Every finding on record at Pinnacle Park Nursing & Rehab Center

Based on observation, interview, and record review, the facility failed to ensure Resident (R) 3 had a physician's order and was assessed for the ability to safely self-administer medications left at the bedside. Findings included: -R3's Electronic Medical Record (EMR) documented diagnoses of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), cerebral infarction (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), hemiplegia (paralysis of one side of the body) and a need for assistance with personal care. R3' s Quarterly Minimum Data Set dated 05/23/26, documented R3 had intact cognition, functional range of motion impairment on one side of the upper and lower extremities, and was dependent on staff for dressing, personal and toileting hygiene, transfers, and bed mobility. R3 was frequently incontinent of urine and bowel. R3's Care Plan dated 06/08/26, documented R3 needed assistance with activities of daily living related to hemiplegia and hemiparesis (weakness and paralysis on one side of the body) following a cerebrovascular disease (any abnormal condition characterized by dysfunction of the heart and blood vessels) affecting the left dominant side. The plan directed staff to transfer R3 using a sit-to-stand lift and two staff members. The Physician Orders directed staff to administer numerous morning medications. On 06/09/26 at 09:30 AM, Licensed Nurse (LN) J prepared R3's morning medication. R3 had been transferred from her electric wheelchair to her recliner. LN J placed the morning medication in a small wooden bowl on the overbed table. LN J reported R3's preference to use a bowl because R3 was able to place the medications into her mouth. R3 took her medications, one pill at a time, followed by a drink of water. On 06/10/26 at 09:28 AM, R3 was sitting in her room in an electric wheelchair. R3 reported she could not reach the bowl of medications placed on the overbed table because the electric wheelchair had lost battery function. R3's wooden bowl had several medications of different sizes and shapes, which were out of reach of the resident, and staff were not present in the room. On 06/10/26 at 09:30 AM, Administrative Nurse D reported LN H was R3's nurse for the shift. LN H stated she thought R3 could reach the medications she left in the bowl but had not stayed in the room while R3 had finished taking the medications. On 06/10/26 at 11:57 AM, Administrative Nurse D stated that LN H should not have left R3's medications in the room. The facility's Resident Self-Administration of Medication policy, dated 2026, documented that a resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment Form, which is placed in the resident's medical record. Upon notification of the use of bedside medication by the resident, the medication nurse records the self-administration on the medication administration record.

Based on observation, record review and interviews, the facility failed to ensure Resident (R) 7 had an appropriate indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat mental disorder characterized by a gross impairment in reality testing). Findings included:- R7's Medical Diagnosis tab of the Electronic Medical Record (EMR) documented diagnoses of cerebral infarction (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), dementia (a progressive mental disorder characterized by failing memory and confusion) with agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, and wanting to die were more intense and persistent than what may normally be felt from time to time), and major depressive disorder (major mood disorder that causes persistent feelings of sadness).R7's Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) Score of 12, which indicated moderately impaired cognition. R7 received an antipsychotic medication during the look back period. A gradual dose reduction (GDR) was last attempted on 08/25/25. The physician documented a GDR was clinically contraindicated on 01/19/26.R7's Psychotropic Drug Use Care Area Assessment (CAA) dated 03/03/26 documented R7 triggered for psychotropic drug use related to taking an antipsychotic medication for mood disorder and adjunct to depression per review.R7's Care Plan regarding psychotropic medications, initiated on 01/04/24, directed staff to: Administer psychotropic medications as ordered by the physician; behavior monitoring for risperidone (an antipsychotic medication); Consult with the pharmacy and physician to consider dosage reduction when clinically appropriate at least quarterly; discuss with the physician and family about the ongoing need for the use of the medications. Review behaviors and interventions and alternate therapies attempted and their effectiveness as per facility policy; educate me/my family/my caregivers about risks, benefits and the side effects and/or toxic symptoms of psychotropic medication drugs being given; do a gradual dose reduction as ordered; Monitor/document/report as needed (PRN) any adverse reactions of psychotropic medications: unsteady gait, tardive dyskinesia (an abnormal condition characterized by involuntary repetitive movements of the muscles of the face, limbs, and trunk), extrapyramidal symptoms (EPS-movement disorders as a result of taking certain medications) (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia (inability to sleep), loss of appetite, weight loss, muscle cramps nausea, vomiting, or behavior symptoms not usual to the person.R7's Care Plan for psychotropic medications had not been revised with new interventions or any non-pharmacological approaches tried.R7's Orders tab in the EMR documented a physician's order dated 01/29/24 for risperidone (antipsychotic0 0.25 milligrams (mg) by mouth two times daily for mood disorder. This order was discontinued on 08/25/25.R7's Orders tab in the EMR documented a physician's order dated 08/25/25 for risperidone 0.25 mg by mouth two times daily for mood disorder. This order was discontinued 08/26/25.R7's Orders tab in the EMR documented a physician's order dated 08/25/25 for risperidone 0.25 mg by mouth in the morning for agitation and give 0.5 mg by mouth at bedtime for agitation. This order was discontinued 08/26/25.R7's Orders tab in the EMR documented a physician's order dated 08/26/25 for risperidone 0.25 mg by mouth in the morning for mood disorder and give 0.5 mg by mouth at bedtime for mood disorder. This order was discontinued on 02/24/26.R7's Orders tab in the EMR documented a physician's order dated 02/24/26 for risperidone 0.25 mg by mouth in the morning and give 0.5.mg at bedtime for adjunct to depression. This order was discontinued on 03/03/26.R7's Orders tab in the EMR documented a physician's order dated 03/03/36 for risperidone 0.25 mg by mouth in the morning and give 0.5.mg at bedtime for adjunct to depression. This order was discontinued on 04/29/26.R7's Orders tab in the EMR documented a physician's order dated 03/29/26 for risperidone 0.25 mg by mouth in the morning for psychosis (any major mental disorder characterized by a gross impairment in reality perception) with delusions and give 0.5 mg by mouth at bedtime for psychosis with delusions.R7's Orders tab in the EMR documented a physician's order dated 03/29/26 for risperidone 0.25 mg via percutaneous endoscopic gastrostomy tube (PEG -a tube surgically placed through an artificial opening into the stomach) in the morning for psychosis with delusions and give 0.5 mg by PEG tube at bedtime for psychosis with delusions. This order was discontinued on 05/21/26.R7's Orders tab in the EMR documented a physician's order dated 03/29/26 for risperidone 0.25 mg by mouth in the morning for psychosis with delusions and give 0.5 mg by mouth at bedtime for psychosis with delusions.R7's Misc tab in the EMR noted a Note to Attending Physician/Provider dated 01/07/26 that documented the resident had an order for risperidone that did not have and FDA-labeled indication. Please review and complete the Risk-Benefit Assessment since the order has a non-FDA -labeled indication. The physician's response dated 01/19/26 indicated the risperidone was given for mood disorder. The order was prescribed for a diagnosed condition and not being used for convenience or discipline. The risperidone was clinically indicated to manage the resident's symptoms or condition where other causes had been ruled out. The residents signs, symptoms, or related causes were persistent or clinically significant enough to warrant the initiation or continuation of medication therapy. The intended or actual benefit was sufficient to justify the potential risk(S) or adverse consequences associated with the medication dose and duration.R7's Misc tab in the EMR noted a Note to Attending Physician/Provider dated 02/10/2026 documented the resident had an order of risperidone 0.25 mg every day and 0.5 mg at bedtime that did not have and FDA-labeled indication. Please assess the resident for a GDR of the risperidone. The physician's response dated 02/16/2026 documented the risperidone's indicated use was for mood disorder. The resident had been assessed, and a GDR was contraindicated because the order had been effective at alleviating the behavioral symptoms that can present a risk of harm to the resident or others, and it was not being prescribed for discipline or staff convenience.On 06/09/2026, R7 sat at a table in the dining room eating his breakfast. R7 received his medications crushed in applesauce by the medication aide. R7 took the medication without rejection or behavior.On 06/10/2026 at 11:54 AM, Administrative Nurse E stated R7 had been on risperidone prior to his admission to the facility. The facility has worked with the physicians and pharmacy to ensure that R7 was not given risperidone for an inappropriate indication for use. Administrative Nurse E stated the most recent diagnosis used had been psychosis, and the physician thought that was an appropriate and approved diagnosis for `. Administrative Nurse E stated that no non-pharamalogical interventions had been tried for R7.On 06/10/2026 at 12:01 PM, Administrative Nurse D stated that the facility held monthly pharmacy consultation meetings with the pharmacist and medical director to go over the psychotropic medications and indications for continued use. The facility had not tried non-pharmacological approaches for R7. Administrative Nurse D stated it had been discussed about the need for the appropriate indication for use of antipsychotics, and the physician indicated that psychosis was an appropriate indication for use. The facility's Use of Psychotropic Medication(s) dated 2025 documented it was the intent of the policy to ensure that residents only receive psychotropic medications when other non-pharmacological interventions were clinically contraindicated. Psychotropic medication was to be used only when a practitioner determined that the medication was appropriate to treat a resident's specific, diagnosed, and documented condition and the medication would be beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medications. Non-pharmacological approaches must be attempted, unless contraindicated, to minimize the need for psychotropic medications, use the lowest dose possible, or discontinue the medications. The policy lacked information on an appropriate indication for the use of psychotropic medications.

Based on observation, interview, and record review, the facility failed to prevent injury when a Certified Nurse Aide (CNA) provided footcare to Resident (R) 13, who had a diagnosis of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), and received a cut to her left great toe. Findings included:- The Electronic Medical Record (EMR) documented R13 had a diagnosis of type 2 DM.R13's Quarterly Minimum Data Set (MDS), dated [DATE], documented R13 had intact cognition. She was dependent upon staff for toileting, lower body dressing, putting on her shoes, mobility, and transfers. It was documented R13 received insulin daily.R13's Quarterly MDS, dated 04/29/2026, documented that R13 had intact cognition. She was dependent upon staff assistance for toileting, showers, lower-body dressing, mobility, and did not ambulate. It was documented R13 received insulin daily.R13's 06/09/2026 Care Plan had interventions dated 09/16/2020, that instructed staff to check R13's body for breaks in the skin and to treat them promptly as ordered by the physician. Staff were not to use over-the-counter remedies for foot corns (a small, hardened cone of thickened skin that typically forms on the tops, sides, or between toes due to friction and pressure) and calluses, and they were to refer R13 to a podiatrist (foot doctor) for treatment. Staff were further instructed to educate caregivers that nails were to always be cut straight across, they were never to cut the corners, and were to file the edges with an emery board. Finally, staff were to inspect R13's feet daily for open areas, sores, pressure areas, blisters, edema, or redness. The 03/04/2026 at 08:42 PM Nurse's Note, documented R13 reported that a CNA cut her toenails. The left great toe was bloody on the left side of the nail, and a small piece of skin had been cut off. The note further documented that the area was cleansed with wound cleanser, a band aid was applied, and staff would notify the wound nurse for further treatment orders.The EMR lacked documentation of a wound assessment or that the physician had been notified.On 06/09/2026 at 09:00 AM, R13 sat in her wheelchair in front of the television. She stated she did not have any concerns with her toenails, and the facility made sure a nurse cut her toenails.On 06/09/2026 at 01:00 AM, Licensed Nurse (LN) G stated she was the wound care nurse and was unaware that a CNA had cut R13's skin when providing foot care. LN G further stated that R13 was diabetic, and CNAs were not to have provided any type of foot care to R13.On 06/10/2026 at 10:43 AM, CNA M stated that the Assistant Director of Nursing (ADON) usually provided the foot care for residents and that, as a CNA, she was not to have provided any type of nail care to residents who were diabetic.On 06/10/2026 at 12:03 PM, Administrative Nurse D stated CNAs should not have provided nail care to diabetic residents, and the physician should have been made aware of the injury R13 had received.The facility's Footcare policy, dated 2025, documented that the facility ensured residents received proper treatment and care within professional standards of practice as applicable to maintain mobility and good foot health. As needed, a licensed nurse with adequate training may perform nail care to non-diabetic residents or diabetic residents who are low risk, as determined by a podiatrist or physician. Nursing assistants would inspect skin during baths and would report any concerns to the residents' nurse immediately after the task.

