Every finding on record at Pinnacle Point Wellness & Rehabilitation

Based on interview and record review, the facility failed to ensure the health, safety, and welfare of Resident #1 was met when the facility provided the resident transportation to the bank and left him/her, returned but did not locate the resident and left without the resident. The resident did not receive his medications as ordered and slept outside in an alley. The resident borrowed a phone and called the facility to come pick him/her up the next morning. This affected one of seven sampled residents. The facility census was 114.On 06/29/26, the Administrator was notified of the past noncompliance which began on 06/17/26. Upon discovery, the facility administration immediately conducted an investigation, and corrective actions were implemented to include staff training regarding resident transportation. The noncompliance was corrected on 06/18/26. Review of the In-Service Training Report dated, 06/18/2026 included:Subject: Resident TransportationSummary of Meeting: 1.) If we transfer a resident, we are liable; 2.) We transfer for medical appointments; 3.) Working phone or way to contact facility for a ride. Review of the facility policy titled, Out on Pass, dated 08/2020, showed:-It is the policy of the facility to meet resident's physical and psychosocial needs to go out on pass;-The facility will make reasonable efforts to ensure resident safety and uphold resident rights;-A responsible person is considered to be a person who is over the age of 18 and can call for medical assistance if required;-Prior to the resident leaving on pass, a licensed nurse will assess the resident's physical and mental status and ensure that the resident has a supply of medications for the time period of the pass;-When the resident returns to the facility, a licensed nurse will re-assess the resident to determine the resident's condition and any medication returned after going out on pass;-The resident is encouraged to give the facility reasonable notice when anticipating going out on pass;-The resident will return to the facility at an agreed upon time, or else notify the facility of any unexpected delay in return to the facility. Review of the residents Face Sheet showed the following diagnoses: -Asthma;-Anemia;-Hypo-osmolality and Hyponatremia;-Alcohol Abuse; -Other Psychoactive Substance Abuse; -Polyneuropathy; - Essential (Primary) Hypertension; -Peripheral Vascular Disease; -Acute Sinusitis;-Other Abnormalities of Gait & Mobility; - History of Falling. Review of Resident #1's Quarterly Minimum Data Set (MDS) a federally required assessment tool completed by facility staff, dated 05/21/26, showed:-The resident was cognitively intact;-The resident had not exhibited any wandering habits;-Diagnoses of abnormalities of gait and mobility, hypertension (high blood pressure), and asthma. Review of the resident's care plan, revised on 05/26/26, showed:-The resident was at a moderate risk for falls and needed a safe environment with even floors free from spills and clutter, the call light in reach, glare-free light, and handrails on walls;-The resident had a history of being unhoused. Review of the resident's sign out sheet, dated 06/17/26, showed: The resident signed out on 06/17/26 at 9:30 A.M. and returned to the facility on [DATE] at 11:55 A.M. Review of the facilities Resident Transportation In-Service Training Report, dated 06/18/26, showed: -If the facility transferred a resident the facility was liable for that resident;-Residents required a working phone or a way to contact the facility for a ride to return to the facility. During an interview on 06/29/26 at 11:06 A.M., the resident said: -He/She had to go to the bank; facility transportation dropped him/her off at the bank and he/she was going to give the transporter a call when he/she was done at the bank;-His/Her phone didn't have any minutes on it, and he/she was not able to get anyone to let him/her borrow a phone;-He/She laid down in an alley behind a fast-food restaurant that night, it was a little damp outside and the temperature was in the 60's;-He/She was able to borrow a phone from another customer at the fast-food restaurant the next morning to call the facility and get a ride back to the facility;-Facility staff were supposed to pick him/her up either at the bank or the fast-food restaurant on 06/17/26. During an interview on 06/29/26 at 1:26 P.M., the Director of Nursing (DON) said: -The facility usually only transported residents to medical appointments but was able to provide transportation to the bank for the resident on 06/17/26;-The resident was going to call the facilities transporter when he/she was done at the bank to get a ride back to the facility;-The transporter had another resident to drop off at another location then returned back to the bank to pick up the resident;-When the transporter returned to the bank the resident was not there, the resident had said that he/she might go to the fast-food restaurant after getting done at the bank and the transporter did not see the resident at the fast-food restaurant either;-The transporter when back to the bank and the fast-food restaurant a few times and did not find the resident;-Even though the resident was his/her own person the facility still needed to make sure he/she was in a safe situation;-The facility was responsible for the resident's safety;-This transportation was not done as safely as it could have been;-Moving forward that facility needed to ensure the resident had a way to contact the facility during any future transportation provided by the facility;-She provided education to administrative staff and the Transporter regarding the facilities liability when transporting a resident and ensuring that residents had a way to contact the facility for a ride back to the facility. During an interview on 06/29/26 at 1:26 P.M. the Assistant Director of Nursing (ADON) said:-The resident said he/she went to a fast-food restaurant after getting done at the bank but the employees would not let him/her stay inside the lobby;- He/She then went to a coffee shop, then to a different bank in that area;-Resident #1 did not take any medication;-She was concerned the resident was not able to be found;-The resident signed out at 9:55 A.M. on 06/17/26 and signed back into the facility at 11:55 A.M. on 06/18/26. During an interview on 06/29/26 at 1:48 P.M. the Transporter said:-She took the resident to the bank and made sure that the resident had his/her number to call her when he/she was done at the bank and ready to be picked up;-The resident said he/she would either be at the bank or the fast-food restaurant when he/she was done at the bank;-She did not receive a call from the resident, and went to the bank and the fast-food restaurant to look for the resident and was unable to find him/her;-She went back to the bank and the fast-food restaurant in between dropping off other residents for appointments and looked for Resident #1;-She let the facilities Administrator know that she was unable to find the resident four hours after she was unable to find him/her;-She was worried about the resident's safety while he/she was out and unable to be found;-She received education regarding the facilities liability when transporting a resident and ensuring that resident's had a way to contact the facility for a ride back to the facility. During an interview on 06/29/26 at 2:56 P.M. the Administrator said: -Facility transportation was able to take the resident to the bank and told him/her that he/she would have to wait to be picked up until other resident's had been dropped off at their appointments, the resident told the transporter that he/she would either be at the bank or at the fast food restaurant;-The transporter gave the resident a phone number to call when he/she was done and ready to be picked up;-The resident signed out of the facility before being transported to the bank;-She went to look around the area of the bank and the fast-food restaurant and was unable to find him/her;-The resident stayed outside around the fast-food restaurant that night;-She was not concerned about the resident's safety while the resident was unable to be found overnight; -The facility stopped looking for the resident around 8:00 P.M. on 06/17/26. -The facility contacted the police department but were unable to file a missing person's report due to the resident being his/her own person and the resident being missing for less than 24 hours;-She received education from the DON regarding the facilities liability when transporting a resident and ensuring that resident's had a way to contact the facility for a ride back to the facility. Intake 3055411

Based on interview and record review the facility failed to allow three residents (Resident #1, #2 and #3) to exercise their right to choose a physician, when the facility limited the choice of physicians to only those who were chosen by the facility, without allowing Residents #1, #2 and #3, to select their own physician. The facility census was 109. Review of the facility's Resident Rights policy, dated August 2020 showed:-All residents have a right to a dignified existence, self determination and communication with and access to persons and services inside and outside the facility; -The facility must treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhanced enhancement of his or her quality of life recognizing each resident's individuality;-The facility will protect and promote the rights of the resident and provide equal access to qualify quality of care regardless of diagnosis severity of condition or payment source;-The facility will ensure the resident can exercise his or her rights without interference, coercion discrimination or reprisal from the facility;-The resident has a right to choose a physician and treatment and to participate in decisions and care planning, including involving representatives and considering all personal and cultural preferences;-The resident will be fully informed and participate in his/her treatment including being fully informed of his/her total health status including medical conditions.Review of the facility's undated admission packet showed the resident had the right to designate which health care professionals and service providers will be involved in their care during their stay at the facility.1.Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 02/02/26 showed:-No cognitive impairment;-Partial assistance of staff for Activities of Daily Living (ADL)s;-Impairment on one side;-Diagnoses included high blood pressure, diabetes and anxiety.Review of the resident's care plan dated 05/11/26 showed:-ADL self care deficit related to hemiplegia (a form of paralysis affecting one side of the body);-Dependent on staff for meeting emotional and physical needs;-Assistance of one staff for personal hygiene;-Assistance of one staff for dressing.Review of the resident's medical record showed:-The resident's face sheet showed Physician A as the resident's attending physician;-A letter dated 04/20/26 showed the resident's attending physician, Physician A, was issued a 30-day termination of services notice by the facility;-The letter said the resident could have Physician B or Physician C as an attending physician;-The letter had refused written across the bottom of the letter;-The resident's name was on the letter.During an interview on 4/30/26 at 9:18 A.M. the resident said:-The new company took over the facility and was forcing him/her to change his/her primary care physician;-He/She did not want to change physicians because he/she is very comfortable with the one he/she has now, physician A.-The Social Services Clerk brought a letter to him/her asking him/her to change physicians;-He/She refused to sign the letter because Physician A, was not a choice;-He/She called Physician A and Physician A said he/she would be able to still see the resident;-He/She felt anxious and upset that the facility would not let him/her keep physician A;-He/She felt like the new owners of the facility did not care about him/her or his/her rights;-He/She had to comfort another resident (Resident #3) because Resident #3 was upset and crying about not getting to see Physician A anymore;-The facility gave Resident #1 no reason why physician A could not be his/her physician.2. Review of Resident #2's admission MDS, dated [DATE] showed:-No cognitive impairment;-Touching assistance for ADLs;-Used a walker for ambulation;-Diagnoses included anxiety, depression and high blood pressure.Review of the resident's care plan dated 04/12/26 showed:-ADL self care deficit related to heart disease;-Independent for meeting emotional and intellectual needs.Review of the resident's medical record showed:-The resident's face sheet showed Physician A as the resident's attending physician;-A letter dated 04/20/26 showed the resident's attending physician, Physician A, was issued a 30-day termination of services notice by the facility;-The letter said the resident could have Physician B or Physician C as an attending physician;-The letter showed the Physician B's name circled;-The letter was signed by the resident.During an interview on 4/30/26 at 10:34 A.M. the resident said:-The Social Services Clerk showed him/her a letter and said the resident needed to pick another physician;-The Social Services Clerk said the physician he/she currently had, Physician A, was no longer going to be with the facility;-He/She did not recognize the new physician's name and did not have his contact information and that made the resident anxious and nervous;-The resident said he/she felt like he/she was forced into choosing another physician.3. Review of Resident #3's care plan dated 03/10/26 showed:-ADL self care deficit related to heart failure;-Dependent on staff for meeting emotional and physical needs:-Had a behavior problem.Review of the resident's Medicare 5 day MDS, dated [DATE] showed:-No cognitive impairment;-Partial assistance of staff for ADLs;-Diagnoses included heart failure, high blood pressure, anxiety and bipolar disorder (a chronic mental health condition).Review of the resident's medical record showed:-The resident's face sheet showed physician A as the resident's physician;-The resident had a guardian;-No letter showing the change in physician's was found.During an interview on 4/30/26 at 10:56 A.M. the resident said:-He/She was told by the Social Services Clerk that he/she would no longer be able to have Physician A as his/her physician;-He/She was upset, nervous and depressed;-He/She said he/she started crying in the hall and Resident #1 had to console him/her;-He/She said he/she did not know any of the new physician's and it was not fair to him/her.During an interview on 4/30/26 at 3:18 P.M., the resident's guardian said:-He/She remembered signing a letter picking a new physician for the resident;-The administrator told him/her that the facility was going in different direction and he/she had to choose a different physician for the resident;-The administrator told him/her that Physician A would still be able to come to the facility if the resident wanted;-Then the facility called back and said Physician A had been sent a 30 day notice and would not be coming back to the facility;-The resident was upset about the change but he/she did what he/she had to do by picking a new physician.During an interview on 4/30/26 at 3:30 P.M., Physician A said:-He had received a 30-day termination of services letter last week, saying that his services would no longer be needed;-He held a current, active medical license in good standing and did not understand why he received a termination letter;-He called the Administrator to ask why he received the letter;-The Administrator told him that the new company had doctors that they wanted to bring in and wanted to use;-The Administrator told him he would no longer be allowed to see residents at the facility;-He asked the Administrator what he had done to not be allowed back into the facility;-He told the Administrator he could still be on call and follow the same protocols as before; -He got no response from the Administrator or the facility;-Resident #1 called him worried and upset;-Resident #1 told physician A he/she wanted to continue using him as his physician;-Physician A told Resident #1 he would be willing to continue to see residents at the facility;-The facility would not tell Physician A if he had done anything wrong and just said they wanted to go in a new direction;-All residents should have the right to choose the physician they like;-Not allowing residents the right to choose the physician they want can cause mental and physical stress;-Residents can feel helpless if they do not get a say in the change.During an interview on 4/30/26 at 3:46 P.M. the Social Service Clerk said:-The administrator instructed him/her to go to all the residents with a letter and have them pick a new physician;-The letter gave the residents the option of Physician B or Physician C;-Physician B and Physician C are new physicians, the new company wanted to use;-The letter said the Physician A would no longer be seeing residents and was not listed as a choice for a physician;-Some residents were not happy about changing physicians;-She told the unhappy residents if they had questions talk to the Administrator;-Residents should get to choose the physician they want. During an interview on 4/30/26 at 03:59 P.M. the Director of Nursing said:-She did not know why Physician A was given a 30 termination notice;-The instruction came from the new company management that took over the facility;-She did not know of any disciplinary action or any reason why Physician A was no longer able to see residents at the facility;-Residents should be able to choose the physician they want. During an interview on 4/30/26 at 04:12 P.M. the Administrator said:-Physician A received a 30 termination notice;-The notice came from company leadership that owns the facility;-The residents had choice of Physician B or Physician C;-The company wanted to go with the physicians that they already had;-She could see no reason why Physician A could not still see residents at the facility, but the decision was not hers to make, but with management above her.Intake 2999923

