Roho (a type of seating cushion designed to distribute weight evenly) cushion to the resident's recliner on 12/20/22. The Care Plan, dated 12/16/22, instructed staff the resident had a recent pressure ulcer develop on his buttocks. The resident required extensive assistance of two staff for transfers and repositioning. The resident had an air mattress on his bed with positioning bars for assistance with turning. The Skin Evaluation Record dated 12/06/22, assess the resident with a quarter -sized open area to his left buttocks, and classified it as friction, sheer or a pressure ulcer with lack of measurements color or presence of drainage. Staff cleansed the area with normal saline and applied Kerra Foam (a type of dressing that absorbs drainage) with instruction to change every three days and as needed. Interview, on 12/15/22 at 10:31 AM, with the resident, revealed the resident preferred to sleep in his recliner. The resident stated the air mattress on the bed was uncomfortable and would like it removed from the bed. Interview, on 12/20/22 at 09:36 AM with Licensed Nurse (LN) H, revealed the resident did spend a lot of time in his recliner and required two staff to assist with repositioning. LN H did not know if staff tried a different air mattress as the resident did not like the one presently on his bed. Observation, on 12.20/22 at 10:00 AM, revealed the resident positioned in his recliner. Certified Medication Aide R emptied the resident's partially filled urinal that was positioned on his overbed table. LN H placed the wound cleanser and cup of gauze sponges directly on the resident's overbed table without first sanitizing the area. Administrative Nurse F assisted the resident to stand. LN H removed the dressing from the resident's right buttocks and cleansed the area with normal saline spray. Observation revealed pink/white open area approximately 0.5 centimeter(cm) in length by 0.25 cm in width with pink tissue surrounding the area. LN H patted the area dry and applied the Kerra Foam dressing. Interview, on 12/20/22 at 10:36 AM with Licensed Nurse (LN) H, revealed the resident did spend a lot of time in his recliner and required two staff to assist with repositioning. LN H did not know if staff tried a different air mattress as the resident did not like the one presently on his bed. LN H stated the over bed table should be sanitized prior to placing the dressing supplies on a paper towel. Interview, on 12/20/22 with Certified Medication Aide (CMA) R, revealed the resident did not lay in bed but preferred his recliner. The resident required extensive assistance of two staff to reposition in his recliner and for toileting needs. Interview, on 12/20/22 at 09:44 AM, with Administrative Nurse D, revealed the resident did not sleep in his bed at home. The resident preferred to sleep in his recliner. The resident required assistance to reposition. Administrative Nurse D stated she would expect staff to assess the resident's positioning preferences and care plan accordingly. Interview, on 12/20/22 at 12:15 PM, with Administrative Nurse E, revealed the admitting nurse was responsible for initiating and completing the Admission Nursing Screen and Care Plan. The facility policy Admission/Readmission, dated 05/16/22, instructed staff that licensed staff initiated the Base Line Car Plan and discusses it with the nursing assistants and team leaders. To assure continuity, the charge nurse reviews the Base Line Care Plan, and serves as coordinator of the plan. Staff instructed to revise the Resident Plan of Care as needed. The facility failed to ensure the Base Line Care Plan,/ Admission Nursing Screen and Care Plan for this resident requiring extensive assistance for bed mobility included interventions for preventive measures for pressure ulcer development.

The facility reported a census of 28 residents. The sample of 15 residents included one resident reviewed for pain management. Based on observation, interview, and record review the facility failed to provide adequate pain management for the Resident (R) 26, when staff failed to administer scheduled pain medication on four occasions due to the unavailability of the physician ordered medication when staff failed to reorder the medication from the pharmacy. The resident stated she had pain at a level worse than a 10 (out of a scale of 0-10, with 10 being the worst) over the weekend due to the lack of scheduled pain medication. Findings included: - Review of R26's Physician Orders, dated 06/01/21, revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS), dated [DATE], documentation included a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. She required extensive staff assistance with activities of daily living (ADLs). She received scheduled and as needed (PRN) pain medication and reported almost constant pain rated as 10/10 during the lookback period. She reported the pain made sleeping difficult. She received opioids for seven days