Based on observation, interview, and record review, the facility failed to hold blood pressure medication, per the physician-ordered parameters, for Resident (R) 13. Findings included:- R13's Electronic Medical Record (EMR) documented diagnoses of hypertension (high blood pressure), atrial fibrillation (rapid, irregular heartbeat), and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) type 2.The Annual Minimum Data Set (MDS), dated [DATE], documented R13 had intact cognition. R13 was dependent upon staff assistance for toileting, transfers, and lower-body dressing. R13 required substantial staff assistance with showers, personal hygiene, and upper body dressing.The Quarterly MDS, dated 04/29/26, documented that R13 had intact cognition. R13 was dependent upon staff assistance for toileting, showers, lower-body dressing, mobility, and did not ambulate.R13's 06/09/2026 Care Plan included the following interventions for R13:10/05/2020- Give medications as ordered and monitor for side effects such as orthostatic hypotension (blood pressure dropping with change of position), increased heart rate, monitor for and document edema (swelling resulting from an excessive accumulation of fluid in the body tissues), and monitor for abnormalities of urinary output.The Physician's Order, dated 08/28/25, directed staff to administer metoprolol (a high blood pressure medication), 37.5 milligrams (mg), one tablet by mouth twice daily for hypertension. Hold the medication if the systolic blood pressure (SBP-the top number, the force your heart exerts on the walls of your arteries each time it beats) is less than 100 millimeters of mercury (mmHg), and the heart rate (the number of times your heart beats in one minute) is less than 60 beats per minute (bpm).R13's Treatment Administration Record (TAR) for April 2026 documented the following days R13 received the metoprolol when the heart rate was under the ordered parameters:04/01/2026- 57 bpm04/04/2026- 59 bpm04/18/2026- 58 bpmR13's TAR, for May 2026, documented the following days R13 received the metoprolol when the heart rate was under the ordered parameters:05/03/2026- 55 bpm05/10/2026- 54 bpm05/24/2026- 57 bpmOn 06/10/2026 at 10:00 AM, Licensed Nurse (LN) I stated that if the heart rate was below 60 bpm, the staff would hold the medication and document it in the progress notes. LN I verified that there were days R13 received the metoprolol when it should have been held.On 06/10/2026 at 12:03 PM, Administrative Nurse D stated the order should have been clarified as the order was not clear as to whether it should have been held when both the SBP and the heart rate were out of parameters. Administrative Nurse D stated she could understand why the medication was held sometimes when the heart rate was out of parameters and administered at other times. Administrative Nurse D further verified that staff were to follow the physician's orders and hold medication when out of parameters.The facility's Medication Administration policy, revised in 2025, documented that the medications were administered as ordered by the physician and in accordance with professional standards of practice. Staff obtain and record vital signs when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters.

The facility identified a census of 56 residents. The sample included 14 residents and five Certified Nurse Aides (CNA) were reviewed for performance evaluations and the associated in-service training. Based on record review and interview, the facility failed to ensure five of the five CNA staff reviewed had the required yearly performance evaluations completed. This placed the residents at risk for inadequate care. Findings included: - A review of the facility's staffing list revealed the following CNAs were employed with the facility for more than 12 months: CNA 0, hired on 08/27/21, had no yearly performance evaluations upon request. CNA P, hired on 08/04/20, had no yearly performance evaluations upon request. CNA Q, hired on 12/12/22, had no yearly performance evaluations upon request. CNA R, hired on 02/21/22, had no yearly performance evaluations upon request. CNA S, hired on 05/27/23, had no yearly performance evaluations upon request. On 07/23/24 at 04:04 PM, Administrative Nurse D stated the facility was not currently up to date on performance evaluations for CNAs and said a performance plan was implemented recently to address the situation. The facility's Evaluation Process policy dated 12/01/19 documented it was the policy of the facility to review the work performance of employees with a formal written evaluation annually. The facility failed to ensure the five CNA staff reviewed had the required yearly performance evaluations completed. This placed the residents at risk for inadequate care.

The facility identified a census of 56 residents. The facility identified two residents on contact-based precautions and six on Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record review, observations, and interviews, the facility failed to follow sanitary infection control standards related to the handling of soiled laundry, hand hygiene, storage of oxygen tubing while not in use, and disinfecting of shared equipment. These deficient practices placed the residents at risk for infectious diseases. Included Findings: - On 07/22/24 at 08:00 AM an electric razor with brown shavings was laid on an EBP cart outside of Resident (R)22's room. The soiled razor was not in a container. On 07/22/24 at 08:10 AM, Certified Nursing Aide (CNA) M pushed the Hoyer (total body mechanical lift) from Resident (R)22's room into R49's room without sanitizing the Hoyer lift. CNA M did not perform hand hygiene upon leaving R22's room and before entering R49's room. On 07/22/23 at 01:28 PM, R18's oxygen cannula was wrapped around her wheelchair and was not in a sanitary container. On 07/23/24 at 08:07 AM CNA M placed R22's soiled linens directly on the floor while changing R22's bed. R22 was on EBP. CNA M did not sanitize the floor immediately after the soiled linens were picked up. On 07/23/24 at 07:08 AM two commercial washers were filled with wet clothing left from the 10:00 PM to 12:00 AM shift. Two commercial dryers had lint in the lint traps. An inspection of the soiled area of the laundry room revealed there was no personal protective equipment (PPE-gloves and gowns used in transmission-based precautions) available. On 07/24/24 at 07:51 AM CNA T pushed a resident down the 200 hall; CNA T had a dirty unbagged hospital gown in her right hand. On 07/24/24 at 07:57 AM, CNA M and CNA N donned two pairs of gloves each, and donned gowns. Neither CNA performed hand hygiene. R18, who was on contact precautions for Methicillin-resistant Staphylococcus aureus (MRSA-a type of bacteria resistant to many antibiotics), laid on her bed on her back. CNA N fastened R18's brief. CNA N and CNA M rolled R18 from left to right, putting her sling underneath her. CNA M and CNA N doffed both sets of gloves. Without performing hand hygiene, CNA M and CNA N each donned clean gloves and put R18 in her wheelchair using the Hoyer lift. Wearing the same gloves, CNA N placed R18's oxygen nasal cannula into R18's nares. CNA M placed R18's urinary catheter bag underneath her wheelchair. Wearing the same gloves, CNA N brushed R18's hair and put her boots on her heels. CNA N doffed her gloves and gown and then performed hand hygiene. CNA M doffed her gloves and gown and then pushed the Hoyer lift to the hallway without sanitizing the Hoyer lift or performing hand hygiene. CNA M proceeded to walk into another room. On 07/23/24 at 07:50 AM Housekeeping Staff V stated she was unaware that laundry could not sit in the washers overnight. She stated the night laundry worker puts a load in the washers before she leaves at 12:00 AM. She stated red red-bagged laundry (indicating transmission-based precautions) was washed separately but she did not do anything different for the red-bagged laundry. She stated gloves were available to the laundry staff. Housekeeping Staff V stated there were gowns on the washer in the clean area if the gowns were needed. She stated she did assess water temperatures for any laundry including the red bagged laundry and said the temperatures were assessed by a supervisor. Housekeeping Staff V said she was unaware if the washers were monitored by temperature or by chemicals. On 07/24/24 at 08:10 AM Housekeeping Staff U stated she was unaware laundry could not sit in the washer overnight and stated that she was told laundry could sit in the washer if the seal on the washing machine wasn't broken. She stated the overnight staff did all the red-bagged laundry, and she had been trained to wear PPE when handling red-bagged laundry. On 07/24/24 at 08:16 AM CNA M stated she did not know she was supposed to clean equipment between residents or how to accomplish that but stated she would ask. CNA M stated she did forget to do hand hygiene before entering R49's room, and said she should have done hand hygiene when going from resident to resident, and when she left the residents' rooms. On 07/24/24 at 11:18 AM Administrative Nurse D stated shared equipment was to be cleaned after each resident's use. She stated oxygen tubing should always be stored in a container when not in use and each resident had their own bag on their canister and wheelchairs. Administrative D stated staff should do hand hygiene when going from resident to resident, dirty to clean, and when leaving a resident's room. The facility's Hand Hygiene, Cleaning and Disinfection of Resident -Care Equipment, Handling of Soiled Linen, Laundry, Transmission-Based Precautions policy documented the facility's undated Hand Hygiene policy documented all staff would perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applied to all staff working in all locations within the facility. The use of gloves did not replace hand hygiene. If the task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Aligning with principles of started precautions, staff shall consider all previously worn clothing and used linens as potentially contaminated. It was the policy of this facility to handle, store, process, and transport linen in a safe and sanitary method to prevent the spread of infection. Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected to break the chain of infection. The facility staff will apply Transmission-Based Precautions (TBP), in addition to standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission. The facility failed to follow sanitary infection control standards related to the handling of soiled laundry, hand hygiene, storage of oxygen tubing while not in use, and disinfecting of shared equipment. These deficient practices placed the residents at risk for infectious diseases.

The facility had a census of 56 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to revise Resident (R)5's Care Plan to reflect her Hoyer lift (total body mechanical lift) transfer requirements. This deficient practice placed R5 at risk for impaired care due to uncommunicated care needs. Findings Including: - The Medical Diagnosis section within R5's Electronic Medical Records (EMR) included diagnoses of heart failure, cerebrovascular disease, major depression (major mood disorder), cognitive-communication disorder, abnormalities of gait, muscle weakness, and unsteadiness of her feet. R5's Quarterly Minimum Data Set (MDS) completed 06/21/24 noted a Brief Interview for Mental Status (BIMS) score of 13 indicating mild cognitive impairment. The MDS indicated she was dependent on staff for bed mobility, transfers, toileting, dressing, bathing, and personal hygiene. The MDS indicated she was at risk for falls. The MDS noted she had two non-injury and one minor injury fall since her last assessment. R5's Functional Abilities Care Area Assessment (CAA) completed 09/26/23 indicated she required staff assistance with most of her activities of daily living (ADLs). The CAA indicated the facility will provide care-planned interventions to reduce the risks related to ADL decline. R5's Falls CAA completed 09/26/23 indicated she was at risk for falls related to her medical diagnoses and impaired balance. The CAA indicated the facility will provide care-planned interventions to reduce the risks related to ADL decline. R5's Care Plan initiated 11/12/23 indicated she required assistance with her ADLs related to her medical diagnoses and weakness. The plan indicated she required substantial to maximal assistance from staff for bathing, toileting, bed mobility, transfers, personal hygiene, and dressing. The plan indicated she used a high-back reclining wheelchair for mobility. The plan indicated she was at risk for falls. The plan instructed staff to anticipate her needs, ensure her call light was within reach, and ensure her environment remained free from spills or clutter. On 11/08/22 R5's plan indicated staff received education on transporting her in a shower chair related to a fall that occurred on 10/29/22. On 01/09/24 R5's plan was updated for fall interventions to show verbal education was provided to a bath aide to ensure R5's chair remained close while bathing for a fall that occurred on 12/28/23. On 06/03/24 R5's plan was updated to use two staff members if the resident needs to stand longer than a pivot. R5's plan lacked indication she required a Hoyer lift for transfers. On 07/23/24 at 08:00 AM R5 sat in her recliner in her room. Her call light was within reach. R5's wheelchair sat next to her bed. Her wheelchair had an auto-lock mechanism installed on it. R5 had bruising around her eyebrows and upper nose. She stated it occurred during a fall. On 07/24/24 at 08:21 AM an inspection of R5's room revealed a Hoyer lift was left placed in her room directly in front of her bed. On 07/24/24 at 10:05 AM CNA MM stated R5 was a high fall risk related to her weakness and inability to know her limitations. She stated R5 required two staff and a Hoyer lift after falling multiple times during care. She stated all direct care staff had access to view the care plans. She stated R5's Hoyer lift transfer requirements should be listed in the care plan. On 07/24/24 at 10:30 AM LN G stated R5 required two staff and a Hoyer lift for transfers due to her recent decline. She stated the care plans indicate the levels of assistance and transfer type for each resident. On 07/24/24 at 11:19 AM Administrative Nurse D stated that R5's ability to assist during care recently declined due to her weakness and physical limitations. She stated R5 required a total mechanical lift due to her inability to safely transfer. She stated that R5's plan of care indicated she was a total mechanical lift. She stated the care plans could be updated by all staff by reviewed by the interdisciplinary team. She stated fall interventions should be implemented within 48 hours of a fall or incident and revised on the care plans. The facility's Care Plan Revisions policy implemented 01/2020 indicated the facility will ensure each resident's care plan will be initiated and revised to reflect the resident's comprehensive care needs. The policy indicated the facility's interdisciplinary team will review and collaborate to provide interventions that meet the resident's care needs. The facility failed to revise R5's care plan to reflect her Hoyer lift transfer requirements. This deficient practice placed R5 at risk for impaired care due to uncommunicated care needs.