Based on interview and record review, the facility failed to inform residents and/or their responsible parties, in advance of the risks and benefits of proposed care, when the facility failed to obtain written consent before beginning psychotropic medications (medications that affect the mind, emotions, and behavior) for four residents (Resident #37, #5, #8, and #79) of the 24 sampled residents. The facility census was 119. Review of facility's Resident [NAME] of Rights policy, dated January 2023, showed: The facility residents have the right to be informed in advance of the risks and benefits of proposed care, of treatment alternatives or treatment options, and to choose the treatment option or alternative he or she prefers. 1.Review of Resident #37's care plan, dated 9/3/25, showed the resident used antidepressant medication for the treatment of depression and also used anti-anxiety medication for the treatment of anxiety. Review of the resident's physician order sheet, dated January of 2025 through February of 2025, showed:-The resident's order for Buspirone (anti-anxiety medication) 10mg (milligram) by mouth three times a day, began on 2/2/25;-The resident's order for Escitalopram (antidepressant medication) 20mg by mouth once a day, began on 1/8/25;-The resident's order for Modafinil (medication for narcolepsy) 100mg by mouth once a day, began on 1/8/25. Review of the resident's consent form for psychotropic medications, dated 8/28/2025, showed: the facility did not obtain verbal consent from the resident's representative until 8/28/25 for the resident to take psychotropic medications that was initiated on 1/8/25 and 2/2/25. 2. Review of Resident #5's care plan, undated, showed:-The resident was dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits;-The resident had impaired cognitive function related to Alzheimer's, dementia, and cerebral infarction (death of brain tissue cause by lack of blood flow);-The resident used antidepressant medication related to depression. Review of the resident's physician order sheet, for the month of August 2025, showed:-The resident's order for Trazodone HCI 25mg (an antidepression medication) by mouth, one time a day and began on 8/17/25.-The resident's order for Rivastigmine Transdermal Patch 4.6mg (a medication used for Alzheimer's disease) apply one patch every 24 hours, began on 8/22/25. Review of the resident's consent form for psychotropic medications, dated 8/28/25, showed: the facility did not obtain consent from the resident's representative prior to the start of Trazodone on 8/17/25 and Rivastigmine on 8/22/25. 3. Review of Resident #8's medication administration record (MAR) for the month of June 2025, showed the resident had a diagnosis of generalized anxiety disorder and depression. Review of the resident's physician order sheet for the month of November 2025, showed:-The resident's order for Buspirone 10mg three times a day, by mouth, began on 11/20/24;-The resident's order for Sertraline HCI 50mg (used to treat depression) one time a day, by mouth, began on 11/1/24. Review of the resident's consent form for psychotropic medications, dated 3/5/25, showed the facility did not obtain consent prior to the start of Buspirone and Sertraline from the resident or the resident's representative. Consent was not obtained until four months after the medication began. 4. Review of Resident #79's care plan, dated 9/3/25, showed the resident used antidepressant medication for the treatment of depression, psychotropic medications for behaviors, and anti-anxiety medications for anxiety. Review of the resident's physician order sheet for the months of January 2025 and February 2025, showed:-The resident's order for Escitalopram Oxalate 20mg daily by mouth, for the treatment of anxiety, began on 1/8/25;-The resident's order for Buspirone 10mg three times a day by mouth, for the treatment of depression, began on 2/2/25;-The resident's order for Modafinil 100mg daily by mouth, for the treatment of narcolepsy, began on 1/8/25. Review of the consent form for psychotropic medications, dated 8/28/25, showed the facility did not obtain consent from the resident's representative prior to taking Buspirone, Escitalopram, and Modafinil until 8/28/25. During an interview on 10/03/2025 at 10:49 A.M., the DON said the nurses or administration would call the family to obtain consent from the resident representative before a psychotropic medication was started. The DON was unaware consent was not being done prior to the administration of psychotropic medications. During an interview on 10/03/2025 at 11:14 A.M., LPN B said the nurse or unit manager was responsible for obtaining consent from the resident or family member before starting a psychotropic medication. During an interview on 10/03/2025 at 11:30 A.M., the corporate nurse said social services or nursing staff should obtain consent from the resident or the resident's family for psychotropic medications before the start of the medication. During an interview on 10/03/2025 at 11:35 A.M., the Administrator said nursing staff or social services should obtain consent from the resident or their family member before starting psychotropic medications.

Based on observation, interview, and record review, the facility failed to treat residents with dignity and respect when staff allowed Resident #64 to scream and yell obscenities in the hall and dining room while Resident #41 sat in the dining room, and when staff failed to acknowledge Residents #22 and #33 when they rang their call light and asked for a snack. This affected three of 24 sampled residents. The facility census was 119.Review of the facility's Resident Rights policy dated, January 2023 showed:-Each resident had the right to a dignified existence, in an environment that promotes maintenance or enhancement of his/her quality of life;-Each resident had the right to self determination, which the facility must promote and facilitate through the support of resident choice;-The resident had the right to a comfortable and home like environment.1. Review of Resident #41's admission minimum data set (MDS) a federally mandated assessment instrument completed by facility staff, dated 8/25/25 showed:-Moderate cognitive impairment;-Independent with Activities of Daily Living (ADLs);-Diagnosis included dementia, high blood pressure, and diabetes.Review of the resident's care plan dated 8/28/25 showed:-The resident had impaired cognitive function related to dementia;-The resident had the potential to be verbally aggressive;-Guide the resident away from sources of distress. 2. Review of Resident #64's quarterly MDS dated [DATE] showed:-Severe cognitive impairment;-Assistance of one staff member for ADLs;-Diagnoses included seizure disorder, traumatic brain injury, and anxiety.Review of the resident's care plan dated 8/2/25 showed:-The resident had a behavior problem;-Made negative statements to other residents;-Verbally aggressive;-Staff are to explain inappropriate behavior to the resident;-Staff are to intervene as necessary to protect the rights of others;-Staff are to divert resident's behavior by offering other tasks such as painting, coloring or journaling.Observation and interview on 09/30/25 at 1:12 P.M., showed:-Certified Nurse's Aide (CNA) D walked with Resident #64 up and down the hall and into the dining room of the memory care unit;-Resident #64 yelled out I hate you and Go to hell as he/she walked past the dining room;-Resident #64 continued to yell out and cry as he/she walked around the dining room with CNA D;-Resident #41 sat in the dining room and said out loud All the yelling that man/woman does gets on my nerves. It is the same thing every day, resident #64 gets up and starts yelling and cussing. It is very negative and hard to deal with every day;-Visitor A sat next to Resident #41 and said he/she came to visit Resident #41 at least three times per week;-Visitor A said Resident #64 is always shouting and yelling obscenities;-Visitor A said Resident #41's room is across from Resident #64's room and it keeps Resident #41 up at night;-Visitor A said the staff knew about the yelling;-CNA B was in the dining room;-Licensed Practical Nurse (LPN) C was at the nurse's station;-No staff explained the inappropriate behavior to Resident #64;-No staff intervened to protect the rights of other residents;-No staff attempted to divert Resident #64's behavior by offering other tasks such as painting, coloring or journaling.Observation and interview on 10/1/25 at 09:35 A.M. showed:-CNA D walked with Resident #64 up and down the hall;-Resident #64 yelled I wish I was dead, I am going to kill you;-CNA D walked with Resident #64 up and down the hall and into to the dining room;-Resident #41 sat in the dining room;-Resident #41 said the yelling is so negative, and so is the cussing and foul language every day, how would you like to wake up to this, it is so hard to deal with day in and day out;-LPN C was at the medication cart at the nurses station;-CNA B was in the dining room;-No staff explained the inappropriate behavior to the resident;-No staff intervened to remove Resident #64 away from Resident #41;-No staff attempted to divert resident's behavior by offering other tasks such as painting, coloring or journaling.During an interview on 10/1/25 at 10:25 A.M., CNA D said:-Resident #64 yelled all the time and the other resident's became agitated;-Resident #41 complained about the yelling;-He/She was not aware of the interventions on how to redirect Resident #64.During an interview on 10/1/25 at 10:39 A.M., CNA B said:-Resident #64 always yelled and cussed;-The yelling upset the other residents;-The other residents tell Resident #64 to shut up;-The staff try to take Resident #64 into his/her room until he/she calms down.During an interview on 10/1/25 at 10:52 A.M., LPN C said:-Resident #64 yelled and cussed out loud several times daily;-Resident #64's disease process had progressed;-The yelling upset other residents daily;-The management knew about the behaviors of Resident #64;-More cognitively intact residents such has Resident #41 complain more;-The staff do the best they can to redirect Resident #64;-It was very agitating to the other residents.During an interview on 10/3/25 at 11:24 A.M., the Director of Nursing said:-Resident #64 had a history of yelling out;-The facility tried to redirect Resident #64 as needed:-She was not aware Resident #41 was upset about Resident #64's behavior;-She expected the interventions included on Resident #64's care plan to be followed;-She expected staff to ensure Resident #41's right to be free from Resident #64's yelling to be followed.During an interview on 09/3/25 at 11:45 A.M., the Administrator said:-Resident #41 had the right to be free from resident #64's yelling and cussing;-He expected staff to utilize the interventions on Resident #64's care plan to redirect the behavior.3. Review of Resident #22's quarterly MDS dated [DATE] showed:-Moderate cognitive impairment;-Set up help with eating and oral care;-Supervision with showers;-Diagnoses included Alzheimer's Disease, diabetes, and anxiety.Review of the resident's care plan dated 7/18/25 showed:-Dependent staff to meet physical and emotional needs;-The resident had an ADL self care deficit Alzheimer's Disease;-Encourage the resident to use call bell for assistance;-The resident had a diagnoses of diabetes. 4. Review of Resident #33's quarterly MDS dated , 7/18/25 showed:-Severe cognitive impairment;-Set up help with eating and oral care;-Dependent on staff for showers and toileting;-Diagnoses included, dementia, anemia, and low sodium in the blood.Review of the resident's care plan dated 8/2/25 showed:-Dependent on staff to meet physical and emotional needs;-The resident had an ADL self care deficit related to dementia;-Encourage the resident to use call bell for assistance;-The resident is at risk for dehydration.Observation on 9/1/25 from 11:11 A.M. to 11:39 A.M., showed:-11:11 A.M., Resident #22 sat in room his/her and yelled into the hall that he/she was hungry and wanted a snack and his/her roommate, Resident #33 wanted a snack also;-11:15 A.M., Resident #22 put his/her call light on and yelled out in the hall again he/she wanted a snack as CNA D walked by the residents' room.-11:13 A.M., Resident #33 yelled out into the hall he/she wanted a snack too;-11:18 A.M., CNA D walked by Resident #22's and #23's room and did not acknowledge the residents;-11:24 A.M., CNA D walked back by the residents' room again and did not give the residents a snack or acknowledge the residents;-11:25A.M., CNA D's pager was still going off as he/she walked past the room of Residents #22 and #23;-11:26 A.M., CNA D walked back by the residents' room to room [ROOM NUMBER] and shut the door without giving Residents #22 and #23 a snack;-11:27 A.M., LPN C walked into the residents' room and shut the call light off and the residents said they wanted a snack;-11:39 A.M., LPN C brought the drink cart to the residents' room, but no snacks.During an interview on 9/1/25 at 11:45 A.M., Resident #22 said:-He/She expected the staff to bring a snack if he/she wanted one;-He/She was a diabetic and needed a snack sometimes;-It made him/her feel disrespected when the staff did not acknowledge him/her.During an interview on 9/1/25 at 11:50 A.M., Resident #23 said:-The staff have a lot to do, but it would be nice if they could come in and at least say they would help him/her in a minute instead of walking by like they do not see him/her;-It made him/her feel like a burden when staff did not bring a snack. During an interview on 9/1/25 at 11:52 A.M., CNA D said:-He/She had to take care of another resident first;-He/She was not aware Resident #22 and #23 wanted a snack;-Residents #22 and #23 have the right to a snack;-He/She should have acknowledged Residents #22 and #23 and told then he/she would come back.During an interview on 9/1/25 at 12:05 P.M., LPN C said:-When Resident #23 and #33 wanted a snack staff should have took a moment to give them one;-It is the resident's right to get a snack;-Staff should at least have told the residents it would be a moment;-He/She took only the drink cart into the residents' room, because lunch was going to be served in a few minutes.-She expected staff to acknowledge Resident #22 and #23 and give then a snack if they wanted one.During an interview on 09/3/25 at 11:45 A.M., the Administrator said:-He expected staff to answer Resident #22 and #23's call light and acknowledge them;-He expected to staff to get a snack and drink for Residents #22 and #23;-He expected staff to treat Resident #22 and #23 with dignity and respect.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, when facility staff failed to utilize appropriate personal protective equipment (PPE) for two Residents (Resident #13 and #112) of 24 sampled residents. The facility census was 119. Review of the facility's Management of Communicable Diseases policy, dated, September 2019, showed: -Standard precautions (a set of evidence-based infection control practices designed to prevent the transmission of infections in healthcare settings which includes: hand washing, wearing gloves, gowns, masks, and regularly cleaning equipment) are intended to be applied to the care of all patients in all healthcare setting, regardless of the suspected or confirmed presence of an infectious agent; -The facility will establish guidelines to prevent the transmission of infections, communicable disease, and healthcare acquired infections. Review of the facility's Enhanced Barrier Precautions policy, dated April 2024, showed:- Enhanced Barrier Precautions (EBP) are indicated for residents with infections or for residents with wounds and/or indwelling medical devices during high-contact resident care activities as these residents are at an increased risk of being infected;- EBPs involve gown and glove use during high-contact resident care activities including, device care or use for central line, urinary catheter, feeding tube, tracheostomy, or ventilator;- EBPs are intended to remain in effect for the duration of the resident stay or until the wound is closed/medical device removed. 1.Review of Resident #112's Care Plan, undated, showed: -The resident had impaired cognitive function due to dementia; -The resident had a diagnosis of diabetes mellitus; -The resident had the potential of impairment to skin integrity due to diabetes, fragile skin. Review of the resident's physician order sheet for the months of September 2025 and October 2025, showed: -The resident had an order for blood sugar checks four times a day; -The resident had an order for insulin Aspart 5 units (a medication to help control blood sugar) to given subcutaneous (an injection under the skin into the fatty layer) before meals. Observation on 10/02/2025 at 11:06 A.M., showed Licensed Practical Nurse (LPN) B sanitized hands while walking into Resident #112's room then administered insulin subcutaneously without wearing gloves. During an interview on 10/03/2025 at 11:14 A.M., LPN B said: -Gloves are to be worn when administering insulin. He/she should have worn gloves; -EBP supplies are worn with catheters, wounds, and feeding tubes, there is a sign placed on the door for residents who need EBP. 2. Review of the Resident #13's Comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/22/25, showed:- Cognitive skills severely impaired;- Dependent on staff for transfers, toilet use, showers, dressing, and personal hygiene;- Diagnoses included: cerebral palsy (a group of movement disorders that affect a person's ability to control their muscles), aphasia (a language disorder that affects a person's ability to communicate effectively), and quadriplegia (a condition that causes paralysis in all four limbs). Review of the resident's care plan, revised 9/9/25, showed:- The resident was to have nothing by mouth due to diagnoses and was to receive nutrition by feeding tube;- Nursing staff would provide tube feeding and flushes as ordered by the physician;- The resident required EBP due to feeding tube;- Nursing staff would place EBP sign on the resident's door and apply personal protective equipment (PPE) for high contact care activities. Observation on 10/01/2025 at 11:56 A.M., showed: - An EBP sign on door to the resident's room and an EBP box hanging on the resident's room door that contained all supplies, such as gowns, gloves, and trash bags; - LPN A entered Resident #13's room to perform tube feeding; - A small handwritten sign above the resident's bedside table that stated to use EBP with high contact resident activities; - LPN A sanitized hands, grabbed wipes, applied gloves and wiped down the resident's bedside table;- LPN A let the table dry, sanitized hands, applied gloves, grabbed a graduate and syringe, and did not apply a gown and continued with the tube feeding process; During an interview on 10/1/25 at 11:59 A.M., LPN A said:- He/She should have put the gown on;- He/She was uncertain why a gown would be needed. 3. During an interview on 10/03/2025 at 8:48 A.M., Certified Nursing Aide (CNA) A said EBP should be used with indwelling devices like catheters and feeding tubes. During an interview on 10/03/2025 at 9:00 A.M., LPN A said EBP should be used anytime when performing cares with a resident with wound, an ostomy, feeding tub. During an interview on 10/03/2025 at 9:20 A.M., Registered Nurse (RN) A said:- Staff should utilize EBP when providing working with a resident's indwelling catheter;- EBP would be used depending on why its required for that resident. If because of a device like a feeding tube or catheter, staff should use EBP with high contact cares, during wound care, and if a highly contagious infection EBP would be used all the time. During an interview on 10/03/2025 at 10:03 A.M., the Corporate Nurse said staff should use EBP for residents with indwelling devices like feeding tubes and catheters and for extended high contact care. During an interview on 10/03/2025 at 12:52 P.M., the Director of Nursing said staff should use EBP when providing high levels of direct patient care like flushing a feeding tube or working with a catheter or wound.