of the look back period. She did not receive non-medication pain interventions. The Quarterly MDS, dated [DATE], documented the following changes, which included she did not receive prn pain medication, while she continued to receive scheduled pain medication. She reported almost constant pain rated at 10/10, which interfered with her day to day activities and sleep. She received opioids for seven days of the look back period. The Pain Care Area Assessment (CAA) and ADL Functional/Rehabilitation Potential CAA, dated 12/03/20, respectively documented during the resident's pain assessment she stated she had constant pain which interfered with her sleep and kept her awake. She rated her worse pain at a10 out of10. She reported she had pain at her toes, joints, and left shoulder. She received scheduled and prn pain medications including [MEDICATION(S)] 50 milligrams (mg) scheduled three times a day and Tylenol/Acetaminophen 325 mg PRN, which she received three days within a seven-day period. Additionally, she received a scheduled pain medication, [MEDICATION(S)] 5mg /Acetaminophen 325 mg at 02:00 AM, per her request. She stated the narcotic [MEDICATION(S)] was effective when given in conjunction with the acetaminophen. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She required extensive assistance of staff for bed mobility, transfers, grooming, dressing, and toileting. She maintained mobility through the use of a wheelchair within her room. The resident had a self-care deficit due to decreased physical functioning, limited mobility, knee weakness/pain, limitation of range of motion (ROM) to her left shoulder, and chronic pain. Review of the most recent Pain Screen, dated 03/31/21 at 09:39 AM, documentation revealed the resident reported daily pain located at bilateral legs, hips, and her head. She reported her pain was relieved by [MEDICATION(S)], Tylenol, and [MEDICATION(S)]. The Care Plan (CP), dated 03/05/21, directed staff the resident experienced impaired memory recall with a BIMS of 12, which indicated moderate cognitive impairment. She was able to still make decisions about her care. The resident required extensive assistance of staff with her ADLs due to weakness, decreased physical functioning, impaired mobility, chronic arthritic joint pain at her knees, right shoulder, and chronic toe pain rated on a scale of 8 to10 out of10. The resident reported her tolerable pain level as a 6 out of10. She preferred not to be awakened during the night, because it was hard for her to get back to sleep. She requested staff only wake her through the night to give her 02:00 AM pain medication ([MEDICATION(S)] 5/325). The resident reported 02:00 AM as the time she experienced the most pain. She used lamb's wool between her left first and second toes. She reported frequent to constant arthritic joint pain for which medication treatment included Tylenol, [MEDICATION(S)], and [MEDICATION(S)]. She preferred to rest in the bed when experiencing pain and reported she had frequent to constant pain in her back, joints, toes, right shoulder, and left knee. The CP directed staff that she always experienced pain and staff should offer non-pharmacological interventions such as exercise, listening to audio books (Bible), and/or warm towels to the affected areas. Review of the Interdisciplinary Notes, (IDN) dated 06/15/21 at 11:09 AM, documented the resident returned from a doctor's appointment with new orders, which included anulcer (an open sore on an external or internal surface of the body, caused by a break in the skin that fails to heal) with tophaceous gout (a chronic form of gout whereby nodular masses of uric acid crystals are deposited in the soft tissues f the body), extruding (forced out) from a bunion (deformity of the joint) on the left foot. Staff were to administer daily dressings with [MEDICATION(S)] (antibiotic ointment) and gauze. Keep her in socks and prevent pressure from the bed as sheets or shoe on the foot. Follow-up appointment in one week. The IDN, dated 06/17/21 at 06:46 PM, documented the resident continued to complain of pain related to the wound on the left side of her foot. The staff notified the physician of the pain and of a new rash going up the left leg. The leg was warm to touch and had two to three plus pitting [CONDITION(S)]. The Physician Orders, dated 06/01/21, documented the following medication orders for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] 50 mg by mouth, three times a day with food, for pain, start date 09/17/19, scheduled for administration at 08:00 AM, 04:00 PM, and 08:00 PM. 2. [MEDICATION(S)] 5 mg/acetaminophen 325 mg, one tablet at hour of sleep for pain, start date 05/20/20, scheduled at 02:00 AM. 3. [MEDICATION(S)] 5 mg/acetaminophen 325 mg, one tablet every six hours as needed (PRN) for pain, start date11/26/19. 