The facility had a census of 56 residents. The sample included 14 residents with seven residents reviewed for accidents and/or hazards. Based on observation, record review, and interview, the facility failed to ensure safe care practices were followed during staff-assisted care resulting in multiple preventable falls for Resident (R)5. This deficient practice placed R5 at risk for further falls and injuries. Findings Including: - The Medical Diagnosis section within R5's Electronic Medical Records (EMR) included diagnoses of heart failure, cerebrovascular disease, major depression (major mood disorder), cognitive-communication disorder, abnormalities of gait, muscle weakness, and unsteadiness of her feet. R5's Quarterly Minimum Data Set (MDS) completed 06/21/24 noted a Brief Interview for Mental Status (BIMS) score of 13 indicating mild cognitive impairment. The MDS indicated she was dependent on staff for bed mobility, transfers, toileting, dressing, bathing, and personal hygiene. The MDS indicated she was at risk for falls. The MDS noted she had two non-injury and one minor injury fall since her last assessment. R5's Functional Abilities Care Area Assessment (CAA) completed 09/26/23 indicated she required staff assistance with most of her activities of daily living (ADLs). The CAA indicated the facility will provide care-planned interventions to reduce the risks related to ADL decline. R5's Falls CAA completed 09/26/23 indicated she was at risk for falls related to her medical diagnoses and impaired balance. The CAA indicated the facility will provide care-planned interventions to reduce the risks related to ADL decline. R5's Care Plan initiated 11/12/23 indicated she required assistance with her ADLs related to her medical diagnoses and weakness. The plan indicated she required substantial to maximal assistance from staff for bathing, toileting, bed mobility, transfers, personal hygiene, and dressing. The plan indicated she used a high-back reclining wheelchair for mobility. The plan indicated she was at risk for falls. The plan instructed staff to anticipate her needs, ensure her call light was within reach, and ensure her environment remained free from spills or clutter. On 11/08/22 R5's plan indicated staff received education on transporting her in a shower chair related to a fall that occurred on 10/29/22. On 01/09/24 R5's plan was updated for fall interventions to show verbal education was provided to a bath aide to ensure R5's chair remained close while bathing for a fall that occurred on 12/28/23. On 06/03/24 R5's plan was updated to use two staff members if the resident needs to stand longer than a pivot. R5's Fall During Staff Assist report completed 10/29/22 indicated R5 fell while Certified Nurses Aid (CNA) LL assisted her in the shower room. The report indicated R5's shower chair had tipped while a CNA LL attempted to provide her with a shower resulting in R5 falling to the floor. The report indicated no injuries occurred during the fall episode. R5's Fall During Staff Assist report completed 12/28/23 indicated R5 fell while CNA KK assisted with undressing her in the shower room. The report indicated R5 reported she needed to sit and could no longer stand. The report indicated the shower chair was not in reach and R5 had to be assisted to the ground. The report indicated R5 had to be laid flat on the grab and lifted with a full lift (Hoyer lift- total body mechanical lift). R5's Fall During Staff Assist report completed 05/30/24 indicated R5 fell during staff bathroom care. The report indicated R5 was standing in the bathroom holding onto the railing. The note indicated CNA T was performing care on her and R5 began to fall. The report indicated that CNA T was unable to hold R5 up and she fell backward against the staff member and then lowered to the ground. The report indicated no injuries occurred during the fall episode. R5's Fall During Staff Assist report completed 07/02/24 indicated R5 fell during staff-assisted toileting. The report indicated R5 stood and held onto the handrail in her bathroom as CNA T unfastened her brief. The report indicated R5 fell against the CNA T and then to the floor. The report indicated CNA T attempted to lift R5 back up to a standing position resulting in a second fall to the floor landing on her bottom and then right side. The note indicated R5 received a bump and bruise around her right eyebrow. No interventions were implemented related to this fall episode. R5's EMR under Progress Notes revealed a nursing note completed on 07/06/24. The note indicated the nurse walked into R5's room and found her on the floor in front of her recliner. The note indicated two direct care staff had attempted to change her incontinence brief and she slid down to the floor. The note indicated no injuries occurred during the fall episode. The report indicated R5 had to be laid flat on the ground and lifted with a full lift. The facility could not provide a fall investigation for this fall incident as requested. R5's Fall During Staff Assist report completed 07/14/24 indicated R5 fell while in her room. The report indicated R5 was pushed in her wheelchair by CNA NN and parked next to her recliner. The report indicated CNA NN left the room to get a bed pad for R5's recliner. The report indicated R5 stood up as CNA NN reentered the room. The report indicated CNA NN attempted to assist but R5 fell face-first into the recliner. The note indicated CNA NN attempted to lift R5 to a standing position but resulted in an assisted fall to the ground. The report indicated R5 had to be lowered to a lying position and transferred to the bed with a full mechanical lift. The report indicated no injuries occurred during the fall episode. No fall interventions were implemented. On 07/23/24 at 08:00 AM R5 sat in her recliner in her room. Her call light was within reach. R5's wheelchair sat next to her bed. Her wheelchair had an auto-lock mechanism installed on it. R5 had bruising around her eyebrows and upper nose. She stated it occurred during a fall. On 07/24/24 at 10:05 AM CNA MM stated R5 was a high fall risk related to her weakness and inability to know her limitations. She stated R5 required two staff and a Hoyer lift after falling multiple times during care. She stated R5 would often fall and had to be supervised closely during transfers and care. She stated R5 had weakness standing up and should not be left standing for long periods of time. On 07/24/24 at 10:30 AM LN G stated R5 required two staff and a Hoyer lift for transfers due to her recent decline. She stated R5 was at a risk for falls and was to be watched closely for care and attempts at standing from her wheelchair. She stated staff were to provide reminders and redirection for her to wait for staff assistance during transfers. On 07/24/24 at 11:19 AM Administrative Nurse D stated that R5's ability to assist during care recently declined due to her weakness and physical limitations. She stated R5 required a total mechanical lift due to her inability to safely transfer. She stated staff should be closely monitoring her during care and attempt to intervene during fall episodes. She stated the facility attempted to promote independence during care, but R5's functional abilities had gotten progressively worse. The facility's Accidents and Supervision (undated) indicated the facility would ensure each resident will be comprehensively assessed for safety and falls. The policy indicated the facility will provide sufficient staff and supervision to reduce the risks of falls and accidents. The facility failed to ensure safe care practices were followed during assisted care resulting in multiple falls for R5. This deficient practice placed R5 at risk for further falls and injuries.

The facility reported a census of 56 residents. The sample included 14 residents with two reviewed for bowel and bladder incontinence. Based on record review, observations, and interviews, the facility failed to implement individualized toileting interventions to improve Resident (R)17's bowel and bladder incontinence or prevent worsening based on his incontinence evaluation. This deficient practice placed R17 at risk for complications related to incontinence. Findings Included: - The Medical Diagnosis section within R17's Electronic Medical Records (EMR) included diagnoses of legal blindness, muscle weakness, stiffness to his right knee, unsteadiness on his feet, and lack of coordination. A review of R17's Quarterly Minimum Data Set (MDS) completed 05/20/24 noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS indicated he required partial to moderate assistance with personal hygiene, toileting, and dressing. The MDS indicated his vision was severely impaired. The MDS indicated he was frequently incontinent of bladder and occasionally incontinent of bowel with no toileting program. The MDS indicated he was at risk for skin breakdown and 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). The MDS noted he had pressure-reducing devices for his bed and chair. R17's Functional Abilities Care Area Assessment (CAA) completed 09/15/23 indicated he required assistance from staff for his activities of daily living (ADLs) related to his impaired gait, muscle weakness, and visual impairment. The CAA indicated the facility will provide care-planned interventions to reduce the risks related to ADL decline. R17 Urinary Incontinence CAA was not triggered for incontinence. R17's Care Plan initiated on 11/12/23 indicated he required assistance with his ADLs. The plan indicated he required assistance with toileting transfers. The plan indicated he was at risk for skin impairment related to bowel and bladder incontinence. The plan instructed staff to provide checks and changes to maintain dignity for urinary incontinence. The plan lacked interventions related to R17's occasional bowel incontinence. The plan instructed staff to provide peri-care after incontinence episodes. The plan lacked individualized interventions to maintain and promote R17's highest level of functioning related to incontinence. R17's EMR revealed a Bowel and Bladder assessment dated [DATE]. The assessment indicated he was incontinent of both bladder and bowel. The assessment indicated he could communicate his needs. The assessment indicated his urinary incontinence was new. The assessment noted he could void correctly without incontinence but was incontinent at least once daily. The assessment indicated he was appropriate for a toileting program and a good candidate for self-toileting. R17's EMR under Tasks revealed he had numerous episodes of bowel and bladder incontinence throughout the month of July 2024. On 07/22/24 at 10:23 AM R17 sat in his recliner in his room. R17's sensory cane rested on his television dresser across the room from him. R17 stated he received staff assistance during care but often would take himself to the restroom. He was not sure if he was placed on a toileting program but stated he often had incontinence. On 07/24/24 at 10:20 AM Certified Nurse Aide (CNA) R said most of the residents were toileted upon request or asked during care interactions. She stated the care plan should include individualized toileting interventions for some residents with incontinence. She stated she was not sure if R17 required a toileting program or interventions. She stated R17 could take himself or he asked to be taken to the restroom. On 07/24/24 at 10:31 AM Licensed Nurse (LN) G stated all residents were screened upon admission for bowel and bladder. She stated toileting interventions should be implemented on residents noted to be appropriate. She stated the care plan should be updated to reflect the toileting interventions. She stated she was not sure if R17 was provided toileting interventions or on a toileting program. On 07/24/24 at 11:19 AM Administrative Nurse D stated each resident was screened for incontinence upon admission, quarterly, annually, and anytime a change of condition occurred related to bowel and bladder. She stated the admission nurse would report the evaluation findings to the interdisciplinary team and individualized interventions would be implemented as needed. She stated each resident should be offered toileting frequently throughout the day and provided preventative skin care. The facility's Incontinence policy revised 09/09/20 indicated all residents assessed for bowel and bladder incontinence will be provided the appropriate treatment and services to prevent infections and improve incontinence to the highest extent possible. The facility failed to implement individualized toileting interventions to improve and/or maintain R17's bowel and bladder function based on his incontinence evaluation. This deficient practice placed R17 at risk for complications related to incontinence.