Based on observation, interview, and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff failed to provide complete perineal care for Resident #165 after an incontinence episode. In addition, the facility failed ensure call lights were answered timely for four residents (Resident #3, #10, #34, and #35). This affected five of 23 sampled residents The facility census was 112. Review of the facility policy, Resident [NAME] of Rights, dated 1/2023, showed: -Receive services in the facility with reasonable accommodation of resident needs and preferences; -Self-determination, which the facility must provide and facilitate through support of resident choice, assessments, and plan of care and make other choices about aspects of his or her life that are significant to the resident, including: activities, health care schedules (including sleeping, waking, bathing, and eating times). Review of the facility policy, A.M. Care, dated 10/2009, showed: -A.M. care will be given to residents daily; -Provide nail care as needed. The facility did not provide a policy regarding call lights. 31102 Review of the facility's policy titled, Incontinent Care, reviewed 1/15 showed:- To provide routine, preventive skin, perineal care to residents after an incontinent episode; - Wash the resident's entire perineal area, and all areas affected by incontinence with a washcloth, soap, warm water, peri-wash or wipes; - Avoid unnecessary exposure of the resident during the procedure; - When washing perineal area, wash the entire area moving from front to back; - Rinse the perineal area and other skin surfaces washed with warm water and a washcloth from front to back; - If using no-rinse perineal wash or wipes, no rinsing is required; - Place a clean incontinent brief on the resident. 1. Review of Resident #165's Admission MDS, dated [DATE] showed; - Cognitive skills intact; - Independent with toilet use, dressing, personal hygiene and transfers; - Always continent of urine; - Had a colostomy (a surgical procedure that creates an opening (stoma) in the abdominal wall to bring out part of the large intestine (colon); - Diagnoses included anxiety, arthritis, chronic obstructive pulmonary disease and blood clots. Review of the resident's care plan, revised 4/2/25, showed the resident had an ADL self-care performance deficit related to impaired balance and weakness. Staff are directed to assist as the resident as needed with ADLs. Observation on 4/8/25 at 12:03 P.M. showed;- Licensed Practical Nurse (LPN) A entered the resident's room wearing a gown and gloves with medication; - The resident laying in bed and was incontinent of urine and his/her colostomy bag had leaked onto the bed; - The resident had a coat and a jacket on underneath the coat and both were wet and soiled; - The resident did not have on an incontinent brief or pants; - LPN A assisted the resident to stand and the resident used his/her seated rolling walker and ambulated to the bathroom and urinated; - LPN A stripped the resident's bed and placed in a pile in the middle of the bed; - LPN A removed gown and gloves, sanitized and left the room to get clean linens; - The resident washed his/her hands, removed the wet and soiled jacket and coat and placed on the bag in his/her room and the jacket fell on to the floor; - The resident was naked and sat down on the side of his/her bed; - The resident pulled his/her colostomy bag off and threw in the trash; - LPN A came in with supplies; - The resident remained naked and moved to sit on his/her seated rolling walker; - LPN A donned a gown and gloves, bagged the soiled linens and cleaned the mattress with a super sani wipe (a disinfectant wipe used to control germs); - LPN A did not clean the area of the mattress where the resident had sat and did not clean the seat of the resident's rolling walker; - The resident used a perineal wipe to cover the stoma; - CNA J and LPN A brought supplies into the resident's room; - CNA J made the resident's bed; - LPN A placed a new colostomy bag on the resident; - LPN A assisted the resident to put on a clean pair of pants and assisted the resident to get under the covers; - LPN A and CNA J did not put a gown on the resident and did not clean any areas of the skin where the urine or feces had touched. During an interview on 4/10/25 at 11:35 A.M., LPN A said he/she should have cleaned the resident's skin where the urine and feces had touched. During an interview on 4/10/25 at 12:06 P.M., CNA J said since the resident was wet with urine and feces, he/she should have cleaned the resident's skin where the urine or feces had touched. During an interview on 4/10/25 at 4:15 P.M., the [NAME] President of Operations said the staff should have cleaned the resident's skin where urine and feces had touched. 2. Review of Resident #10's Annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/20/25 showed: - Cognitive skills intact; - Upper and lower extremities impaired on both sides; - Required set up and clean up assistance for eating and oral care; - Dependent on the assistance of staff for toilet use, showers, dressing. personal hygiene and transfers; - Always incontinent of bowel and bladder; - Diagnoses included RA, muscle spasms, muscle weakness, vitamin deficiency and thyroid disorder. Review of the resident's care plan, revised 11/26/24 showed: - The resident had an Activities of Daily Living (ADLs) self-care performance deficit related to rheumatoid arthritis (RA, a chronic inflammatory disorder usually affecting the small joints in the hands and feet), muscle spasms, dizziness, muscle weakness, vitamin deficiency and fatigue; - The resident was independent with bed mobility; - The resident had contractures (shortening of a muscle that causes decreased flexibility) of the right hand. - Staff to provide skin care as needed to keep clean and prevent skin breakdown; - The resident required physical assistance of one staff for dressing, showers and personal hygiene; - The resident was able to eat independently. Review of the resident's call light log showed the call light was on for the following amount of time: - 4/9/25 at 1:50 P.M., 33 minutes and 31 seconds; - 4/8/25 at 5: 32 A.M., 17 minutes, five seconds; - 4/8/25 at 11:00 A.M., 17 minutes, 51 seconds; - 4/8/25 at 3:24 P.M., 17 minutes, 57 seconds. Observation on 4/9/25 at 2:04 P.M., showed: - The resident's call light came on; - At 2:25 P.M., the call light was answered. During an interview on 4/10/25 at 12:28 P.M., the resident said: - It made her upset when it took so long for the call light to get answered; - His/Her call light had been on for over an hour before. 3. Review of Resident #35's Admission MDS, dated [DATE] showed: - Cognitive skills intact; - Upper extremity impaired on one side; - Required partial to moderate assistance with toilet use, dressing, and transfers; - Dependent on the assistance of staff for showers. Review of Resident #35's care plan, revised 11/26/24 showed: - The resident had an ADLs self-care performance deficit related to dementia, atrial fibrillation (A-fib, a condition where the upper chambers of the heart (atria) beat irregularly and rapidly), lumbago with sciatica (low back pain (lumbago) accompanied by nerve pain that radiates down the leg and buttocks), and muscle weakness; - The resident required physical assistance of one staff for showers, dressing, personal hygiene, toilet use and transfers; Review of the resident's call light log showed the call light was on for the following amount of time: - 4/9/25 at 6:47 P.M., 20 minutes, 47 seconds; - 4/9/25 at 2:03 P.M., 21 minutes, 11 seconds; - 4/9/25 at 11:10 A.M., 15 minutes, 34 seconds; - 4/9/25 at 10:49 A.M., 18 minutes; - 4/8/25 at 1:44 P.M., 150 minutes, 41 seconds; - 4/8/25 at 7:44 A.M., 25 minutes, 48 seconds. Observation on 4/9/25 at 2:04 P.M., showed: - The resident's call light came on; - At 2:25 P.M., the call light was answered. During an interview on 4/7/25 at 7:57 A.M., the resident said: - He/she had waited for hours for the call light to get answered; - It made him/her feel very anxious when it took so long for staff to answer the call light. 4. Review of Resident #3's Annual MDS, dated [DATE], showed: - Resident is cognitively intact with difficulty speaking needs; - Resident is dependent on staff for toileting hygiene, mobility, transfers, and bathing; - Diagnosis: diabetes stroke, bipolar, anxiety and PTSD. Review of Resident's care plan, revised 2/10/25, showed: - Resident has an Activities of Daily Living (ADL) self-care performance deficit. Resident can't transfer and toilet independently; - Resident has mood and mental health conditions and triggers include loud noises such as call light continually alarming and being left soiled for too long; During an interview on 4/10/25 at 10:21 A.M., the resident said: - Resident requires help from staff to use the toilet; - He/she has had to wait for his/her call light to be answered at night sometimes three to four hours at least three times a month, which results in him/her having an accident in bed and lying in his/her own waste. - He/she feels filthy when this happens and it triggers his/her PTSD and childhood issues which causes panic and fear. - Night staff does not consistently check on him/her at night so it's important when the call is used, it is answered. During a group interview of the resident council on 4/8/25 at 2:04 P.M., several residents said: - Call light time waits of over 20 minutes in the last week and sometimes they have had to wait two to four hours before being helped; - They had been helping other residents with their care issues because staff were taking too long to answer call lights; - Call light response times are the worst from 2 P.M. to 10 P.M. with B hall reporting the longest waits. 5. Review of Resident #34's Quarterly MDS, dated , 3/13/2025 showed: -Cognition was intact; -Required set up and clean up assistance with oral care and meals; -Dependent on nursing staff for toileting, transfers, showers, dressing, and rolling from left to right; -Diagnoses include: respiratory failure, asthma, depression, seizure disorder, and kidney failure. During an interview on 4/8/2025 at 9:13 A.M., the resident said: -Sometimes it took over 30 minutes for the call light to be answered; -He/She had resorted to yelling out to get assistance when the call light is not answered in a reasonable amount of time; -When the call light took a long time to be answered, he/she felt abandoned; -He/She was miserable and in pain when his/her back hurt and had to wait a long time for the call light to be answered so a wedge could be placed behind his/her back. 6. Observation on 4/08/2025 from 11:15 P.M. to 11:25 P.M. showed: -Two aides were sitting at a table in the back of the B hall dining room; - LPN E was on a personal cell phone for ten minutes discussing personal matters at the nurse's station; -A resident came to the nurse's station and waited for the nurse to notice him/her; - LPN E told the person on the phone to hold on, asked the resident what he/she needed, then gave the resident medication, and got back on the phone call; -CNA F was sitting in a chair out of the line of sight of the [NAME] call light system; -Three call light nursing staff pagers were sitting on the nurse's station desk unattended. During an interview on 4/8/2025 at 11:32 P.M., CNA's E, F, and G said he/she was not wearing a call light pager , but stated it was required to be worn when working. During an interview on 4/9/2025 at 1:06 A.M., LPN E said: -CNAs must wear pagers at all times unless they were on break; -CNAs should not all go on break at the same time. During an interview on 4/10/2025 at 11:10 A.M., LPN D said he/she expected call lights to be answered within five minutes. During an interview on 4/10/25 at 11:35 A.M., LPN A said; - Sometimes the staff will leave the resident's call light on until the resident's need is met (example- if a resident wanted a pain pill), then it would get shut off; During an interview on 4/10/25 at 12:06 P.M., CNA J said: - He/She tried to answer the call lights as quick as possible; - He/She thought they should try and be answered within five to ten minutes. During an interview on 4/15/25 at 1:12 P.M., CNA I said he/she tried to answer the call lights right away. During an interview on 4/10/25 at 4:15 P.M., the [NAME] President of Operations said: - Call lights should be answered in a reasonable amount of time, meal times could impact that time; - Sometimes staff do not reset the call light until they finish cares which could be 15 minutes; - All staff should be carrying their pagers; - They have a total of 13 pagers, one for each Charge Nurse (CN) and for CNAs who have room assignments; - Call lights go on the marquee signs and then it goes to the CNAs and it should go to the nurse if not answered within five minutes; - Two of the marquees have been replaced; - The pagers will escalate to upper management to help monitor call lights once they arrive; - If staff are assigned rooms, then they should have a pager; - At night, they should all have pagers; - No exceptions to carrying pagers if they are assigned a room; - If the staff clock out, they can take the pager off, but if they stay on the premises, they keep the pagers on their person; - Staff do not take breaks at the same time, they are staggered. 47195 50980