4. Tylenol 325 mg, give two tablets PRN for pain, start date 04/13/20. The Medication Administration Record (MAR), dated 06/01/21 through 06/22/21, documentation revealed the following concerns: 1. [MEDICATION(S)] 50 mg, by mouth, three times a day scheduled for 08:00PM, was not administered on 6/19/21 and 6/20/21, due to not being available from the pharmacy. 2. [MEDICATION(S)] 50 mg, by mouth, three times a day scheduled for 04:00PM, was not administered on 06/20/21, due to not being available from the pharmacy. 3. [MEDICATION(S)] 50 mg, by mouth, three times a day scheduled for 08:00 AM, was not administered on 06/20/21, due to not being available from the pharmacy. 4. [MEDICATION(S)] 50 mg, by mouth, three times a day scheduled for 08:00 AM dose was not administered on 06/21/21 until11:00 AM, after staff contacted the pharmacy and made them aware of the unavailability of the resident's scheduled [MEDICATION(S)] medication since the last dose Saturday on 06/19/2021 at 04:10 PM. Further review of the MAR from 06/01/21 through 06/22/21 revealed the resident received [MEDICATION(S)] 5 mg/acetaminophen 325 mg, on 06/19/21 at 07:57 PM and 06/21/21 at 10:10 AM. The resident did not receive her PRN Tylenol 325 mg from 06/19/21 through 06/21/2021. The Individual Narcotic Record, for [MEDICATION(S)], revealed staff administered the last dose of scheduled [MEDICATION(S)] on 06/19/21 at 04:10 PM. The resident did not receive her scheduled [MEDICATION(S)] from the 06/19/21 08:00 PM dose, until the 06/21/21 10:10 AM dose, which resulted in 4 missed doses of her pain medication over a 36-hour period. The IDN, dated 06/21/21 at 05:30 PM revealed a fax communication to the physician that documented the resident was currently out of [MEDICATION(S)]. The pharmacy was waiting on the physician approval for refill of the medication. Received a new order from the physician to continue current medication regimen until follow-up visit on 06/29/21. The pharmacy delivered the [MEDICATION(S)] medication to the facility at approximately11:00 AM on 06/21/21. The scheduled 08:00 AM dose of [MEDICATION(S)] was then given to the resident. The IDN lacked evidence staff monitored the resident's level of pain during this time period. On 06/16/21 at 08:37 AM, the resident sat in the chair with a bandage to her left foot. The resident reported her foot hurt bad since her appointment with the foot doctor (06/15/21). She stated the doctor dug around in her foot to get the infection out and it still hurt badly. Additionally, she stated her right knee was crippled from walking to compensate for her other knee hurting, her back, and her shoulder hurt. The resident stated, the only joints that don't hurt when I move are my neck and right hip. She stated she took medication for pain, but the Tylenol does not help. She reported she received some pain medication earlier. The resident stated she was supposed to receive scheduled pain medication at 08:00 AM, 04:00PM, and 08:00PM and she received [MEDICATION(S)] at 02:00 AM. She explained she did not get her 08:00AM pain medication until 10:00 AM this day. On 06/16/21 at 04:07 PM, Certified Nurse Aide (CNA) N stated the staff did not put a shoe on the resident's foot and used a foot cradle to keep the covers off of her left foot. She occasionally complained about pain. When she complained they reported to the Certified Medication Aide (CMA) or the nurse. CNA N stated she assumed the CMA or nurse went back to see if the pain medication was effective. On 6/17/21 at 10:58 AM, Licensed Nurse (LN) F reported the resident had a skin condition related to sebaceous (relating to oil or fat) gout and had a bunion on her left foot for [AGE] years. On 06/17/21 at 02:05 PM, LN E, removed the dressing on the resident's left foot and revealed an open wound at the junction of the left great toe to the foot. The resident refused measurements of the wound; however, the open area appeared approximately 2.0 centimeters (cm) in length by 2.0 cm width by 0.2 cm deep. Her left lower leg was edematous. The open area was red and edematous with white tissue present (slough). LN H reported the resident was diagnosed with some type of gout resulting in the wound. On 06/21/21 at 09:02 AM the resident sat in her wheelchair with her bandaged foot on the floor. She tearfully reported, the bunion on her left foot hurt terrible. She stated she told the staff she was in pain, but they had not brought her 08:00 AM pain medication yet. The resident stated she had a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/21/21 at 09:15 AM, the resident made CMA S aware of her pain. CMA S informed the resident she would give her the scheduled (for 08:00 AM) [MEDICATION(S)], pain medication. On 06/21/21 at 09:31 AM, CMA S stated the resident received [MEDICATION(S)] 50 mg three times daily for pain as well as a [MEDICATION(S)] 5/325 mg at 02:15 AM. While preparing the medications in applesauce, CMA S noted the resident did not have any [MEDICATION(S)]. She checked the overflow and there was not any [MEDICATION(S)] in the overflow stock. She explained