The facility had a census of 58 residents. The sample included 15 residents. Based on observation, record review, and interview the facility failed to store, distribute, and serve food in accordance with professional standards for food service safety for the 58 residents who resided in the facility and received their meals from the facility kitchen , when the facility kitchen failed to ensure clean and sanitary food prep areas, failed to dispose of expired food items, and had expired Parts Per Million (PPM-sanitizer strength test) strips. This placed the 58 residents at risk for foodborne illness. Findings included: - On [DATE] at 8:00 AM, observation revealed in the following in the kitchen: The walk-in refrigerator had six uncovered hamburger patties on a tray, 21 hotdogs in an unsealed plastic container, and three uncovered slices of cheese on a plastic container. The floor had clear standing water underneath the air conditioner to the wall underneath the three-well sink, approximately five feet (ft) long, two ft wide, by ,d+[DATE] inch (in) deep. The white upright freezer had approximately one half inch of ice all over the inside of the freezer. Numerous areas of varying sizes of brownish substance was observed on the wall above and below the sink located by the entrance door. The pipes underneath the sink located by the entrance door, and underneath the three-well sink had a blackish substance on them. The mopboard all around the kitchen had a brownish substance on it. On [DATE] at 8:15 AM, observation revealed staff conducted a PPM using a bottle of strips expired on [DATE]. On [DATE] at 08:35 AM, Certified Dietary Manager (CDM) CC verified the findings in the walk-in refrigerator and stated staff should not place food items uncovered, unlabeled or undated in the refrigerator. Observation revealed CDM CC discarded the food items. On [DATE] at 11:41 AM, CDM BB verified the issues in the kitchen and stated kitchen staff had a daily cleaning schedule and should follow it. CDM BB verified the PPM strips were expired and staff should not use them to test the PPM of the dishwasher water. The Kitchen Cleaning Schedule documented daily tasks the cooks, dietary aides, and dishwasher should complete. The facility's Food Storage Policy, dated ,d+[DATE], documented sufficient storage facilities would be provided to keep foods safe, wholesome and appetizing. All containers must be legible and accurately labeled and dated. Food would be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. The facility's General Sanitation of Kitchen Policy, dated [DATE], documented food and nutrition services staff would maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. The facility to store, distribute, and serve food, in accordance with professional standards for food service safety, This placed the 58 residents who resided at the facility and received food from the facility kitchen at risk for receiving a foodborne illness.

The facility had a census of 58 residents. The sample included 15 residents. Based on observation, interview, and record review the facility failed to ensure hazardous chemicals were securely stored. This deficient practice placed four cognitively impaired, independently mobile residents at risk for accidents. Findings included: - On 06/29/22 at 08:00 AM, observation revealed a sink in the dining room, by the kitchen, with a broken lock on the door under the sink. A one-quart sized spray bottle with at least 50 milliliters (ml) of orangish colored fluid, without a label was in the unsecured cabinet. On 06/29/22 at 08:00 AM, Certified Nurse Aide (CNA) M stated she did not know what was in the spray bottle and verified it should be thrown away. On 06/29/22 at 08:12 AM, observation revealed the 100 hall shower room unlocked and a one-quart sized spray bottle of yellowish liquid with a label stating C-diff solution tablets, Keep Out of Reach of Children, hazardous to humans and animals. unsecured. On 06/29/22 at 08:12 AM, Certified Nurse Aide (CNA) M verified the shower room door should have been locked and stated the door stayed unlocked until physically pulled shut. 06/30/22 07:47 AM, Administrative Staff A verified the cleaning chemicals should have been locked up. The Accidents and Supervision policy, dated 11/2017, documented the facility would establish and utilize a systemic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. All staff were to observe for potential hazards in the environment and develop interventions. The facility failed to ensure hazardous chemicals were inaccessible to residents, placing the four independently mobile, cognitively impaired residents at risk for accidents.

The facility had a census of 58 residents. The sample included 15 residents. Based on observation, record review, and interview the facility failed to provide an accurate reconciliation of controlled drugs at the end of daily work shifts. This placed residents at risk for misappropriation of medications by staff. Findings included: - On 06/29/22 at 08:02 AM, observation on the 100-hall medication cart revealed staff counted and signed the Controlled Drug Record flow sheet for one work shift on 06/01/22, 06/08/22 and 06/11/22 (three times out of a possible 58 work shifts). On 06/29/22 at 08:15 AM, observation on the 200-hall medication cart revealed staff counted and signed the Controlled Drug Record flow sheet for one work shift on 06/02/22, 06/11/22, 06/13/22, 06/23/22 and 06/29/22 (five times out of a possible 58 work shifts). On 06/22/22 at 08:15 AM, Licensed Nurse (LN) H stated two staff should count the narcotic drugs every shift and sign the Controlled Drug Record flow sheet to verify the narcotic count was accurate. On 07/06/22 at 08:44 AM, Administrative Nurse D stated two staff should count the narcotic drugs every shift and sign the Controlled Drug Record flow sheet to verify the narcotic count was accurate. The Controlled Substance Administration & Accountability, policy, dated 01/01/20, directed staff to follow safeguards/guidelines to prevent loss or diversion of narcotic medications. The Controlled Substance Administration & Accountability, policy directed two staff to conduct an audit of narcotic medications at the end of every shift and sign the Controlled Drug Record flow sheet to verify the narcotic count was accurate. The facility failed to provide an accurate reconciliation of controlled drugs at the end of daily work shifts, placing residents at risk for misappropriation of medications by staff.

The facility had a census of 58 residents. The sample included 15 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility's consultant pharmacist failed to notify the Director of Nursing (DON), medical director, or physician of recommendations for a 14 day stop date or physician's rationale for extended use with a stop date for as needed (PRN) [CONDITION(S)] medications (medications used to treat mental illness, moods, behaviors) for one sampled resident, Resident (R) 43. This placed the resident at risk for unnecessary [CONDITION(S)] medications and adverse side effects. Findings included: - The Physician Order Sheet, dated 06/02/22, recorded R43 had diagnoses of end-stage [CONDITION(S)] (medical condition in which a person's kidneys cease functioning ), [CONDITION(S)] Disease (disorder of the central nervous system that affects movement and often includes tremors, stiffness, rigidity), [CONDITION(S)] (mental health disorder characterized by persistent depressed mood, causing significant impairment of daily life), and anxiety (mental health disorder characterized by worry and fear that interferes with daily life). The Quarterly Minimum Data Set (MDS), dated [DATE], recorded R43 had a Brief Interview for Mental Status score of 15 (cognitively intact) with no behaviors. The MDS recorded R43 required limited staff assistance with all activities of daily living (ADLs) and received scheduled antianxiety medication (medications used to calm and relax people with excessive anxiety, nervousness, and tension) seven days a week. The Medication Care Plan, dated 05/20/22, recorded R43 had frequent anxiety and restlessness related to her health problems and family concerns. The care plan directed staff to administer R43's medications as ordered by the physician, and monitor the medications for effectiveness, and/or adverse side effects. The Physician's Order, dated 01/18/22, directed staff to administer [MEDICATION(S)] (antianxiety medication used to treat anxiety, agitation, and behavior problems) 1.0 milligrams (mg) every 6 hours PRN to R43 for anxiety. Review of R43's medical record lacked documentation the PRN [MEDICATION(S)] had a 14 day stop date or physician's rationale for extended use with a stop date. Review of the February 2022 Medication Administration Record (MAR), recorded staff administered prn [MEDICATION(S)] to R43 eighteen times. Review of the March 2022 MAR, recorded staff administered prn [MEDICATION(S)] to R43 twenty-six times. The Pharmacist Medication Reviews, dated 02/10/22 and 03/12/22, lacked documentation the pharmacist addressed the 14 day stop date or a physician's rationale for extended use for R43's PRN [MEDICATION(S)]. The Pharmacist Medication Recommendation, dated 04/13/22, requested the physician provide a rationale to continue use of R43's PRN [MEDICATION(S)] without a stop date. The Pharmacist Medication Recommendation recorded the physician completed the rationale on 04/15/22 to continue R43's PRN [MEDICATION(S)] without a stop date. Review of the April 2022 MAR, recorded staff administered prn [MEDICATION(S)] to R43 nineteen times. Review of the May 2022 MAR, recorded staff administered prn [MEDICATION(S)] to R43 sixteen times. Review of the June 2022 MAR, recorded staff administered prn [MEDICATION(S)] to R43 fourteen times. On 06/30/22 at 07:52 AM, observation revealed R43 walked with a walker in her room and transferred herself to a recliner. On 07/06/22 at 08:47 AM, Administrative Nurse D stated the pharmacist had not addressed R43's PRN [CONDITION(S)] medications without a 14 day stop date or physician's rationale for extended use with a stop date. The facility's Medication Regimen Review policy, dated 01/01/20, directed the pharmacist to ensure medication orders followed federal regulations and report irregularities to the attending physician, DON and medical director. The facility's consultant pharmacist failed to notify the Director of Nursing (DON), medical director, or physician of recommendation for a 14 day stop date or physician's rationale for extended use with a stop date forR43's PRN [CONDITION(S)] medication, placing the resident at risk for unnecessary [CONDITION(S)] medications and adverse side effects.

The facility had a census of 58 residents. The sample included 15 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure a 14 day stop date or physician's rationale for extended use with a stop date for PRN (as needed) [CONDITION(S)] medication (medications that affect a person's mental state) for one sampled resident, Residents (R) 43. This placed the residents at risk for unnecessary [CONDITION(S)] medications and adverse medication side effects. Findings included: - The Physician Order Sheet, dated 06/02/22, recorded R43 had diagnoses of end-stage [CONDITION(S)] (medical condition in which a person's kidneys cease functioning ), [CONDITION(S)] Disease (disorder of the central nervous system that affects movement and often includes tremors, stiffness, rigidity), [CONDITION(S)] (mental health disorder characterized by persistent depressed mood, causing significant impairment of daily life), and anxiety (mental health disorder characterized by worry and fear that interferes with daily life). The Quarterly Minimum Data Set (MDS), dated [DATE], recorded R43 had a Brief Interview for Mental Status score of 15 (cognitively intact) with no behaviors. The MDS recorded R43 required limited staff assistance with all activities of daily living (ADLs) and received scheduled antianxiety medication (medications used to calm and relax people with excessive anxiety, nervousness, and tension) seven days a week. The Medication Care Plan, dated 05/20/22, recorded R43 had frequent anxiety and restlessness related to her health problems and family concerns. The care plan directed staff to administer R43's medications as ordered by the physician, and monitor the medications for effectiveness, and/or adverse side effects. The Physician's Order, dated 01/18/22, directed staff to administer [MEDICATION(S)] (antianxiety medication used to treat anxiety, agitation, and behavior problems) 1.0 milligrams (mg) every 6 hours PRN to R43 for anxiety. Review of R43's medical record lacked documentation the PRN [MEDICATION(S)] had a 14 day stop date or physician's rationale for extended use with a stop date. Review of the February 2022 Medication Administration Record (MAR), recorded staff administered prn [MEDICATION(S)] to R43 eighteen times. Review of the March 2022 MAR, recorded staff administered prn [MEDICATION(S)] to R43 twenty-six times. The Pharmacist Medication Reviews, dated 02/10/22 and 03/12/22, lacked documentation the pharmacist addressed the 14 day stop date or a physician's rationale for extended use for R43's PRN [MEDICATION(S)]. The Pharmacist Medication Recommendation, dated 04/13/22, requested the physician provide a rationale to continue use of R43's PRN [MEDICATION(S)] without a stop date. The Pharmacist Medication Recommendation recorded the physician completed the rationale on 04/15/22 to continue R43's PRN [MEDICATION(S)] without a stop date. Review of the April 2022 MAR, recorded staff administered prn [MEDICATION(S)] to R43 nineteen times. Review of the May 2022 MAR, recorded staff administered prn [MEDICATION(S)] to R43 sixteen times. Review of the June 2022 MAR, recorded staff administered prn [MEDICATION(S)] to R43 fourteen times. On 06/30/22 at 07:52 AM, observation revealed R43 walked with a walker in her room and transferred herself to a recliner. On 06/30/22 at 02:22 PM, Licensed Nurse (LN) G stated R43 was alert and oriented, had frequent anxiety and restlessness, and would request staff administer her PRN [MEDICATION(S)]. On 07/06/22 at 08:47 AM, Administrative Nurse D stated the facility had not addressed R43's PRN [CONDITION(S)] medications without a 14 day stop date or physician's rationale for extended use with a stop date. The facility's [CONDITION(S)] Drug policy, dated 01/01/20, directed staff to ensure PRN [CONDITION(S)] medications had a 14 day stop date, or a physician's rationale for extended use with a stop date. The facility failed to ensure a 14 day stop date or physician's rationale for extended use with a stop date for R43's PRN [CONDITION(S)] medications, placing the resident at risk for unnecessary [CONDITION(S)] medications and adverse medication side effects.