Based on observation, interview, and record review, the facility failed to ensure staff provided care in a manner to prevent infection or the possibility of infection when staff failed to clean and disinfect a resident's mattress and seated rolling walker after being soiled with urine and feces, which affected one of the 23 sampled residents, (Resident #165), failed to use and failed to use personal protective equipment (PPE, equipment worn to minimize exposure to a variety of hazards, examples included gloves, gowns and masks) for residents who were on Isolation for Contact requirements or Enhanced Barrier Precautions (EBP, infection control measures that go beyond standard precautions and focus on reducing the transmission of multidrug-resistant organisms (MDROs), for Resident #1 and #103. The facility census was 112. Review of the facility's policy titled, Enhanced Barrier Precautions, dated 4/24 showed: - Enhanced Barrier Precautions are indicated for residents with infections or colonization with a Centers for Disease Control (CDC)-targeted MDRO when contact precautions do not apply or for residents with wounds and/or indwelling medical devices without secretions /excretions that are unable to be covered/contained and are not known to be infected/colonized with any MDRO during high-contact resident care activities as these residents are at an increased risk of being infected; -Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multi-drug resistant organisms, (MDROs), in Nursing Homes; - EBP involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition; - EBP only require use of gown/gloves when performing high contact resident activities: dressing, bathing/showering, transferring (in room, shower/tub rooms and therapy gyms), AM/PM care, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter (sterile tube inserted into the bladder to drain urine), or feeding tube; wound care: any skin opening requiring a dressing; - EBP are intended to remain in effect for the duration of the residents stay or until the wound is closed/medical device is removed; - Door sign that reads, Enhanced Barrier Precautions or Visitors Must See Nurse Before Entering; - A private room is not required; - No special precautions are needed for dishes, glasses, cups or eating utensils. The facility did not provide a policy for disinfecting mattresses or equipment. 1. Review of Resident #165's Admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 4/2/25 showed; - Cognitive skills intact; - Independent with toilet use, dressing, personal hygiene and transfers; - Always continent of urine; - Had a colostomy (a surgical procedure that creates an opening (stoma) in the abdominal wall to bring out part of the large intestine (colon); - Diagnoses included anxiety, arthritis, chronic obstructive pulmonary di and blood clots. Review of the resident's care plan, revised 4/2/25, showed: - The resident had an ADL self-care performance deficit related to impaired balance and weakness; - The resident is able to turn and reposition independently; - The resident is independent with personal hygiene and oral care; - The resident is independent with toilet use and transfers. Assist as needed with toileting and transfers. Observation on 4/8/25 at 12:03 P.M. showed; - Licensed Practical Nurse (LPN) A entered the resident's room wearing a gown and gloves with medication; - The resident laying on bed and was incontinent of urine and his/her colostomy bag had leaked onto the bed; - The resident had a coat and a jacket on underneath the coat and both were wet and soiled; - LPN A assisted the resident to stand and the resident used his/her seated rolling walker and ambulated to the bathroom; - LPN A stripped the resident's bed and placed in a pile in the middle of the bed; - LPN A removed gown and gloves, sanitized and left the room to get clean linens; - The resident washed his/her hands, removed the wet and soiled jacket and coat and placed on the bag in his/her room and the jacket fell on to the floor; - The resident was naked and sat down on the side of his/her bed; - The resident pulled his/her colostomy bag off and threw in the trash; - LPN A came in with supplies; - The resident remained naked and moved to sit on his/her seated rolling walker; - LPN A donned a gown and gloves, bagged the soiled linens and cleaned the mattress with a super sani wipe (a disinfectant wipe used to control germs); - LPN A did not clean the area of the mattress where the resident had sat and did not clean the seat of the resident's rolling walker; - The resident used a perineal wipe to cover the stoma (ostomy site); - CNA J and LPN A brought supplies into the resident's room; - CNA J made the resident's bed; - LPN A placed a new colostomy bag on the resident; - LPN A assisted the resident to put on a clean pair of pants and assisted the resident to get under the covers. During an interview on 4/10/25 at 11:35 A.M., LPN A said: - He/She should have cleaned the mattress where the resident had sat and should have cleaned the seat of the resident's rolling walker; During an interview on 4/10/25 at 12:06 P.M., CNA J said: - He/she should have sanitized the mattress where the resident sat and the seat of the rolling walker; During an interview on 4/10/25 at 4:15 P.M., the [NAME] President of Operations said staff should have cleaned the mattress and the seat of the rolling walker. 2. Review of Resident #1's Quarterly MDS, dated [DATE], showed: - Cognitive skills intact; - Upper and lower extremities impaired on both sides; - Dependent on the assistance of staff for eating, oral care, toilet use, dressing, personal hygiene and transfers; - Had a supra pubic catheter ( a catheter surgically inserted through the wall of the abdomen; - Always incontinent of fecal material; - Diagnoses included neurogenic bladder ( a dysfunction that results from interference with the normal nerve pathways associated with urination), anxiety, depression and MS. Review of the resident's care plan, revised 11/18/24 showed: - The resident has an activities of daily living (ADL) self-care performance deficit related to Multiple Sclerosis depression, muscle weakness, and anxiety; - The resident is totally dependent on one staff for all ADLS; - The resident has contractures of the hands and feet; - Required the use of a mechanical lift and the assistance of two staff for transfers; Observation on 4/8/25 at 10:20 A.M., showed: - There was a sign posted outside the resident's door related to EBP and PPE was provided in a container hanging on the door; - The resident was in bed and was incontinent of bowel and had a supra pubic catheter; - CNA I and CNA J donned (put on) gloves after they entered the resident's room and did not don a gown; - CNA J emptied the resident's urinary drainage bag; - CNA I and CNA J donned a gown after emptying the drainage bag. During an interview on 4/10/25 at 12:06 P.M., CNA J said: - He/She should have donned a gown and the gloves before entering the resident's room. During an interview on 4/15/25 at 1:12 P.M., CNA I said: - A gown and gloves should be worn with catheter care. During an interview on 4/10/25 at 4:15 P.M., the [NAME] President of Operations said; - Staff should wear PPE when providing catheter care or wound care. 50980 3. Review of Resident #103's Admission MDS, dated , 2/10/25, showed: - Resident is cognitively intact; - Diagnosis: heart disease, inflammatory bowel disease; diabetes, hip fracture, indwelling urinary catheter, and stroke; Review of Resident's Care Plan, revised 3/11/25, showed: - Resident requires Enhanced Barrier Precautions for a catheter and wounds. Staff to apply PPE for high contact care activities; Review of Resident's Face Sheet Diagnosis, dated 4/9/25, showed: - Resident has enterocolitis due to clostridium difficile (antibiotic-associated diarrhea which requires contact precautions by staff); During an observation on 4/8/25 at 8:11 A.M., showed: - HSK A went into resident's room and emptied the trash can within the room without donning any Personal Protective Equipment (PPE). The room had a sign for Contact Isolation which requires anyone entering the room to wash their hands and to don gloves and a gown; During an interview on 4/8/25 at 8:13 A.M., HSK A said: - Even though there was a Contact Isolation sign posted on the resident's room it did not require him/her to don any special protective equipment before entering the room; During an observation on 4/9/25 at 11:40 A.M, showed after a resident transfer with a Hoyer lift was completed in the resident's room, which has Contact Isolation requirements (mask, gown, gloves, at all times when entering the room), HSK A entered the room without PPE and failed to completely sanitize all contact areas on the Hoyer lift before removing the lift from the room and re-locating it to another location within the facility; During an interview on 4/9/25 at 1:35 P.M., LPN F said he/she is the Infection Preventionist for the facility and that housekeeping staff are expected to don PPE when entering isolation contact rooms to clean or sanitize.