the emergency kit did not have pain medications available. CMA S checked the MAR and reported the resident had not received her scheduled [MEDICATION(S)] since her 04:00 PM dose on Saturday 06/19/21. She explained the resident had orders for Tylenol that could be given between her routine medication and she had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . CMA S stated she would check with the nurse to see what she wanted her to do. CMA S proceeded to administer the other scheduled medications to the resident stating Here are your morning medications. She did not inform the resident that her medications did not include her scheduled [MEDICATION(S)], nor did she ask the resident about her pain. CMA S documented [MEDICATION(S)] as not available. On 06/21/21 at 09:57 AM, CMA S informed LN E the resident was out of [MEDICATION(S)] since Saturday. LN H instructed CMA S to call the pharmacy. CMA S informed LN E the resident complained of pain. LN H instructed CMA S to give the resident her PRN [MEDICATION(S)]. LN E did not go and assess the resident's pain level. On 06/21/21 at 12:53 PM, LN I stated she just learned of the resident's bunion and associated open area today. She reported the resident was diagnosed with gout. Upon review of the resident's clinical record, LN I verified the wound at the left great toe and foot measurements dated 06/18/21 as 1.3 cm x 1.0 depth of 0.2 cm. The resident reported pain and received a scheduled and PRN pain medication, which included [MEDICATION(S)] three times a day, [MEDICATION(S)] 5/325 mg PRN (last dose 01:10 AM 06/21/21 and 06/19/21 at 7:57 PM), and Tylenol 325 mg, 2 tabs PRN (last administered on 06/17/21). LN I stated The resident did not receive her [MEDICATION(S)] on Saturday at 08:00PM, and on Sunday at 08:00AM, 04:00PM or 08:00 PM. LN I verified the documentation noted the resident requested [MEDICATION(S)] for painon 6/19/21 at 07:57AM. On 06/21/21 at 04:53 PM, the resident stated the new physician diagnosed me with gout, but I have not received any new medications for gout. On inquiry, she tearfully stated, My pain last night and this morning was worse than a ten. It was the worst pain I have ever had. I have been in so much pain I am confused for the first time this morning. When I woke up, I did not know if it was day or night. I don't get my medicine like I am supposed to. I try not to complain to anyone. I am in here to be taken care of. I am 94 and I cannot take care of myself. She stated my pain, right now is not more than a three since they gave me two medications for pain. On 06/22/21 at 11:57 AM, Administrative Nurse D, stated she expected staff to document the reason for administering a PRN medication and to document the effectiveness within an hour of administration. She expected the CMAs to report to the charge nurse if the resident's medication was not available and to notify the on-call nurse if staff could not provide the medication. There was a pharmacist on call 24/7. Pain medications were not available in the emergency kit. She stated she would expect the pharmacy to deliver medications within the day of notification of the need. Administrative Nurse D reported she was not made aware of the concerns regarding the unavailability of pain medication for this resident prior to the survey. She stated the staff should complete a pain assessment/pain scale for a resident who received PRN pain medication, but not with scheduled pain medications. On 06/23/21 at 12:02 PM, Consultant Physician HH, stated he had just taken over the care of the resident and he was not informed the resident did not receive her prescribed pain medications during the time frame as noted above. He stated the staff should notify him of the lack of medication administration and the need for a refill. Consultant HH verified he did not get a refill request or notification of unmanaged pain over the weekend of 06/19/21 through 06/21/21. Additionally, he stated he would expect staff to provide PRN medication as ordered to control pain and assess for effectiveness of the medication. The facility policy for Pain Management, dated 06/10/2019, documentation included each resident would be screened at regular intervals to determine whether symptoms of pain or discomfort were present and to clarify the cause(s), severity, and location of the pain. Residents experiencing pain would be monitored for effectiveness of treatment. Staff would review the Matrix Care Pain Screen quarterly, with any significant change or more often if necessary and consider the resident's tolerance for pain and resident's beliefs related to pain. The facility failed to provide adequate pain management, as prescribed by the physician, when facility staff failed to ensure the availability of scheduled pain medication. The resident went for at least 36 hours without administration of her scheduled pain medication. The resident experienced severe pain, worse than a 10, during this time.