The facility had a census of 54 residents. The sample included three residents reviewed for quality of care. Based on record review and interview, the facility failed to notify Resident (R)1's physician and R1's Durable Power of Attorney for Healthcare (DPOA) of a decline in R1's condition. This placed R1 at increased risk for delayed treatment and impaired decision-making ability by R1's DPOA due to lack of communication. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of one which indicated severe cognitive impairment. The Quarterly MDS further documented R1 required extensive to totally dependent on one to two staff for all activities of daily living. The Quarterly MDS documented R1 had an indwelling catheter (tube inserted into the bladder to drain urine into a collection bag). The Indwelling Catheter Care Area Assessment (CAA), dated 07/15/21 documented R1 had an indwelling catheter and needed extensive assistance with toileting. The Indwelling Catheter Care Plan, dated 07/21/21, directed staff to monitor, record, report, to R1's doctor signs and symptoms of a urinary tract infection: pain, burning, blood tinged urine, cloudiness of urine, no output, deepening color of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns. The Nurses Note dated 02/09/22 at 11:04 AM, documented R1's indwelling catheter was to be changed. The balloon on the catheter tubing was deflated but the catheter tubing would not come out of the bladder. The balloon on the catheter tubing could not then be re-inflated upon attempt and the catheter would not go back in. R1's doctor was notified. The catheter urine collection bag was noted to have 200 milliliters (ml) of thick cloudy urine. The EMR lacked evidence of notification to R1's DPOA regarding the complication. The Nurses Note, dated 02/09/22 at 06:15 PM, documented R1's doctor called and told the facility to leave the catheter in place and let it come out naturally and it may take some time. The EMR lacked evidence of notification of the complication to R1's DPOA. The EMR lacked any documentation regarding when the catheter naturally dislodged from R1's bladder. The EMR documented on 02/14/22 at 12:42 PM R1 had a blood pressure of 80/51 millimeters of mercury (mmHg). The EMR lacked any physician notification of the low blood pressure (low blood pressure is defined as a blood pressure of less than 90/60 mmHg). The Nurses Note on 02/14/22 at 02:01 PM, documented R1 did not want to eat lunch but did drink 400 ml of liquids. R1's blood pressure was improved at 117/58 mmHg. The EMR documented on 02/14/22 R1 ate 0-25 percent (%) of his breakfast, 0-25% of his lunch, and refused supper. The Nurses Note on 02/15/22 at 01:05 PM documented R1's physician was contacted regarding R1's catheter and what should be done as R1 had been on a catheter break since it was removed. The physician told the facility the preference was to discontinue the catheter but since the family wanted the catheter long term, R1's family needed to be asked about their preference. The Nurses Note on 02/15/22 at 05:05 PM, documented R1's representative authorized leaving the catheter out. The Nurses Note on 02/15/22 at 05:07 PM, documented R1's physician was notified that R1 had burning with urination and foul smelling urine. The physician ordered a urinalysis (UA)with culture and sensitivity to be obtained. The UA was obtained and sent to the hospital lab. The Nurses Note on 02/15/22 at 05:38 PM, documented the hospital lab called the facility and notified them the urine specimen was too turbid (thick with suspended matter) to be ran for a urinalysis but after looking at the urine under the microscope the urine was full of bacteria. The lab stated they were running the urine for culture and sensitivity, but their machine would not run the urinalysis. The EMR lacked any physician notification of the lab's findings or notification to the DPOA. The EMR documented on 02/15/22 R1 ate only 0-25% of his breakfast, 0-25% of his lunch, and refused supper. The EMR documented on 02/16/22 R1 was unavailable for breakfast, only ate 0-25% of lunch, and ate 26-50% of supper. The Nurses Note dated 02/17/22 at 05:10 AM documented R1 was unresponsive. R1's blood pressure was 80/53mmHg, pulse was 138 beats per minute (normal pulse rate 60-100), and oxygen saturation was 60% (normal level of oxygen is 95% or higher) on room air. Oxygen was administered to R1 at 2 liters via nasal canula. R1's physician was notified, and orders were given to send R1 to the emergency room . Report was given to the emergency room and the nurse spoke to the emergency room physician about R1's status. The Emergency Department Report dated 02/17/22 documented the physician obtained R1's history from the nursing staff at the facility and the nursing staff reported R1 had a slow decline over the last two to three days. Facility nursing staff reported R1 had not been eating, drinking, or taking his pills. R1's EMR lacked any documentation regarding any kind of a decline, reported decline to R1's physician, or reported decline to R1's representative. On 03/14/22 at 10:00 AM, Licensed Nurse (LN) G stated if she had received a phone call from the lab stating the UA was unable to be conducted because of the urine being too thick and the urine contained a large amount of bacteria, she would notify the resident's physician. On 03/14/22 at 10:30 AM, Administrative Nurse D stated that R1's low blood pressure should have been reported to the physician. She stated the lab being unable to run R1's UA should have been reported to the physician. She also reported any complications with R1's care should have been reported to his emergency contact. On 03/14/22 at 10:45 AM, Administrative Staff A stated that the facility knew R1 was having a decline and she had recommended for therapy to take a look at him to see if they could pick him up for therapy. The facility's Notification of Changes policy, dated 2017, documented the facility must inform the resident, consult the resident's physician, and notify with his or her authority, resident's representative when there is a change requiring notification. Circumstances requiring notification include: significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental or psychosocial status that may include life threatening conditions or clinical complications; circumstances that require a need to alter treatment that may include new treatments, discontinuation of current treatment due to adverse consequences, acute condition, or exacerbation of a chronic condition. The facility failed to notify R1's physician and failed to inform R1's DPOA of a decline in R1's condition. This placed R1 at increased risk for delayed treatment and impaired decision-making ability by R1's DPOA due to lack of communication.

The facility had a census of 54 residents. The sample included three residents reviewed for quality of care. Based on record review and interview, the facility failed to provide the necessary cares and services for Resident (R) 1 to prevent urosepsis (a condition where a urinary tract infection leads to a systemic infection that spreads throughout the body) and hospitalization from occurring when they failed to report, and [MEDICATION(S)] in response to R1's significant clinical findings which included low blood pressures, decreased appetite and inability to conduct the physician ordered urinalysis (lab examination of urine). This placed R1 at increased risk for delayed treatment and hospitalization . Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of one which indicated severe cognitive impairment. The Quarterly MDS further documented R1 required extensive assistance to total dependence on one to two staff for all activities of daily living. The Quarterly MDS documented R1 had an indwelling catheter (tube inserted into the bladder to drain urine into a collection bag). The Indwelling Catheter Care Area Assessment (CAA), dated 07/15/21 documented R1 had an indwelling catheter and needed extensive assistance with toileting. The Indwelling Catheter Care Plan, dated 07/21/21, directed staff to monitor, record, and report to R1's doctor signs and symptoms of a urinary tract infection: pain, burning, blood tinged urine, cloudiness of urine, no output, deepening color of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns. The Nurses Note dated 02/09/22 at 11:04 AM, documented R1's indwelling catheter was to be changed. The balloon on the catheter tubing was deflated but the catheter tubing would not come out of the bladder. The balloon on the catheter tubing could not then be re-inflated upon attempt and the catheter would not go back in. R1's doctor was notified. The catheter urine collection bag was noted to have 200 milliliters (ml) of thick cloudy urine. The Nurses Note, dated 02/09/22 at 06:15 PM, documented R1's doctor called and told the facility to leave the catheter in place and let it come out naturally and it may take some time. The EMR lacked any documentation regarding when the catheter naturally dislodged from R1's bladder. The EMR documented on 02/14/22 at 12:42 PM R1 had a blood pressure of 80/51 millimeters of mercury (mmHg). The EMR lacked any physician notification of the low blood pressure (low blood pressure is defined as a blood pressure of less than 90/60 mmHg). The Nurses Note on 02/14/22 at 02:01 PM, documented R1 did not want to eat lunch but did drink 400 ml of liquids. R1's blood pressure was improved at 117/58 mmHg. The EMR documented on 02/14/22 R1 ate 0-25 percent (%) of his breakfast, 0-25% of his lunch, and refused supper. The Nurses Note on 02/15/22 at 01:05 PM documented R1's physician was contacted regarding R1's catheter and what should be done as R1 had been on a catheter break since it was removed. The physician told the facility the preference was to discontinue the catheter but since the family wanted the catheter long term, R1's family needed to be asked about their preference. The Nurses Note on 02/15/22 at 05:05 PM, documented R1's representative authorized leaving the catheter out. The Nurses Note on 02/15/22 at 05:07 PM, documented R1's physician was notified that R1 had burning with urination and foul smelling urine. The physician ordered a urinalysis (UA)with culture and sensitivity to be obtained. The UA was obtained and sent to the hospital lab. The Nurses Note on 02/15/22 at 05:38 PM, documented the hospital lab called the facility and notified them the urine specimen was too turbid (thick with suspended matter) to be ran for a urinalysis but after looking at the urine under the microscope the urine was full of bacteria. The lab stated they were running the urine for culture and sensitivity, but their machine would not run the urinalysis. The EMR lacked any physician notification of the lab's findings. The EMR documented on 02/15/22 R1 ate only 0-25% of his breakfast, 0-25% of his lunch, and refused supper. The EMR documented on 02/16/22 R1 was unavailable for breakfast, only ate 0-25% of lunch, and ate 26-50% of supper. The Nurses Note dated 02/17/22 at 05:10 AM documented R1 was found unresponsive. R1's blood pressure was 80/53mmHg, pulse was 138 beats per minute (normal pulse rate 60-100), and oxygen saturation was 60% (normal level of oxygen is 95% or higher) on room air. Oxygen was administered to R1 at 2 liters via nasal canula. R1's physician was notified, and orders were given to send R1 to the emergency room . Report was given to the emergency room and the nurse spoke to the emergency room physician about R1's status. The Emergency Department Report dated 02/17/22 documented the physician obtained R1's history from the nursing staff at the facility and the nursing staff reported R1 had a slow decline over the last two to three days. Facility nursing staff reported R1 had not been eating, drinking, or taking his pills. R1's EMR lacked any documentation regarding any kind of a decline, reported decline to R1's physician, or reported decline to R1's representative. On 03/14/22 at 10:00 AM, Licensed Nurse (LN) G stated if she had received a phone call from the lab stating the UA was unable to be conducted because of the urine being too thick and the urinecontained a large amount of bacteria, she would notify the resident's physician. On 03/14/22 at 10:30 AM, Administrative Nurse D stated that R1's low blood pressure should have been reported to the physician. She stated the lab being unable to run R1's UA should have been reported to the physician. She also reported any complications with R1's care should have been reported to his emergency contact. On 03/14/22 at 10:45 AM, Administrative Staff A stated that the facility knew R1 was having a decline and she had recommended for therapy to take a look at him to see if they could pick him up for therapy. The facility's Quality of Care Policy and Procedure, dated 2017, documented it is the policy of the facility that each resident receives the necessary care to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the resident's comprehensive assessment and plan of care. To achieve the goal of providing quality care the facility shall: ensure that each resident receives the necessary care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care; ensure that a resident who is incontinent of bladder must receive appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible; and establish an infection control program under which it investigates, controls, and prevents the spread of infections in the facility. The facility failed to provide quality care to R1 by not notifying his physician of changes in R1's physical status and the inability of the lab to perform the physician ordered urinalysis.