Based on observation, interview and record review, the facility failed to ensure a resident representative was notified of a change in condition for two of the 23 residents sampled (Residents #102 and #86). The facility census was 112. Review of facility's Notification of Change In a Resident's Status Policy, dated 11/2017, showed: -The attending physician/physician extender and the resident representative will be notified of a change in a resident's condition, per standards of practice and Federal and/or State regulations; -Responsibility: all licensed nursing personnel; -Guideline for notification of physician and responsible party (not all inclusive): a) Onset of pressure sores; b) Any accident or incident; -Documentation of notification of responsible party in the Interdisciplinary Team Notes. 1. Review of Resident #86's Quarterly MDS (minimum data set), a federally mandated clinical assessment, completed by facility staff), dated 12/20/2024, showed: -Cognition not intact. -Dependent on staff for all ADLs (activities of daily living); -Diagnoses include: heart failure, stroke, dementia, and depression. Review of resident's PPS (prospective payment system) Five Day Scheduled Assessment, dated 3/9/2025, showed: -Brief Interview of Mental Status (BIMS) of 3 indicated severe cognitive impairment. Review of resident's progress notes, dated 12/9/2024, showed: -Patient continued on antibiotic therapy for pressure wound. Review of the resident's electronic and paper medical records showed no documentation of the resident's representative being notified of the onset of a pressure injury. Review of the resident's progress notes showed no documentation of an attempt to contact the resident's representative regarding the resident's pressure injury prior to 12/13/2024. During an interview on 4/7/25 at 1:03 P.M. Resident Representative A said: -He/She was not notified about a pressure injury until after it healed; -He/She was concerned with the facility's lack of communication. 2. Review of Resident #102's Quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Dependent on staff for all ADLs; -Diagnoses include: depression and risk for malnutrition. Review of resident's progress notes, dated 2/2/2025, showed: -The Nurse Practitioner was notified and agreed to send the resident to the hospital; -The resident was sent to the hospital for a ripped feeding tube per Nurse Practitioner. Review of resident's progress notes showed no documentation of an attempt to contact the resident's representative regarding the resident's 2/2/2025 hospitalization . During an interview on 4/9/25 at 1:34 P.M., Resident Representative B said: -There was no communication from the facility regarding resident's 2/2/2025 hospitalization ; -He/She expects communication from the facility regarding hospitalization s. 3. During an interview on 4/10/25 11:10 A.M., LPN D said: -Resident representatives should be notified immediately of a resident's change in condition; -Calls to resident representatives should be documented in the resident's chart; -The documentation should include who was contacted, time and date of contact. During an interview on interview on 4/10/2025 at 4:15 P.M., the [NAME] President of operations said: -The resident's representative should be notified immediately of a hospitalization or injury; -He/She expects the charge nurse to contact the resident's representative; -He/She expects notification to be documented in the progress notes when a resident representative is contacted; -He/She expects notification to be documented for a follow up on a 24 hour report when a resident representative cannot be reached.

Based on observation and interviews, the facility failed to ensure a clean, comfortable, and homelike environment and comfortable sound levels. Additionally, the facility failed to ensure resident wheelchairs were clean and maintained in good repair. This affected six sampled residents (Resident #26, #29, #48, #83, #21, and #315) out of 23 sampled residents. The facility census was 112. Review of the facility policy, Resident Rights, dated 1/2023, showed residents have the right to a clean and homelike environment. The facility did not provide a policy on maintaining resident medical equipment. Review of the facility policy, Resident Room Cleaning, dated 6/2018, showed: -Spot clean walls; - Remove trash. 47195 1. Review of Resident #29's Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 1/11/25, showed: -Cognition severely impaired; -He/She was dependent on a wheelchair; -Diagnoses included: dementia and Alzheimer's disease Observation on 4/7/25 at 8:02 A.M. showed the resident's wheelchair arm was cracked on right side arm of his/her wheelchair. The wheelchair seat cushion had food residue on it. Observation on 4/9/25 at 10:19 A.M. showed resident's arm rest on his/her wheelchair had black plastic fabric peeling off and foam was showing through. 2. Review of Resident #83's 5-day assessment MDS, dated [DATE], showed: -Cognition severely impaired; -He/She was dependent on manual wheelchair; -He/She used a wheelchair and was dependent for mobility for 50-150 feet; -Diagnoses included fracture of neck of right femur, dementia, and depression. Observation on 4/7/25 at 6:48 A.M. showed the resident had food on his/her wheelchair cushion. No meal had been served yet for the day. 3. Review of Resident #21's Quarterly, MDS, dated [DATE], showed: -Cognition severely impaired; -He/She was dependent on a wheelchair; -Diagnoses included dementia, asthma, and depression. Observation on 4/7/25 at 6:48 A.M. showed food stuck on resident's seat of his/her wheelchair. 4. Review of Resident #26's Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 12/17/24, showed: -Cognition intact; -Resident makes needs known. -He/She was dependent on a wheelchair; -He/She was independent with wheeling 50 feet and 150 feet; -Diagnoses included stroke, dementia, and hearing loss. Review of care plan, revised 12/4/24, showed: -Resident required assistance by one staff to move between surfaces as necessary. Observation on 4/07/25 at 10:09 A.M. showed the armrests of wheelchair had fabric that was coming away from the on the right side of wheelchair. 5. Review of Resident #48's Significant change MDS, dated [DATE], showed: -Cognition severely impaired; -He/She was dependent on a wheelchair; -He/She required partial to moderate assistance with sitting to lying, and rolling mobility; -He/She was dependent for wheeling 50 feet and wheeling 150 feet in the wheelchair; -Diagnoses included dementia, arthritis, stroke, and abnormalities of gait and mobility. Review of care plan, revised 4/3/25, showed the resident was able to transfer independently; Observation on 4/07/25 at 9:12 A.M. showed both of arm rests of Resident's wheelchair were torn and foam was coming through the arm rest, and fabric was missing from the foam. 6. Review of Resident #315's Admission MDS, dated [DATE], showed the resident dependent on a wheelchair for mobility. Review of resident's face sheet, dated 3/25/2025, showed diagnoses included: injury of popliteal artery, right leg; open wound, right knee; fracture of lower end of right femur. Observation on 4/7/20255 at 10:35 A.M., showed both arms of wheelchair were covered with duck tape. During an interview on 4/09/25 at 11:15 A.M., CNA H said: -The night shift was responsible for cleaning resident's wheelchairs; -Wheelchairs were cleaned on the same day as a resident's shower days were scheduled. During an interview on 4/9/25 at 1:45 P.M., LPN C said: -The wheelchairs were to be cleaned during the night shift; -Administration took hydration off of night shift's to do list and added the wheelchair cleaning; During an interview on 4/10/25 at 4:15 P.M., [NAME] President of Operations said he/she expected resident's medical equipment to be cleaned and maintained and free of spills. He/she expected resident's wheelchairs to be in good operational condition and free from tears to the armrests. 7. Observation of the sunshine unit on 4/07/25 at 8:08 A.M., showed the dining room floor had spilled food including food crumbs laying under table. No meals had been served yet for the day. Observation of the sunshine unit on 4/07/25 at 8:58 A.M., showed the walls of the dining room had streaks of running liquid that had dried on the wall. Observation on sunshine unit on 4/9/25 at 11:15 A.M. showed: -The window seals at end of hallways and entry to sunshine unit had missing paint with rust coming through; -Lower chair rail ledges have visible dirt and dust standing on them; -Vent returns in hallway by shower have dirt caked on the registers; -Chair rails in hallway had paint missing; -Doorframes to dining room had missing paint and metal was showing through; -room [ROOM NUMBER] had paint missing from the door; -room [ROOM NUMBER] the upper rubber seal was hanging down from doorway; -room [ROOM NUMBER] had paint missing off blue door with orange showing through; -Edges of tile and baseboards had dirt and grime built up; -Varnish finishing on tables in dining room had worn off; -Sanitizer dispenser outside of room [ROOM NUMBER] has no sanitizer in it; -Doorway next to shower room has paint missing on the door; -Dayroom curtain at end of hall had stain on it. During an interview on 4/9/25 at 10:41 A.M., Housekeeper B said: -He/She was supposed to sweep dining room after breakfast and lunch; -He/She would sweep after breakfast and if floor was not dirty he/she would wait to mop the floors until after lunch; -There was no housekeeping staff working after 4:30 P.M.; -It was the CNA's responsibility to clean up messes after housekeeping hours ended at 4:30 P.M.; -His/Her cleaning routine including going to resident's rooms and wiping down counters, cleaning mirrors, looking at air units, and seeing if anything needed wiped down; -He/She would look at windows and see if they needed wiped down; -He/She would wipe down the walls in the bathroom and in resident bedrooms; -If he/she knew of spills or items running down walls he/she would wipe them down; -He/She had wiped dining room walls down twice since he/she had worked in facility; -He/She wiped down dining room tables daily. During an interview on 4/9/25 at 1:45 P.M., LPN C said: -Dining room should be cleaned after dinner by the floor staff working on sunshine unit. During an interview on 4/10/25 at 4:15 P.M., [NAME] President of Operations said: -He/She expected walls in resident's living environment to be free from spills, missing paint, and scrapes and in good condition. 8. Observation of the sunshine unit on 4/07/25 from 6:40 A.M. showed two residents in dining room and loud door alarms were sounding. The marquee at end of hall showed the TCU dining room exit door was open. During a continuous observation of the sunshine unit beginning at 7:15 A.M. showed: -7:42 A.M., Loud beeping noise sounding on the on unit. Marque at end of hallways showed 'TCU dining room exit' and 'end of hall exit' scrolling across the screen; -7:54 A.M., Loud beeping noises continues to sound on unit. Marque showed 'TCU dining room exit' and 'end of hall exit' scrolling across the screen; -8:09 A.M., loud beeping noises continuing to sound, marque continues to show 'dining room exit' scrolling across the screen; -8:21 A.M., loud beeping noises continuing to sound on the unit; -8:44 A.M., loud beeping alarm sounding that could be heard in the dining room. Observation showed staff in dining room went and put in code on key pad and alarm began going off again immediately; -8:58 A.M., RN A said He/She put the code in the door alarm key bad the but alarm will keep going off because all the residents are located in the dining room; -9:02 A.M., Director of Nursing (DON) observed put code in the door alarm, and door alarm began going off again within five seconds of the code being entered into key pad; -9:04 A.M., DON said he/she escalated the alarm issue because he/she did not know why the alarm kept triggering in the dining room but had notified people of the issues; -9:05 A.M., loud beeping alarm continued to sound, marque showed TCU dining unit scrolling across the screen; -9:06 A.M., Maintenance Director arrived to sunshine unit and was observed entering the alarm code into key pad. Maintenance Director said the alarm would not shut off because of the wander guard system and staff were right by it; -9:09 A.M., Maintenance Director observed using a screw driver to alarm key code panel. Maintenance Director continued to enter the key code to the pad of alarm system. He/She then was observed disconnecting a wire to the key pad. -9:11 A.M., Alarm stopped sounding after wire disconnected. Maintenance Director was observed removing keypad and leaving wires exposed and left the dining room. -9:21 A.M., Maintenance Director came back to sunshine unit and placed a plate over the key pad where wires had been exposed from the disconnected wires; -9:26 A.M., Alarm going off on sunshine unit, the marque showed 'TCU dining exit'. During an interview on 4/7/25 at 9:16 A.M., LPN C said: -Alarm in dining room always sounded when residents were in dining room; -The residents could not hear the television, do activities, and could not hear over the alarm during meals. During an interview on 4/7/25 at 9:21 A.M., Maintenance Director said: -He/She disconnected the alarm; -The system would still alarm to the marque; -He/She had been waiting on a part for three weeks to a month; -The door that was alarming also had its own alarming box; -Someone would hear that other alarm if a resident tried to go out of that door; -He/She had just disconnected the horn part of the alarm, but the door alarm was still activated. During an interview on 4/7/25 at 9:26 A.M., CNA N said: -The alarm in dining room was not pleasant; it would frequently alarm; -Every time he/she entered the code on the key pad the alarm would go back off again in five seconds. During an interview on 4/9/25 at 10:41 A.M., Housekeeper B said: -Staff would shut off the alarms on key pad; -Every time a resident would walk by the exit the alarm would start sounding again; -Residents were observed getting agitated by the audible alarms; -Residents would say what is that noise? turn it off. During an interview on 4/09/25 at 11:15 A.M., CNA H said: -The alarm on sunshine unit would go off anytime a resident with a wander guard went to close to the door; -He/She had to enter a code on the keypad to get the alarm to stop sounding; -If resident chose to stay by the exit doors in dining room, or end of hall exits, then the alarm would begin sounding again. During an interview on 4/9/25 at 1:45 P.M., LPN C said: -Maintenance Director had just messed with the door alarms the prior week; -Maintenance Director said he had to do something to the alarm and ever since he/she had worked on them the alarms had been sounding; -He/She had heard residents #11 and #16 complain regarding the door alarm noises; -Resident #90 had told him/her the alarm was annoying.