The facility had a census of 51 residents, the sample included 3 residents reviewed for abuse. Based on observation, record review, and interview, the facility failed to report an allegation of abuse in a timely manner, when Certified Nurse Aide (CNA) M alleged that Licensed Nurse (LN) G abused Resident (R) 1. - Findings included R1's Annual Minimum Data Set, (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status, (BIMS) of 5, indicating she had severely impaired cognition. The MDS documented the resident required limited assistance of one staff for bed mobility, transfers, walking in room and corridor, extensive assistance of one staff for dressing, toileting, personal hygiene, bathing, supervision of one staff for locomotion on and off the unit, and supervision after staff set-up for eating. The MDS documented the resident used a walker and a wheelchair for mobility. R1's Psychosocial Care Plan, dated 01/25/21, directed staff to encourage R1 to participate in making her own decisions, explain all procedures, treatments, medications, condition, all changes, rules, and options, provide opportunities for the resident to participate in her care, and when there was conflict, to remove R1 to a calm, safe, environment and allow her to vent and share her feelings. On 03/09/21 at 12:45 PM, observation revealed CNA N propelled R1 in her wheelchair from the dining room to her room. Further observation revealed CNA N placed a gait belt on R1 and asked her to use the grab bars in her bathroom to stand up. R1 replied, no, I don't want to. CNA N encouraged R1 to try to stand and assured her she would not let her fall. R1 agreed and stood without any problem with CNA N's assistance. CNA N transferred R1 into her wheelchair, placed her a few feet in front of her recliner, then placed her walker in front of her. CNA N encouraged R1 to stand and ambulate to her recliner several times before R1 completed the task. Observation revealed CNA N explained what she wanted the resident to do, she was kind, polite, and patient with R1 during her cares. On 03/10/21 at 11:15 AM, CNA M stated on 03/05/21 between 08:00-09:00 PM, she witnessed LN G abuse R1 when R1 would not get up from her recliner to get ready for bed. CNA M stated LN G dragged R1 from her recliner, onto the floor, and into the bathroom, then to her bed where she roughly placed R1 partway onto the bed. CNA M stated she told CNA O about what she witnessed but did not report it to anyone else until 03/07/21 (two days after the incident), when she told LN H about it. She stated LN H directed her to report the incident to Administrative Nurse D. On 03/10/21 at 01:20 PM, LN G stated she worked on 03/05/21, but she did not recall if she helped anyone with R1. LN G stated she had not ever abused R1 or any other resident in any way. On 03/10/21 at 02:00 PM, CNA O stated on the evening of 03/05/21, CNA M asked her to help with R1, but LN G offered to help. Afterward, CNA M told CNA O she was upset because LN G dragged R1 out of her recliner and pushed her face into the bed. CNA O said she told CNA M to report it if she was uncomfortable with the situation. CNA O stated she did not report the incident because she did not witness the incident. On 03/09/21 at 09:30 AM, Administrative Nurse D stated CNA M did not follow the facility's Abuse, Neglect, and Exploitation policy, when she did not immediately report an allegation of abuse she witnessed on 03/05/21, until 03/08/21. The facility's undated Abuse, Neglect, and Exploitation Policy, documented all alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of resident property, are reported in the proper time frame pursuant to the policy. The facility failed to report an allegation of abuse against LN G, in a timely manner, when CNA M did not report the allegation for three days after the incident occurred.

The facility had a census of 41 residents. The sample included 14 residents with five reviewed for pressure ulcers. Based on observation, record review, and interview the facility failed to provide interventions to prevent the development of pressure ulcers for two of five sampled residents, Resident (R) 33, who developed a Stage 3 pressure ulcer (full thickness skin loss potentially extending into the subcutaneous tissue layer, just under the skin), and R11, who developed one unstageable pressure ulcer (wound bed covered with slough,dead tissue that may be white, tan, or yellow or eschar,a dry dark scab). Findings included: - R33's Physician order [REDACTED]. R33's Admission/5-Day Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS documented the resident required extensive assistance of two staff for transfers and toilet use, extensive assistance of one staff for bed mobility and personal hygiene, and supervision with one staff assistance for eating. The MDS documented R33 was frequently incontinent of urine and always incontinent of bowel. The MDS documented R33 had a Stage 2 pressure ulcer (partial thickness skin loss into but no deeper than the dermis, outer layer of skin) present on admission. The MDS documented the resident had pressure reducing devices for his chair and bed, required nutrition or hydration program interventions for skin problems, was not on a turning/repositioning program, and required no pressure ulcer/injury care. The Pressure Ulcer Care Area Assessment (CAA), dated 12/20/20, documented the resident was at risk for pressure related skin breakdown related to decreased functioning with activities of daily living (ADLs) and incontinent of bladder and bowel. The Basic Care Plan, dated 12/16/20, documented R33 was dependent for meeting his emotional, intellectual, physical, and social needs related to cognitive deficits and was focused on the activities that R33 enjoyed. The care plan lacked interventions for prevention of pressure ulcers. The Braden Scale, (predicts risk for pressure ulcers) dated 12/14/20, documented a score of 11 (high risk). The Skin Integrity Care Plan, dated 01/06/21, directed staff to educate the resident, resident's family, and caregivers to the causes of skin breakdown including transfer/positioning requirements, good nutrition, and frequent repositioning. The care plan further directed staff to avoid positioning R33 on his left buttock, to monitor nutritional status, and obtain lab work. The care plan documented a Stage 3 pressure ulcer to left buttock and directed staff to apply treatment as ordered. The ADL Assistance Care Plan, dated 01/06/21, recorded the resident required extensive staff assistance with bed mobility, and directed staff to turn and reposition the resident every two hours and as necessary. The Admission Skin assessment dated [DATE], documented R33 had a healing sore to the left gluteal fold measuring 1 centimeter (cm) x 0.5 cm. The Skin/Wound Note, dated 12/18/20, documented redness and an open area to inner left buttocks area. Staff cleaned, dried, and applied A&D ointment (ointment to treat minor skin irritations). No measurements documented in the note. The Weekly Skin Assessment Note, dated 12/23/20, documented no new areas of concern. The Nurse's Note, dated 12/24/20, documented a pea sized open area to left buttock and staff applied a foam dressing to the area. No measurements documented in the note. The Weekly Skin Assessment, dated 12/28/20, documented skin intact and no new skin areas identified. The Weekly Skin Assessment, dated 01/04/21, documented redness to left buttock. The Skin/Wound Note, dated 01/05/21 at 02:47 PM, documented R33 had a declining area to his left buttock, treatments were not effective due to loose stools. Staff informed the Director of Nursing (DON) and the resident's family of area. Air mattress placed to bed, Roho cushion (pressure relieving cushion) placed in wheelchair, and repositioning program implemented. Staff called R33's physician and requested a multivitamin with minerals, Prostat (protein supplement), and Vitamin C and awaited a return call. The Wound Note, dated 01/05/21 at 03:13 PM, documented a Stage 3 pressure ulcer to left gluteal fold that measured 1.76 cm x 0.7 cm x 0.2 cm with 70% [MEDICATION NAME] (the thin tissue layer forming the outer layer of the body's surface) and 30% slough. Staff notified the primary care physician of the wound and he gave orders to apply skin prep (protective solution to protect good skin from adhesive) to peri wound, silver alginate (natural fiber dressing that absorbs drainage and forms a gel-like covering over the wound) to wound bed, cover with foam dressing, and change dressing daily. Staff would request orders for Prostat, Vitamin C, and multivitamin for wound healing. Staff would place the resident on a turning and repositioning program and air mattress. The note documented staff educated the resident about repositioning program to be implemented and placed a Roho cushion in the resident's wheelchair. The note documented staff continued to monitor area with cares and would reassess. Awaited return call for nutritional supplements. The Skin/Wound Note, dated 01/12/21, documented the Stage 3 pressure ulcer was 100% closed. On 01/07/21 at 01:30 PM, observation revealed Licensed Nurse (LN) removed the old foam wound dressing revealing a moderate amount of bright bloody drainage. Observation revealed the wound tear drop shaped and open, with a red, beefy wound bed. LN H cleansed the wound with wound cleaning solution, applied skin prep to the peri-wound, applied Silver alginate to the wound bed, and covered with a new foam dressing. On 01/07/21 at 01:45 PM, LN H stated R33 was very incontinent of stool. When R33 came to this facility he had no appetite and had an area to his left buttock that had just healed, but no open areas. After he obtained the pressure ulcer, the facility placed a Roho cushion in his wheelchair, started a turning/repositioning schedule when he was in bed, obtained a new mattress with a special overlay, and started him on Prostat, Vitamin C, and a multivitamin for wound healing . On 01/11/21 at 09:02 AM, LN I stated R33 did not have any pressure relieving interventions prior to developing the pressure ulcer. Staff were going in and checking and changing his incontinent brief, so he had been repositioned some, and R33 was able to reposition himself if he wanted to. On 01/12/21 at 09:56 AM, LN HH stated that she had performed the admission skin assessment and R33 had no open areas to his buttocks. He did have an area of newly healed skin to his right buttock that measure 1 cm x 0.5 cm. It was healthy pink skin but fragile. On 01/12/21 at 01:48 PM, CNA P stated she and another CNA toileted and showered R33 on 12/24/20. CNA P stated when she wiped the resident's buttocks the wipe was bloody and there was an open area. CNA P stated she informed the nurse and the nurse placed a foam dressing to the open area. On 01/12/21 at 03:46 PM, LN K stated her regional nurse consultant performed the admission MDS and documented a Stage 2 pressure ulcer. LN K contacted the regional nurse consultant by email and was told she got her information from the hospital's admission packet. The packet documented a Stage 2 pressure ulcer to the right superior buttock. On 01/12/21 at 03:50 PM, LN H stated if she would have known R33 had a pressure ulcer on admission she would have ensured pressure relieving measures were in place. LN H stated the usual protocol for any open areas was to report them to her upon finding them, document the measurements, and implement interventions. LN H stated she did not know why the nurses who documented the previous open areas did not inform her of them or document them better and did not know how the Weekly Skin Assessments did not show that there were any areas of concern. On 01/12/21 at 04:28 PM, LN L stated she was informed on 12/24/20 that the resident had an open area to his left buttock. LN L stated she did not measure the area and did not inform the wound care nurse about the area. On 01/12/21 at 10:12 PM, LN GG stated she found an open area to the left buttock on 12/18/20 at 04:39 AM that measured 2.0 cm x 0.5 cm. LN GG stated she notified the charge nurse the next morning by leaving her night sheet on the charge nurse's desk and also gave verbal report about the open area to the morning nurse that was taking over for her. On 01/12/21 at 04:04 PM, Administrative Nurse D stated R33 did not have a Stage 2 pressure ulcer prior to his admission to the facility. After reviewing the resident's admission documentation Administrative Nurse D stated the facility missed it and if she had known she would have ensured that interventions were in place to ensure R33 did not obtain any pressure ulcers. Administrative Nurse D stated the nurses that found the open areas to R33's left buttock should have notified her or the wound care nurse about them and documented the measurements and interventions in the nurse's notes. The facilities Pressure Injury Prevention and Management policy, dated 01/01/20, documented in order to prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries that facility will implement evidence-based interventions by implementing individualized interventions that will address specific factors identified in the resident's risk assessment and skin assessment; prevention devices will be utilized in accordance with manufacturer's recommendations; interventions will be documented in the care plan and communicated to all staff; licensed nurses will conduct a pressure injury risk assessment, using the Braden Scale, on resident's upon admission/readmission, weekly times four weeks, then quarterly; and licensed nurses will perform assessments of pressure injuries and ensure the assessments are documented in wound rounds or in Skin/Wound Portal in Point Click Care. The staging of pressure injuries will be clearly identified. The facility failed to implement individualized interventions for R33 to prevent pressure ulcers, failed to adequately monitor the resident's skin condition, and failed to document and communicate R33's open areas to his left buttocks, placing the resident at risk for worsening pressure areas. - R11's physician's orders [REDACTED]. R11's Annual MDS, dated [DATE] documented a BIMS of three, indicating severe cognitive impairment. The MDS documented R11 required two staff extensive assistance with transfers and toileting, extensive assistance of one staff for bed mobility, dressing, personal hygiene, and bathing, and independent with staff supervision for eating. The MDS documented the resident had no weight loss or difficulty eating, and no pressure ulcers. R11's Quarterly MDS, dated [DATE], documented the resident had severe cognitive impairment. The MDS recorded R11 had long and short-term memory problems and severely impaired decision-making process. R11 required extensive assistance of two staff for bed mobility, transfers, toilet use, personal hygiene, and bathing, supervision of one staff for eating and locomotion on the unit, no weight loss, no difficulty eating, and at risk for pressure ulcers. The MDS documented the resident had no pressure ulcers, and had a pressure relieving devices for the bed and chair. The Pressure Ulcer/Injury CAA, dated 03/26/20, documented R11 was at risk for pressure related skin breakdown and required extensive assistance with bed mobility, dressing, hygiene, and bathing, total staff assistance with toileting and transfers. The CAA documented R11 was non-ambulatory, required limited assistance with locomotion, and used a wheelchair for mobility. The CAA documented R11 was incontinent of bowel and bladder and unable to voice the need for elimination. The CAA directed staff to turn and reposition R11 with rounds if needed, monitor skin condition as needed, and perform weekly skin checks. The 01/07/21 update directed staff to apply an air mattress to the resident's bed and Roho (pressure cushion) to the resident's wheelchair. The Skin Integrity Care Plan, dated 01/03/21 documented R11 was at risk for alterations in skin integrity related to decreased mobility and fragile skin. The care plan directed staff to educate R11, family, and caregivers as to causes of skin breakdown including transfer/repositioning requirements, good nutrition, and frequent repositioning. The care plan directed staff to ensure use of pressure redistribution surface to bed and chair, to assess skin during routine cares, and encourage repositioning assisting if R11 was unable to himself. The Skin Integrity Care Plan, dated 01/07/21 documented R11 had an unstageable pressure ulcer to the left inner buttock and directed staff to follow treatment as ordered. The Braden Scale, dated 06/26/20 and 09/26/20 , documented a score of 12 (high risk). The Weekly Skin Check, dated 12/28/20, documented no new skin concerns, various bruises, and skin tears in various stages of healing. The Weekly Skin Check, dated 01/05/21, documented no new skin areas of concern. The Skin/Wound Assessment, dated 01/07/21 documented an unstageable pressure ulcer to the right buttock that measured 1.16 cm x 0.65 cm x 0.1 cm. The Skin/Wound Note, dated 01/07/21, documented the resident had an open area to the right inner buttock that measured 1.2 cm x 0.6 cm x 0.1 cm. The note documented R11 was incontinent of bowel and bladder, staff provided incontinence care every 2-3 hours, and repositioned every 2-3 hours while in bed at night and as needed. The note documented R11 was combative with staff at times and had numerous bruises in different stages of healing to bilateral arms. Therapy gave the resident a new wheelchair with a new cushion this week. The Nurses Note, dated 01/07/21, documented the facility had placed a Roho cushion to R11's wheelchair and had ordered an air mattress. The air mattress was put in place on 01/11/21. The facility placed R11 on a turning/repositioning schedule of being laid down after meals and the every 2 hours while in bed on 01/07/21. The Nurses Note, dated 01/07/21, documented R11's physician assessed the resident and recommended discussion with resident's family to admit to hospice care. Family would like R11 to finish his skilled days, then reassess, and proceed with hospice after re-evaluating. The Nurse's Note, dated 01/07/21, documented the physician ordered dressing changes to the right inner buttock every three days, cleanse area to right inner buttock with wound cleanser, apply skin prep, cover with Duoderm (foam dressing) and administer liquid protein 30 milliliters (ml) twice a day, Thera tablet (multi vitamin) 1 tablet daily, and Vitamin C 500 milligrams (mg) daily. On 01/07/21 at 01:50 PM, observation revealed CNA O and CNA P checked R11's incontinent brief. After CNA O cleaned resident buttocks observed a pressure ulcer on the right buttock. Staff notified LN H who came to R11's room, cleaned the area, applied skin prep to the peri wound, and covered the wound with a foam dressing. The wound measured 1.16 cm x 0.65 cm x 0.1 cm, wound covered with yellow slough and peri wound purplish/red in color all the way around the wound. On 01/11/21 at 08:51 AM, LN I stated the facility performed weekly skin assessments and assessed the skin during showers two times a week. R11 was able to turn and reposition some in the bed, once up in the wheelchair he stayed up from breakfast until after lunch and then will lay down after lunch. LN I stated R11 had a pressure relieving mattress and a Roho (pressure relieving cushion) cushion in his wheelchair. On 01/11/21 at 01:50 PM, CNA O stated she previously reported the skin area to LN Land stated she always reported any bumps, rashes, bruises, or open areas to her nurse, the charge nurse, or the wound care nurse. CNA O stated she should have notified the wound care nurse when she found the area. On 01/11/21 at 04:30 PM, LN H stated she felt the pressure ulcer came from him constantly scooching around in his wheelchair. R11 had a foam cushion in his wheelchair and we have since changed it to a Roho cushion. On 01/12/21 at 04:15 PM, LN L stated she saw the wound to R11's right buttocks on 01/04/21. LN L stated she told LN H about it and LN H said she would go later and look at it and put a patch on it. LN L stated she did not measure the wound because she thought LN H wound do that when she looked at it. On 01/12/21 at 03:21 PM, Administrative Nurse D stated she heard R11 had an open area to his buttocks and supposedly the nurse who found it said she told me about it the same day, but I don't recall her telling me. The nurse should have documented the area, told the wound nurse about the area so interventions could have been put in place the same day. The facilities Pressure Injury Prevention and Management policy, dated 01/01/20, documented in order to prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries that facility will implement evidence-based interventions by implementing individualized interventions that will address specific factors identified in the resident's risk assessment and skin assessment; prevention devices will be utilized in accordance with manufacturer's recommendations; interventions will be documented in the care plan and communicated to all staff; licensed nurses will conduct a pressure injury risk assessment, using the Braden Scale, on resident's upon admission/readmission, weekly times four weeks, then quarterly; and licensed nurses will perform assessments of pressure injuries and ensure the assessments are documented in wound rounds or in Skin/Wound Portal in Point Click Care. The staging of pressure injuries will be clearly identified. The facility failed to implement individualized interventions for R11 to prevent pressure ulcers, failed to adequately monitor the resident's skin condition, and failed to document and communicate R11's open areas to his left buttocks, placing the resident at risk for worsening pressure areas. R11 developed an unstageable pressure ulcer.

The facility had a census of 41 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections, when staff cleaned a [MEDICAL CONDITION] ([MEDICAL CONDITION]-infection of the large intestine (colon) caused by bacteria) resident's room in the 100 Hall, and failed to change gloves appropriately when providing incontinent cares for Resident (R) 11 and R12. Findings included: - On 01/07/21 at 12:00 PM, observation, during cleaning of a [MEDICAL CONDITION] resident's room, revealed Housekeeping Staff (HS) U, wearing an N95 mask, parked her housekeeping cart in the hall outside of the room entrance door, applied gloves and a gown, and tied the waist string but not the top string of the gown in the back. HS U took a white cloth, duster on a long handle, spray bottle of premixed [MEDICAL CONDITION] solution, mop with mop pad which had been presoaked in Virex (disinfectant cleaner) solution, then entered the resident's room. HS U sprayed the [MEDICAL CONDITION] solution on her cloth, wiped off the room door handles, door frame, then continued around the room using same procedure to wipe off bedside table (removing items), dresser (removing items) and high touch areas of the room. Continued observation revealed HS U used the duster and dusted all around the room where the wall met the ceiling, tied up the two trash can bags in the room, with her gown falling down in front past her chest towards the floor, leaving the chest area open, and name badge showing. Continued observation revealed HS U wiped down the bathroom door handle, bars, sink, and toilet top, then toilet seat and underneath the lid. HS U then removed and discarded gloves in the bathroom trash, mopped the bathroom floor, then returned to the housekeeping cart in the hall outside the resident's room carrying the [MEDICAL CONDITION] spray bottle, mop with contaminated mop pad on it, and placed the dust mop in the cart with the duster part up. HS U then placed the mop pad on the floor in front of the housekeeping cart, touching the carpet, then removed and discarded the mop pad in a plastic bag on her cart, and removed and discarded gloves and gown in the red container in the hall outside the resident's room. HS U applied a new disposable gown and gloves, went back into the room, retrieved the trash bags, removed her gown in the bathroom trash bag, and tied up the bag. HS U then brought the trash bags out, placed them in the red container along with her gloves, and applied hand sanitizer on her hands. On 01/07/21 at 12:30 PM, HS U verified she had not fastened the top string on her disposable gown and it kept coming down in front, brought contaminated dust mop and mop pad into the hall and placed on the carpeted floor. HS U stated she used the dust mop to clean in other resident rooms. On 01/07/21 at 12:30 PM, HS V stated housekeeping staff, when cleaning a [MEDICAL CONDITION] isolation room, should tie the top of their gowns, discard a contaminated mop pad inside the resident's room, and not reuse a dust mop after being contaminated. On 01/07/21 at 01:49 PM, Administrative Nurse J stated the procedure for staff when entering a [MEDICAL CONDITION] isolation room, should use contact isolation precautions (wear gown and gloves) when providing cares and should also wear foot covers. Administrative Nurse J stated the housekeeping supervisor was in charge of training her staff on how to clean the room. The facility's Management of [MEDICAL CONDITION] Infection policy, dated 03/01/20, documented all staff are to wear gloves and a gown upon entry into the residents room and while providing care for the resident with [MEDICAL CONDITION] infection. Hand hygiene should be performed by handwashing with soap and water in accordance with facility policy for hand hygiene. Use disposable equipment whenever possible. The facility failed to provide a sanitary environment to prevent the transmission of [MEDICAL CONDITION] when housekeeping staff failed to tie the top of her gown contaminating her clothing, used a mop in the isolation resident's bathroom, brought in the hall and touched the floor carpet, and brought a contaminated duster to the cart to be reused in other residents' rooms, placing the 41 residents at risk for acquiring an infection. - On 01/11/21 at 02:17 PM, observation revealed Certified Nurse Aide (CNA) Q and CNA MM entered R12's room, applied gloves, placed a gait belt on the resident and propelled her to the bathroom in her wheelchair. CNA MM locked the brakes of the wheelchair, cued the resident to stand, and assisted her to stand and pivot turn to the toilet. CNA MM pulled the resident's pants down, the resident sat down on the toilet, and immediately started to urinate. When finished, CNA Q and CNA MM assisted the resident in standing using a gait belt. CNA MM provided peri-care, then with the same soiled gloves, pulled up the residents pants and incontinent brief, took hold of the resident's gait belt, assisted the resident to stand, and transferred to her wheelchair. Observation revealed CNA Q propelled the resident to her bed. CNA Q and CNA MM, with the same soiled gloves, assisted the resident to stand and transferred to the bed. CNA MM, wearing the same soiled gloves, assisted the resident to lie down by lifting her legs into bed and then removed her shoes. CNA MM then removed and discarded her gloves. On 01/12/21 at 09:11 AM, observation revealed CNA MM and CNA NN entered R12's room, applied a gait belt to the resident's waist, and CNA NN propelled the resident in a wheelchair to the bathroom. CNA NN locked the brakes, both CNAs assisted the resident to stand and pivoted over the toilet. CNA MM pulled down the resident's pants and removed her urine saturated incontinent brief, wet pants, and shoes. CNA NN brought CNA MM two clean briefs and clean pants, and CNA MM, with the same soiled gloves, applied the incontinent briefs, pants, and shoes on the resident. Further observation revealed both aides assisted the resident to stand and CNA MM, with the same soiled gloves, pulled up the residents pants after CNA NN provided peri-care with his right hand, removed and discarded his right hand glove. Further observation revealed CNA MM and CNA NN assisted the resident to a wheelchair, then CNA MM removed and discarded her gloves. On 01/12/21 at 09:25 AM, CNA MM verified the resident's brief was saturated with urine, she had not changed gloves, after removing the resident's incontinent brief and wet pants, and stated she should have changed them. On 01/12/21 at 11:30 AM, Administrative Nurse D stated she expected staff to change gloves between dirty and clean when providing incontinent cares for the resident. The facility's Infection Prevention and Control Program policy, dated 11/01/19, directed staff to wash hands and change gloves to prevent contamination and spread of infection. The facility staff failed to change gloves, after they became contaminated while providing incontinent cares for R12, placing the resident at risk for infection. - On 01/07/21 at 09:23 AM, observation revealed CNA O transferred R11 to bed and provided incontinent cares. Observation revealed CNA O wore gloves and removed R11's soiled brief, cleansed the resident's groin and buttocks, and applied a clean incontinent brief wearing the same soiled gloves. On 01/11/21 at 09:21 AM, observation revealed CNA O entered R11's room to provide incontinent cares, R11 incontinent of bowel and urine. Continued observation revealed CNA O wore gloves and removed R11's soiled brief, cleansed the resident's groin and buttocks, and wearing the soiled gloves, applied ointment to R11's buttocks. On 01/07/21 at 09:35 AM, CNA O stated she was not aware she needed to change her soiled gloves before touching R11's clean skin, incontinent briefs, and clothes. On 01/12/21 at 03:58 PM, Administrative Nurse D stated the facility provided staff education and training for handwashing, gloving, and infection control, and staff should provide appropriate incontinent cares. The facility's Infection Prevention and Control Program policy, dated 11/01/19, directed staff to wash hands and change gloves to prevent contamination and spread of infection. The facility failed to ensure staff changed gloves appropriately while providing incontinent cares for R11, placing the resident at risk for infection.