Based on record review and interview, the facility failed to to reimburse residents and/or their responsible parties within the 30 day time frame, after the residents were discharged from the facility, which affected eleven residents. The facility's census was 112. The facility did not provide a policy regarding conveyance of personal funds. Review of Interim Aged Analysis Summary, dated [DATE], showed: -Resident #215, discharged on [DATE], had a balance of $1,471.48; -Resident #219, discharged on [DATE], had a balance of $.09; -Resident #217, discharged on [DATE], had a balance of $3,296.00; -Resident #218, discharged on [DATE], had a balance of $1437.00; -Resident #220, discharged on [DATE], had a balance of $573.00; -Resident #221, discharged on [DATE], had a balance of $5450.00; -Resident #222, discharged on [DATE], had a balance of $2,351.26; -Resident #223, discharged on [DATE], had a balance of $204.16; -Resident #224, discharged on [DATE], had a balance of $1584.00; -Resident #225, discharged on [DATE], had a balance of $505.41; -Resident #226, discharged on [DATE], had a balance of $5,886.00; -Resident #227, discharged on [DATE], had a balance of $2,115.08; -Resident #228, discharged on [DATE], had balance of $1,000; -Resident #229, discharged on [DATE], had a balance of $5,065.00; -Resident #230, discharged on [DATE], had a balance of $1,161.38; -Resident #231, discharged on [DATE], had a balance of $2,101.00; -Resident #232, discharged on [DATE], had a balance of $6,126.59; -Resident #233, discharged on [DATE], had a balance of $.09; -Resident #234, discharged on [DATE], had a balance of $2,654.00; -Resident #235, discharged on [DATE], had a balance of $612.00; -Resident #236, discharged on [DATE], had a balance of $1388.52; -Resident #237, discharged on [DATE], had a balance of $3,189.60; During an interview on [DATE] at 8:31 A.M., the Business Office Manager said: -He/She started in the position in February; -Resident #215 was deceased , he/she did not know why funds were not returned to resident; -Resident #219 was deceased , he/she could not see if a medicaid letter went out; -He/she did not have any knowledge of funds being returned to Residents #217, #218, #220, #221, #222, #223, #224, #225, #226, #227, #228, #229, #230, #231, #232, #234, #235, #236, and #237 ; -The facility operator transferred everything over to a new electronic medical record system in November and there had been lots of issues with items not transferring over in the system correctly; -The facility had five days to return funds after a resident discharged from facility or was deceased ; -If resident had funds in their trust account they would notify Medicaid and then send funds back to Medicaid, and then complete a check request with their corporate office; -He/She did not have copies of check requests or knowledge of resident's funds being returned to them since he/she was a new employee with corporation; -He/She would have to check with their corporate office regarding resident funds being returned and follow up. During an interview on [DATE] at 4:15 P.M., [NAME] President of Operations said he/she expects staff to issue a refund to the resident within thirty days of discharge.

Based on observation and interview, the facility failed to ensure residents received information and contact information for State and local advocacy organizations when the facility staff did not provide information to the residents on how to file a complaint with the State Survey Agency and did not prominently display this information in the facility for residents to view. The facility census was 112. Review of facility policy, Resident [NAME] of Rights, revised [DATE], showed facility residents shall have the right to receive from the facility a written description of legal rights including a list of names, addresses, (mailing and email), and telephone numbers of all pertinent State regulatory and informational agencies such as the State Survey Agency for information for filing grievances and complaints. 1. Review of Resident #80's Admission Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 3/11/25, showed the resident is cognitively intact. During an interview on 4/9/25 at 12:56 P.M., the resident said he/she doesn't remember where in the facility the phone number is posted or when the facility last trained the residents about contacting the state to file a grievance. 2. Review of Resident #18's Quarterly MDS, dated [DATE], showed the resident is cognitively intact. During an interview on 4/9/25 at 12:59 P.M., the resident said he/she does not know how to contact the state survey agency and did not know that he/she could file a complaint with the state survey agency. 3. Review of Resident #89's Quarterly MDS, dated [DATE], showed the resident is cognitively intact. During an interview on 4/9/25 at 1:00 P.M., the resident said he/she does not know where the number to contact the State survey agency is located in the building. During a group interview on 4/8/25 at 2:04 P.M., the residents said: - Nine of nine residents did not know where the State Survey Agency contact information for filing a complaint was displayed in the building; - Five of nine residents did not have knowledge of the phone number to the State Survey Agency for filing a complaint. During a Record Review of Resident Council Minutes on 4/8/25, showed: - 1/5/25 Resident Council meeting under the section review of resident rights there was no training on how to contact the State Agency to file a complaint; - 2/19/25 Resident Council meeting under the section review of resident rights there was no training on how to contact the State Agency to file a complaint; - 3/19/25 Resident Council meeting under the section review of resident rights there was no training on how to contact the State Agency to file a complaint; - 4/2/25 Resident Council meeting under the section review of resident rights there was no training on how to contact the State Agency to file a complaint; During an interview on 4/10/25 at 4:15 P.M., Administrator said the plaque with the State Survey Agency's phone number is located in the front lobby and it should be bigger than the one currently there. Signs should also be posted throughout the facility, though they are not currently. Resident council information is provided on reporting complaints to the State quite frequently and Social Services is responsible for providing that information to the residents.

Based on observation, interview, and record review, the facility failed to ensure staff treated residents in a manner to maintain their dignity when staff failed to knock on a resident's door and wait for a response before entering which affected four of 23 sampled residents, (Resident #1, #30, #104, and #165) and additionally when staff opened Resident #1's door exposing the resident's bare skin from the waist down, in view of the hallway. The facility also failed to shower one resident (Resident #32) per his/her preference. The facility census was 112. Review of the facility's policy titled, Resident [NAME] of Rights, revised 1/23, showed: - Each resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life, regardless of diagnosis, severity of condition or payment source and to exercise those rights as a citizen of the United States, without interference or coercion. -Receive services in the facility with reasonable accommodation of resident needs and preferences; -Self-determination, which the facility must provide and facilitate through support of resident choice, assessments, and plan of care and make other choices about aspects of his or her life that are significant to the resident, including: activities, health care schedules (including sleeping, waking, bathing, and eating times). Review of facility policy, Resident [NAME] of Rights, dated January 2023, showed: -Resident had a right to a dignified existence. Review of facility policy, A.M. Care, dated October 2009, showed: -A.M. care will be provided to residents daily. -Provide and assist with shaving (male and female) as needed. 1. Review of the resident's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/2/25, showed: - Cognitive skills intact; - Upper and lower extremities impaired on both sides; - Dependent on the assistance of staff for eating, oral care, toilet use, dressing, personal hygiene and transfers; - Had a supra pubic catheter ( a catheter surgically inserted through the wall of the abdomen; - Always incontinent of fecal material; - Diagnoses included neurogenic bladder ( a dysfunction that results from interference with the normal nerve pathways associated with urination), anxiety, depression and MS. Review of Resident' #1's care plan, revised 11/18/24 showed: - The resident has an activities of daily living (ADL) self-care performance deficit related to Multiple Sclerosis (MS, a chronic, autoimmune disease that affects the central nervous system (brain and spinal cord), depression, muscle weakness, and anxiety; - The resident is totally dependent on one staff for repositioning and turning in bed; - The resident has contractures of the hands and feet; - The resident required physical assistance of one staff for dressing, personal hygiene and oral care; - Required the use of a mechanical lift and the assistance of two staff for transfers. Observation on 4/8/25 at 10:20 A.M., showed: - The resident's door was open; - Certified Nurse Aide (CNA) I and CNA J entered the resident's room without knocking or announcing themselves; - CNA I and CNA J were providing incontinent and catheter care when Licensed Practical Nurse (LPN) A opened the resident's door to talk and the resident's incontinent brief and lower extremities were exposed to the opened doorway; - Staff Development knocked on the door and opened it while the resident was turned on his/her side with his/her bare buttocks and lower extremities exposed to the opened doorway. During an interview on 4/7/25 at 1:32 P.M., Resident #1 said: - Staff open his/her door without knocking and the resident has to remind the staff to close his/her door; - The resident felt like staff were disrespectful and he/she did not like it. 2. Review of Resident #165's Admission MDS, dated [DATE] showed;- Cognitive skills intact; - Independent with toilet use, dressing, personal hygiene and transfers; - Diagnoses included anxiety, arthritis, chronic obstructive pulmonary disease. Review of the resident's care plan, revised 4/2/25, showed: - The resident had an ADL self-care performance deficit related to impaired balance and weakness; - The resident is independent with toilet use and transfers. Assist as needed with toileting and transfers. Observation on 4/9/25 at 12:24 P.M., showed: - CNA J lightly knocked and opened the resident's door and did not announce him/herself; - The resident said, Why don't you knock louder and say who you are?. During an interview on 4/10/25 at 11:50 A.M., the resident said he/she would like for the staff to knock on his/her door and say who they are before they open the door. 3. Review of the resident's Admission MDS, dated [DATE] showed: - Cognitive skills intact; - Independent with toilet use, personal hygiene and transfers; - Diagnoses included anxiety and depression. Review of Resident #104's care plan, revised 3/21/25 showed;- The resident had an ADL self-care performance deficit related to disease process; - The resident is able to turn and reposition independently; During an interview on 4/7/25 at 11:21 A.M., the resident said;- The staff do not always knock on his/her door and announce themselves; - He/She would prefer for the staff to knock first because it made him/her feel uncomfortable when the staff just walk in to his/her room unannounced. 4. During an interview on 4/10/25 at 11:35 A.M., LPN A said:- Staff should knock and announce themselves before they enter into a resident's room; - The resident's door should not be left opened when the resident's skin is exposed; - The staff should ensure the privacy curtain is pulled to maintain the residents privacy. During an interview on 4/10/25 at 12:06 P.M., CNA J said: - Staff should always knock and announce themselves before opening the resident's door; - He/she made a mistake when he/she did not knock loud enough and announce him/herself to the resident; - Staff should try and pull the privacy curtain and not open the resident's door when the resident's bare skin is exposed. During an interview on 4/15/25 at 1:08 P.M., Staff Development said: - Staff should knock and announce themselves before they open the resident's door; - The resident's privacy curtain should be pulled so the resident is not exposed if the door is opened. During an interview on 4/15/25 at 1:12 P.M., CNA I said: - Staff should knock on the resident's door and announce themselves before they enter. - The privacy curtain should be pulled so if staff open the door, the resident is not exposed. 51166 5. Review of Resident #32's Quarterly MDS, dated [DATE], showed: -Resident is cognitively intact; -Diagnoses include: heart disease, diabetes, stroke, traumatic brain injury, anxiety, and depression. During an interview on 4/07/2025 at 11:13 A.M., the resident said: -The nurse walked in the room, unannounced, this morning at 5:30 A.M.; -The nurse did not knock, wait for a response, or introduce themselves; -He/She would prefer staff to knock and wait for a response before entering the room; -He/She feels like they don't count and are treated like second class citizens when staff enters his/her room without knocking or waiting for an invitation to come in. Observation on 4/10/2025 at 10:43 A.M. showed: -CNA B walked into resident #32's room without knocking; -CNA B did not announce him/herself before entering the resident's room. During an interview on 4/10/2025 at 10:53 A.M., CNA B said: -Staff should knock before entering a resident's room, introduce themselves, and let the resident know what they are they for. -Staff should wait for the resident to give permission to enter into the residents room. During an interview on 4/10/2025 at 11:10 A.M., LPN D said staff should knock, announce themselves, and wait for the resident to say it is okay before entering a resident's room. During an interview on 4/10/25 at 4:15 P.M., the [NAME] President of Operations said: - Staff should knock and announce themselves before they enter the resident's room; - The privacy curtain should be pulled so the resident is not exposed when the door is opened. 47195 6. Review of Resident #25's Quarterly MDS, dated [DATE], showed: -Cognition severely impaired; -She displayed no behaviors related to rejection of care; -She required supervision and one person assist with bathing, personal hygiene, dressing, and toileting, and toilet and shower transfers; -She was independent with most mobility; -Diagnoses included: heart failure, chronic kidney disease, high blood pressure, and dementia. Review of care plan, revised 12/10/24, showed: -She had an ADL self-care performance deficit due to dementia, chronic heart disease and heart failure -Bathing and Showering: The resident required physical assist by one staff with showering on Monday,Thursday, and as necessary; -Personal Hygiene: The resident required physical assist by one staff with personal hygiene and oral care. Observation on 4/7/25 at 8:19 A.M. showed resident scratching at her chin hair. Resident was told by peer at dining table why didn't she take a razor to that. During an interview on 4/7/25 at 8:23 A.M. resident said the chin hair bothered her because she is not man. Observation on 4/7/25 at 11:40 A.M. showed resident continued to grab and pull at her chin hairs. Observation on 4/08/25 at 7:35 A.M. showed resident kept touching her chin hair. Observation on 4/8/25 at 8:17 A.M. showed Licensed Practical Nurse (LPN) C telling the resident in the dining room that he/she had take care of the resident's chin hairs today. LPN C was pointing and touching resident's facial hair on her chin. Review of April shower log book, located at the nurses station showed: -The Resident was scheduled to receive showers on Monday and Thursday; -The Resident received two of three scheduled showers during April on 4/1, 4/3, and Refused on 4/7 Review of shower sheets, dated 2/1/25-4/7/25, showed: -During the month of February, she received seven of eight scheduled showers on 2/10, 2/12, 2/17, 2/20, 2/23, 2/24, and 2/27 -During the month of March, she received five of nine scheduled showers on 3/1, 3/3, 3/13, 3/20, and 3/24; -During the month of April, she received shower on 4/3/25 During an interview on 4/9/25 at 11:15 A.M., Certified Nurse Aide (CNA) H said: -the resident liked to be shaved; -she preferred to have a close shave of the chin; -the resident had to be in the mood to be shaved and at times had to be re-approached at a later time; -the resident would pick at her chin if the chin hair was bothering her. During an interview on 4/9/25 at 1:45 P.M., Licensed Practical Nurse (LPN) C said: -He/She had shaved resident on 4/4/25; -He/She noted resident was picking her chin hair out; -He/She had observed the residents long chin hairs yesterday; -He/She ensured the resident was shaved when showered; -He/She received a shower and was shaved on 4/9/25. 7. Review of Resident #32's Quarterly MDS, dated [DATE], showed: -Resident is cognitively intact; -Resident requires assistance with showering; -Diagnoses include: heart disease, anemia, kidney failure, diabetes, stroke, traumatic brain injury, asthma, anxiety, and depression. Review of the resident's January, 2025 shower record showed: -Shower was given on 1/15/2025. Review of the resident's February, 2025 shower record showed: -Shower was given on 2/5/2025; -Shower was given on 2/6/2025; -Shower was given on 2/25/2025. Review of the resident's March, 2025 shower record showed: -Shower was given on 3/4/2025; -Shower was given on 3/11/2025; -Shower was given on 3/16/2025; -Shower was given on 3/17/2025; -Shower was given on 3/26/2025. During an interview on 4/07/2025 at 11:10 A.M., the resident said: -He/She was only given a choice to pick two shower days; -He/She would like at least three showers each week; -He/She was not viewed as someone who can make decisions for himself/ herself. During an interview on 4/09/25 at 2:07 P.M., CNA C said residents should be provided with two showers each week, unless the resident asks for more. During an interview on 4/10/25 at 11:10 A.M., LPN D said residents should receive two showers each week or whenever they ask for more. During an interview on 4/10/2025 at 4:15 P.M., the [NAME] President of Operations said he/she expects the number of showers residents get each week to be based on their preferences.