The facility had a census of 41 residents. The sample included 14 residents with five reviewed for immunizations. Based on record review and interview, the facility failed to provide the current Centers for Disease Control and Prevention (CDC) pneumococcal and influenza vaccine information to make an informed decision for five of five sampled residents or their representative, Resident (R) 26, R20, R12, R36, and R10. Findings included: - On 01/12/21 at 03:00 PM, review of R26, R20, R12, R36, and R10's immunization records documented the use of the CDC's Inactive Influenza Vaccine, What You need to Know Vaccine Information Statement, dated 08/15/19, and the Pneumococcal [MEDICATION NAME] Vaccine (PPSV23): What you need to Know Vaccine Statement, dated 11/05/15, but lacked the current fact sheet dated 10/30/19. On 01/12/21 at 03:15 PM, Medical Record Staff GG verified the facility did not provide the residents or their representative with the current CDC information for the administration of influenza and pneumococcal immunizations. On 01/12/21 at 11:30 AM, Administrative Nurse D stated she expected staff to provide the residents or representatives with the current CDC information for the administration of influenza and pneumococcal immunizations. The facility's influenza Vaccination policy, dated 11/01/19, documented prior to administration of the influenza vaccine, the resident receiving immunization, or his/her legal representative, would be provided a copy of CDC's current vaccination information statement relative to influenza vaccination. The facility's Pneumococcal Vaccination policy, dated 11/01/19, documented prior to administration of the pneumococcal vaccine, the resident receiving immunization, or his/her legal representative, would be provided a copy of CDC's current vaccination information statement relative to pneumococcal vaccine. The facility failed to provide R26, R20, R12, R36, and R10, or their representatives, with the current CDC influenza and pneumococcal immunization information, placing the residents at risk for making uninformed decisions.

The facility had a census of 57 residents. The sample included 20 residents with 3 reviewed for accidents. Based on observation, record review, and interview the facility failed to provide adequate supervision to prevent accidents for 2 of 3 sampled residents who spilled hot liquids on his/her lap. (#1, #53) Findings included: - Resident #1's physician order [REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated 2/07/2019, recorded the resident had short and long term memory loss, with moderately impaired cognition. The assessment revealed the resident required extensive assistance of one staff for bed mobility, transfers, locomotion off the unit, and set up assistance with eating. The 11/12/2018 (ADL) Activities of Daily Living (CAA) Care Area Assessment documented the resident required staff assistance with most ADLs. The care plan, dated 11/12/2018, directed staff to set up and assist the resident with meals. The care plan recorded the resident sat at a table that was too high for him/her but requested to stay at that table. The 11/28/2018 at 11:00 AM, nurse's notes documented the resident spilled hot coffee to his/her thighs, staff transferred the resident to his/her room, and cleansed the burned area with cold water. The 11/30/2018 at 6:00 AM, late entry nurse's notes documented staff completed a skin assessment on 11/29/18 and noted the resident had redness and blisters to his/her bilateral inner thighs from spilling hot coffee on him/herself on 11/28/2018. The notes documented the resident voiced discomfort to the area with assessment, staff called the physician's office and requested [MEDICATION NAME] (topical antibiotic used [MEDICAL CONDITION] prevent infections) cream to the area twice a day. The 12/05/2018 at 4:00 AM, nurse's notes documented staff completed a skin assessment on 12/03/2018 and noted the resident's bilateral inner thighs red, with fluid filled blisters to his/her right and left inner thighs, 1 intact blister and 1 non-intact blister, with no signs of infection to the non-intact blister site. The 1/03/2019 at 10:50 AM, nurse's notes documented staff completed a skin assessment on 12/31/2018. The note documented the resident's bilateral inner thighs continued to have yellow slough (dead tissue), with yellow/greenish drainage. The area around the non intact blisters continued to be red, the resident voiced pain and discomfort to the areas with assessment and treatment/dressing change, but denied the need for pain medication. The 1/28/2019 at 7:10 AM, nurse's notes documented staff completed a skin assessment on 1/27/2019 and noted the resident's inner bilateral thighs continued to have yellow/brownish slough, with no drainage noted. Staff cleansed the areas with soap and water, a [MEDICATION NAME] (a controlled release dressing that keeps the wound moist and promotes healing) sheet was placed on the area, secured with tape at the corners, and the resident denied discomfort at that time. The 3/05/2019 at 7:20 AM, nurse's notes documented staff completed a skin assessment on 3/04/2019 and noted the resident's inner thighs continued to be red and skin remained intact to the area, with no signs and symptoms of infection or drainage. Staff cleansed the area with soap and water, a [MEDICATION NAME] sheet was placed on the area and secured with tape. The 3/14/2019 at 6:30 AM, nurse's notes documented a skin assessment was completed on 3/11/2019 and noted the resident's inner thighs continued to be red and the skin remained intact, with no open areas. Staff cleansed the area with soap and water, a [MEDICATION NAME] sheet was placed on the area, secured with tape at the corners, and the resident denied discomfort at that time. The 4/12/2019 skin assessment, completed 4/5/2019, noted the left and right inner thighs without redness or open areas, healed at that time. The note recorded the treatment discontinued due to the area healed. Review of the medical records lacked a hot liquid assessment for the resident. On 5/15/2019 at 12:30 PM, observation revealed Nurse Aide N assisted the resident from his/her wheelchair to the toilet using a gait belt and transfer bar. Continued observation revealed the resident had reddened areas on his/her bilateral inner thighs, approximately 5 inches by 3 inches, from the 11/28/18 coffee burn. On 5/15/2019 at 1:10 PM, Administrative Staff A stated the facility performed assessments on admission, but had not completed a hot liquid assessment. Administrative Staff A implemented a plan of action to the facility and staff to cool all the coffee down before serving the hot liquids to the residents, and the nurses completed a hot liquid assessment on the residents. The 11/2016 facility's Incident and Accident Standards of Care policy documented the facility environment would be as free from accident hazards over which the facility has control and that each resident receives adequate supervision and assistance devices to prevent avoidable accidents. The facility failed to assess risks, and implement interventions for cognitively impaired Resident #1, who spilled hot liquids on his/her lap and experienced [MEDICAL CONDITION] his/her bilateral inner thighs. The facility further failed to investigate the event and implement new interventions to prevent further accidents. - Resident #53's physician order [REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated 1/21/19, recorded the resident had severely impaired cognition with inattention, disorganized thinking and verbal behaviors. The MDS recorded the resident required extensive staff assistance with all (ADLs) Activities Daily Living, including eating. The 10/31/18 care plan recorded the resident ate independently and preferred soup for dinner. The 12/15/18 at 5:56 PM, nurse's notes recorded staff delivered a meal tray to the resident, turned around to assist another resident, and a nurse heard the resident yell it burns. The note recorded a cup of chicken noodle soup had spilled onto the resident's lap, the clothing with the hot liquid was immediately removed from the resident's skin and cool washcloths were applied to the reddened areas. The note documented multiple reddened areas to the residents left abdomen, left forearm, bilateral inner thighs and top of his/her left thigh. The nurse's note recorded staff notified the physician and received an order to apply [MEDICATION NAME] (topical antibiotic used [MEDICAL CONDITION] prevent infections) cream to red areas on the abdomen, bilateral thighs and left forearm twice a day. The note documented staff notified the resident's family and the director of nursing. The 12/18/18 at 11:44 AM, nurse's notes recorded staff completed a skin assessment on 12/17/18, and noted the resident had redness to his/her abdomen and bilateral inner thighs, and a non-intact blister to the top of his/her left thigh. The note documented the resident voiced discomfort to the area with assessment and stated, don't touch it, it hurts. Staff cleansed the areas with soap and water and applied [MEDICATION NAME] cream. The 1/9/19 at 10:14 AM, nurse's notes recorded staff completed a skin assessment on 1/7/19, and noted intact scabs to the left abdomen and left thigh. The note documented the resident voiced no discomfort with assessment, staff cleansed the area and left open to air. The medical record lacked evidence the facility investigated the accident, assessed the resident's safety for handling hot liquids or food, or revised the care plan to prevent further accidents involving hot liquids. On 5/15/19 at 12:08 PM, observation revealed staff sat next to the resident at the dining table and assisted him/her to eat and drink. On 5/15/19 at 2:41 PM, Administrative Staff A stated staff had not completed an investigation, assessed the risks, or revised the care plan after the resident spilled hot soup on his/her lap. The facility's undated Incident and Accident Standards of Care policy documented the facility environment would be as free from accident hazards over which the facility has control and that each resident receives adequate supervision and assistance devices to prevent avoidable accidents. The policy directed the facility to investigate accidents to identify the cause, assess hazards and/or risk, and implement interventions to prevent further accidents. The facility failed to assess risks, and implement interventions for cognitively impaired Resident #53, who spilled hot liquids on his/her lap and experienced [MEDICAL CONDITION] his/her abdomen, thigh and arm. The facility further failed to investigate the event and implement new interventions to prevent further accidents.