Based on observation, interview, and record review, the facility failed to ensure accurate and timely update of assessments when one resident's (Resident #48) change in functional abilities and use of a wheelchair, was not updated with a significant change and when one resident (Resident #86) had a change in cognitive status from cognition intact to cognition severely impaired on the Minimum Data Set (MDS) ( a federally mandated assessment completed by facility staff). This occurred for two of twenty-three sampled residents (Resident #48 and #86). The facility census was 112. The facility did not provide a policy regarding updating the MDS when residents have a change of condition. 1. Review of Resident #48's, Significant change MDS, dated [DATE], showed: -Cognition severely impaired. -Hospice care added, which was not on prior MDS; -He/She was dependent on a walker; -He/She required set up or clean up assistance with eating only; -He/She required partial to moderate assistance with toileting, bathing, dressing, and personal hygiene; -He/She was independent with mobility. Review of Resident #48's, quarterly MDS, dated [DATE], showed: -Cognition severely impaired; -He/She was not on hospice; -He/She was dependent on a walker; -He/She was independent with eating; -He/She required partial to moderate assistance with toileting, bathing, dressing, and personal hygiene; -He/She was independent with mobility; Review of care plan, dated 3/18/25, showed: -He/She was admitted to hospice; -Bed mobility: Resident was independent with bed mobility; -Eating: The resident was able to eat independently. Observation on 4/07/25 at 9:12 A.M. showed resident was wheeled to dining room in a wheelchair. Resident had steri strips (thin adhesive strips used to close wounds) on the right side of forehead. During an interview on 4/7/25 at 9:12 A.M. the resident said he/she fell and hit his/her head. Observation on 4/8/25 at 8:52 A.M. showed resident was wheeled into the dining room in a wheelchair. The Resident was then served his/her breakfast tray. Staff sat next to the resident and fed the resident. Observation on 4/9/25 at 10:21 A.M. showed the resident sitting in dining room in the wheelchair falling asleep at table. Observation on 4/9/25 at 11:39 A.M. showed the resident in dining room sitting in the wheelchair leaning over the side of the chair. Observation on 4/9/25 at 12:58 P.M. showed resident being fed meal by facility staff. Review of 24 hour nursing reports at the nurses' station showed: -3/18/25 - Resident was admitted to hospice; -3/19/25 - Resident was admitted to hospice; -4/9/25 -Resident fell with laceration to his/her head. Review of progress notes, dated 1/1/25-4/8/25 showed: -On 1/3/2025 at 8:42 P.M., Resident very restless and anxious, attempting to stand up alone, generalized weakness, no safety awareness, wheelchair used for mobility. -On 1/4/25 at 2:19 P.M., Resident was found lying on the floor on back. Resident was sitting in a wooden chair and attempted to self-transfer to his/her wheelchair with the brakes unlocked. -On 1/7/25 at 1:18 P.M., wheelchair for mobility and assisted by staff with cares; -On 1/10/25 at 7:46 P.M., Resident assisted with cares and feeding; -On 1/13/25 at 1:11 P.M., Resident when awake self propelling; -On 1/14/25 at 11:30 A.M., Resident was sitting in wheelchair in dining room when he/she reached for another resident and fell out of the wheelchair; -On 1/15/25 at 1:24 P.M., Resident continuing to try and stand up out of the wheelchair; -On 1/15/25 at 8:50 P.M., Resident made several attempts to get up out of the wheelchair without assistance or bending down fidgeting with footwear. Mechanical soft diet with poor intake and refused staff assistance with meal intake; -On 1/19/25 at 4:20 A.M., Resident assisted for meal intake and cares; -On 3/31/25 at 11:31 A.M., Received verbal order from nurse practitioner to downgrade diet to mechanical soft texture thin liquids with a non-spill cup due to aspiration risk related to current diet. -On 4/1/25 at 10:44 A.M., Resident is now requiring feeding assistance and is not able to pick up silverware. Reclining wheelchair would arrive later today or tomorrow for resident; -On 4/2/25 at 6:43 A.M., Residents diet changed to puree with NTL (a type of diet for individuals with swallowing difficulties meanings pureed or smoothed food with no coarse texture, accompanied by thickened liquids); -On 4/2/25 at 9:25 A.M., Resident is assist of one staff with all his/her cares. During an interview on 4/7/25 at 7:40 A.M., Licensed Practical Nurse (LPN) C said: -Resident was now on hospice; -He/She had a change in condition after falls occurred. During an interview on 4/9/25 at 11:53 A.M., LPN C said: -Resident was declining; -He/She went from a mechanical soft diet to thin liquids and was now on a puree diet. During an interview on 4/10/25 at 12:45 P.M., LPN C said: -Resident could stand and pivot; -Resident did not ambulate down the halls or use a walker; During an interview on 4/10/25, Certified Nurse Aide (CNA) L said: -Resident had not walked on his/her own. -Resident had always been in a wheelchair. During an interview on 4/10/25 at 1:14 P.M., the MDS Coordinator said: -The MDS should be updated with any significant change in resident's condition; -MDS should be updated when resident went on hospice; -He/She would have expected the resident's functional abilities and goals section to also be updated with resident's significant change of condition; -He/She did not know resident was using a wheelchair and now required feeding assistance; -He/She would have expected the MDS to reflect resident's current ADL ability status and to have been updated. During an interview on 4/10/25 at 4:15 P.M., [NAME] President of Operations said: -He/She expected changes in functional abilities such as eating assistance, mobility, use of a wheelchair to be included in a significant change and update on the MDS; -He/She expected MDS to be completed quarterly and with significant changes to a resident's condition. 51166 2. Review of Resident #86's Quarterly MDS, dated [DATE], showed: -Brief Interview of Mental Status (BIMS) of 12 indicated moderate cognitive loss; -Diagnoses included: heart failure, stroke, dementia, and depression. Review of resident's PPS (prospective payment system) Five Day Scheduled Assessment, dated 3/9/2025, showed: -Brief Interview of Mental Status (BIMS) of 3 indicated severe cognitive loss. Review of Resident's electronic and paper medical records showed: -No quarterly MDS assessment was done in March 2025; -No significant change MDS assessment was completed when resident's cognitive abilities declined. During an interview on 4/10/2025 at 10:53 A.M., CNA B said the resident did not talk or respond to questions. During an interview on 4/10/2025 at 11:22 A.M., CNA D said: -The resident used to go outside to smoke, wheel around independently, and was independent with dressing and toiling; -He/She noticed a decline in the resident's physical and cognitive abilities more than six months ago; -The resident was not able to make decisions. During an interview on 4/10/2025 11:10 A.M., LPN D said the Resident was alert and oriented times two (a person is aware and knows who they are and where they are, but may not know the time or what is happening to them). During an interview on 4/10/2025 at 1:51 P.M., the MDS Coordinator said: -He/She expects the social services director to complete a questionnaire to determine a resident's BIMS score; -A decline in a resident's cognition and ability to carry out ADLs constitutes a need for a significant change MDS assessment; -He/She was not aware of a significant change in the resident's cognitive abilities; -He/She expects staff to fill out Stop and Watch forms to be filled out when a resident has a change of condition; -Staff are educated on the process to fill out the Stop and Watch forms during new employee training and during staff meetings; -He/She expects a resident's change in cognition to be reported to the unit coordinator, who updates the DON and brings the issue to the IDT (interdisciplinary team) meeting; -Resident #86's condition had not been discussed for a long time.

Based on observation, interview, and record review, the facility failed to ensure staff developed and updated a care plan consistent with resident's specific conditions and needs (Resident #74), resident's shaving preferences (Resident #25), and resident's change in mobility status and need for feeding assistance (Resident #48) which affected three (Resident #74, #25, and #48) of 23 sampled residents. The facility census was 112. Review of facility policy, comprehensive person-centered care plans, dated 1/2025, showed: -Each resident would have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that would identify how the interdisciplinary team would provide care. -Care plan could be revised at quarterly intervals in conjunction with the completion of MDS quarterly, significant change, and annual assessments per the RAI manual; -The Interdisciplinary team along with resident and or resident's representative will identify resident problems, needs, strengths, life history, preferences, and goals; -For each problem, need or strength a resident-- centered goal is developed. Goals should be measurable; -Upon a change in condition, the comprehensive person-centered care plan or baseline care plan would be updated. 1. Review of Resident #74's Annual Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 3/2/25, showed: - Resident has moderate cognitive impairment; - Dependent on staff for toileting hygiene, bathing, dressing, personal hygiene, mobility, and all transfers; - Diagnoses: Renal insufficiency (kidney impairment), obstructive uropathy (urine flow is blocked in the urinary tract), septicemia (infection in the bloodstream), arthritis, and schizophrenia. Review of the resident's care plan, revised 3/19/25, showed: - Resident has an ADL self-care performance deficit due to morbid obesity, spinal stenosis, gout, movement disorder and abnormalities of gait and mobility; - Resident requires assistance by two staff with a Hoyer lift for transfers and requires two staff for repositioning; - Resident had chronic pain; - No goals or interventions pertaining to air mattress for the resident. Review of the physician order dated 1/9/25, showed an order for an air mattress to be checked every shift by staff. Review of the resident's Treatment Administration Record (TAR), dated 4/1-4/30/25, showed no requirements listed for nursing staff to check the operation of an air mattress installed in the resident's room. Review of the resident's Medication Administration Record (MAR), dated 4/1-4/30/25, showed: - No requirements listed for nursing staff to check the operation of an air mattress installed in the resident's room. During an observation on 4/7/25 at 1:05 P.M., showed an air mattress installed for the resident with an electronic control board at the foot of the bed for monitoring and adjusting air pressure; During an interview on 4/7/25 at 1:14 P.M., resident said he/she did not remember ever seeing staff check his/her air mattress. If it were to deflate they would know it because it would cause them pain though that has not happened to the resident since they were admitted . During an interview on 4/10/25 at 11:07 A.M., LPN B said nurses do the resident air mattress checks for flow rate and inflation and then log it into the MAR or TAR electronically. This should be accomplished according to the orders put in place by the physician. Currently there are no requirements in the MAR or TAR to do checks for the resident. He/she would expect checks to be in place for a resident that has an order for an air mattress. 47195 2. Review of Resident #48's, Significant change MDS, dated [DATE], showed: -Cognition severely impaired. -He/She was dependent on a walker; -He/She required set up or clean up assistance with eating only; -He/She required partial to moderate assistance with toileting, bathing, dressing, and personal hygiene; -He/She was independent with mobility. Review of care plan, dated 3/18/25, showed: -Bed mobility: Resident was independent with bed mobility; -Eating: The resident was able to eat independently; -Transfer: The resident was able to transfer independently; -Resident was an elopement risk/wanderer due to dementia; -Care plan did not show resident was dependent on a wheelchair, no longer ambulatory, and required assistance with feeding at meals. Observation on 4/07/25 at 9:12 A.M. showed resident was wheeled to dining room in a wheelchair. During an interview on 4/7/25 at 9:12 A.M. resident said he/she fell and hit his/her head. Observation on 4/8/25 at 8:52 A.M. showed resident was wheeled into the dining room in a wheelchair. Resident then was served his/her breakfast tray. Staff sat next to resident to assist to feed resident. Observation on 4/9/25 at 10:21 A.M. showed resident sitting in dining room in the wheelchair falling asleep at table. Observation on 4/9/25 at 11:39 A.M. showed resident in dining room sitting in the wheelchair leaning over the side of the chair. Observation on 4/9/25 at 12:58 P.M. showed resident being fed meal by facility staff. Review of progress notes, dated 1/1/25-4/8/25 showed: -On 1/3/2025 at 8:42 P.M., Resident very restless and anxious, constantly attempting to stand up, generalized weakness, no safety awareness, wheelchair used for mobility. -On 1/4/25 at 2:19 P.M., Resident was found lying on floor in his/her back. Resident was sitting in a wooden chair and attempted to self-transfer to his/her wheelchair with the brakes unlocked. -On 1/4/25 at 5:00 P.M., Resident using wheelchair and self propelling on unit. -On 1/7/25 at 1:18 P.M., wheelchair for mobility and assisted by staff with cares; -On 1/10/25 at 7:46 P.M., Resident assisted with cares and feeding; -On 1/13/25 at 1:11 P.M., Resident when awake self propelling; -On 1/13/25 at 4:17 P.M., Residents diet order changed per dietary recommendation and medical doctor approval; -On 1/14/25 at 11:30 A.M., Resident was sitting in wheelchair in dining room when he/she reached for another resident and fell out of the wheelchair; -On 1/15/25 at 1:24 P.M., Resident continuing to try and stand up out of the wheelchair; -On 1/15/25 at 8:50 P.M., Resident made several attempts to get up out of the wheelchair without assistance or bending down fidgeting with footwear. Mechanical soft diet with poor intake and refused staff assistance with meal intake; -On 1/17/25 at 11:09 P.M., Resident attempted to get up from wheelchair a couple of times but was easily redirected. He/She was assisted for meal intake and care; -On 1/19/25 at 4:20 A.M., Resident assisted for meal intake and cares; -On 3/31/25 at 11:31 A.M., Received verbal order from nurse practitioner to downgrade diet to mechanical soft texture thin liquids with sippy cup due to aspiration risk related to current diet. Speech therapy to evaluate during next visit; -On 4/1/25 at 10:44 A.M., Resident is now a feeder and is not able to pick up silverware. Reclining wheelchair would arrive later today or tomorrow for resident; -On 4/2/25 at 6:43 A.M., Residents diet changed to puree with NTL (a type of diet for individuals with swallowing difficulties meanings pureed or smoothed food with no coarse texture, accompanied by thickened liquids); -On 4/2/25 at 9:25 A.M, Resident is assist of one staff with all his/her cares. During an interview on 4/09/25 at 11:53 A.M., LPN C said: -The resident was declining; -The resident diet changed from mechanical soft diet to a thin liquid diet and now a puree diet. During an interview on 4/10/25 at 12:45 P.M., LPN C said: -The resident could stand and pivot; -The resident did not ambulate down the halls or use a walker. During an interview on 4/10/25, Certified Nurse Aide (CNA) L said: -The resident had not walked on his/her own since he/she started working in facility; -The resident had always been in a wheelchair. During an interview on 4/10/25 at 1:14 P.M., MDS Coordinator said: -The MDS should be updated with any significant change in resident's condition; -MDS should be updated when resident went on hospice; -He/She would have expected the resident's functional abilities and goals section to also be updated with resident's significant change of condition; -He/She did not know resident was using a wheelchair and required feeding assistance; -He/She would have expected the MDS to reflect resident's current ability status and to have been updated. 3. Review of Resident #25's Quarterly MDS, dated [DATE], showed: -Cognition severely impaired; -He/She displayed no behaviors related to rejection of care; -He/She required supervision or touching assisting with personal hygiene -Diagnoses included: dementia, pain, and reactions to severe stress. Review of care plan, revised 12/13/24, showed: -Personal hygiene: The resident required physical assistance by one staff with personal hygiene and oral care; -Shaving preferences were not care planned. Observation on 4/7/25 at 8:19 A.M. showed the resident scratching at his/her chin hair. The Resident was told by a peer at the dining table that he/she should take a razor to that. During an interview on 4/7/25 at 8:23 A.M. the resident said the chin hair bothered him/her and he/she preferred to not have chin hairs. Observation on 4/7/25 at 11:40 A.M. showed the resident continued to grab and pull at his/her chin hairs. Observation on 4/08/25 at 7:35 A.M. showed the resident kept touching his/her chin hair. During an interview on 4/9/25 at 11:15 A.M., Certified Nurse Aide (CNA) H said: -The resident liked to be shaved; -The resident preferred to have a close shave of the chin; -The resident had to be in the mood to be shaved and at times had to be re-approached at a later time; -The resident would pick at his/her chin if chin hair was bothering him/her. During an interview on 4/10/25 at 1:53 P.M., the MDS Coordinator said: -He/She expected care plans to be updated with resident's current mobility, eating assistance support levels, and their use of a wheelchair; -He/She expected behaviors to have care planned interventions for staff to implement and redirect those behaviors; -He/She expected new fall interventions to be put in place in the he care plan after a fall had occurred for a resident; -He/She expected shaving preferences to be care planned; -The activity director was responsible for the care plan section on activities. During an interview on 4/10/25 at 2:02 P.M., the Activity Director said he/she expected care plans to be personalized to residents interests in regards to activity preferences and likes and dislikes. During an interview on 4/10/25 at 4:15 P.M., the [NAME] President of Operations said: -He/She expected resident's current mobility, eating assistance, and use of a wheelchair to be reflected in the resident's care plan. -He/She expected care plans to include behavioral interventions for staff on how to redirect resident behaviors; -He/She expected new interventions to be added to the care plan after a resident experienced a fall; -He/She expected care plans to be personalized to residents likes and dislikes and include their past preferred activities; -He/She expected care plans to be person centered.

Based on observation, interview, and record review, the facility staff failed to ensure residents remained free from accident hazards when staff pushed residents in their wheelchairs without foot pedals in place for three residents (Resident #29, #83, and #79) of the 23 samples residents. The facility census was 112. Review of the facility policy, Resident [NAME] of Rights, dated January 2023, showed the facility shall provide a safe environment. Facility did not provide a policy on regarding accident prevention. Review of facility policy, Accident and incident documentation and investigation, dated July 2018, showed: -Accidents and/or incidents involving resident care will be investigated and documented on there resident incident report entry form in the long term care system. An incident is defined as an occurrence which is not consistent with routine operation of the facility or the routine care of a particular resident. Accidents and incidents will be analyzed for trends or patterns to enable the facility to enhance preventative measures to reduce the occurrence of incidents. 1. Review of Resident #29's Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 1/11/25, showed: -Cognition severely impaired; -He/She had no impairment to upper or lower extremity range of motion; -He/She was dependent on a wheelchair; -He/She was dependent for all mobility; -Diagnoses included: dementia and Alzheimer's disease. Review of care plan, revised 3/20/25, showed: -Bed mobility: The resident is independent with bed mobility; -Transfers: The resident required physical assist of 2 staff to move between surfaces. Observation on 4/7/25 at 8:16 A.M., showed Licensed Practical Nurse (LPN) C pushed the resident out of the dining room to his/her room without foot pedals on the wheelchair. Observation on 4/07/25 at 12:45 P.M., showed the resident without foot pedals on his/her wheelchair and was pushed out of the dining room by LPN C to complete his/her blood sugar. Observation on 4/10/25 at 12:58 P.M., showed the resident did not have leg rests on his/her wheelchair. 2. Review of Resident #83's 5-day MDS assessment , dated 1/29/25, showed: -Cognition severely impaired; -He/She used a wheelchair and was dependent for mobility for 50-150 feet; -He/She had history of fall, had a fall prior to admission, and in last 2-6 months; -He/She had a fracture related to a fall; -He/She had surgery in last 100 days; -Diagnoses included fracture of neck of right femur, dementia, and edema. Review of care plan, revised 2/10/25, showed: -Bed mobility: Resident was independent with bed mobility; -Transfers: Resident was able to transfer independently with roller walker; -Resident to be assisted to wheelchair upon awakening in the morning; -Ensure the resident is wearing appropriate footwear non-skid socks when mobilizing in wheelchair. Observation on 4/8/25 at 8:47 A.M., showed the resident was pushed into the dining room without foot pedals on his/her wheelchair. Observation on 4/10/25 at 12:58 P.M., showed the resident was pushed into the dining room and did not have foot pedals on the wheelchair. During an interview on 4/9/25 at 11:15 A.M., CNA H said the resident would not allow him/her to put foot pedals on his/her wheelchair. 50980 3. Review of Resident #79's Annual MDS, dated [DATE], showed: - Resident was cognitively intact; - Resident uses a wheelchair for mobility; - Resident was independent for self-care activities of daily living; - Resident was independent for mobility and transfers and requires supervision for shower transfers; - Resident was independent for wheelchair mobility for at least 150 feet; - Diagnosis: atrial fibrillation (heart rhythm disorder), diabetes, hip fracture, and Parkinson's disease. Review of the care plan, revised 11/12/24, showed: - Resident requires physical assist by one staff with showering; - Resident is to wear appropriate footwear shoes or non-skid socks when ambulating or mobilizing in wheelchair; Observation on 4/9/25 at 11:05 A.M., showed CNA A pushed the resident's wheelchair to the shower room without foot pedals in place. The resident was observed raising his/her feet up off the ground while being pushed down the hall. At 11:25 A.M., the resident returned from the shower room being pushed again by CNA A to their room without foot pedals in place. Observation on 4/9/25 at 12:25 A.M., showed CNA K pushed a resident (unidentified) in a wheelchair through wings F and B with the resident holding up his/her feet and no foot pedals attached to the wheelchair. During an interview on 4/9/25 at 11:15 A.M., Certified Nurse Aide (CNA) H said it was not safe to push residents in their wheelchairs without foot pedals. During an interview on 4/9/25 at 1:45 P.M., LPN C said residents in wheelchairs should have foot pedals in place before they were propelled by staff. During an interview on 4/10/25 at 4:15 P.M., the [NAME] President of Operations said he/she expected foot pedals to be on wheelchairs for residents who were propelled by staff.

Based on observation, interview, and record review, the facility failed to ensure staff administered medications with an error rate of less than five percent (5%). Staff made two errors out of 25 opportunities for error, which resulted in an error rate of 8%. This affected one of the 23 sampled residents, (Resident #72). The facility census was 112. Review of the facility's policy titled, Medication administration-general guidelines, revised 8/16, showed: - Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so; - Personnel authorized to administer medications do so only after they have familiarized themselves with the medication; - Prior to administration, the medication and dosage schedule on the resident's medication administration record (MAR)/eMAR (electronic MAR) is compared with the medication label; - Information on the medication should be checked against the MAR/eMAR or treatment administration record (TAR)/electronic TAR (eTAR) at least three times during the med preparation and administration process; - If the label and MAR/eMAR or TAR/eTAR are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule prior to administering. Review of the facility's policy titled, Nasal Inhalation Administration Procedures, reviewed 8/16 showed: - To administer nasal inhalation medications in a safe and accurate manner; - Have resident gently blow nose to clear the nostrils to ensure that nasal passages are not blocked by mucous material; - Shake inhaler well and remove cap from nozzle; - Hold the inhaler in upright position between second and index fingers, with thumb on bottom of canister; - With resident's head tilted back, carefully insert nozzle into one nostril and close the other nostril with one finger; - While resident gently inhales through open nostril, activate medication canister with thumb; - Instruct resident to hold breath for five to ten seconds, then breathe out through the mouth; - If more than one inhalation is ordered, repeat steps in each nostril for the number of inhalations ordered. Review of the manufacturer guidelines for Flonase Sensimist use show: - In order for FLONASE Sensimist to work the way it was meant to, it ' s important you get a full dose every time. - Before each use, shake the bottle of FLONASE Sensimist vigorously, and with your thumb and your forefinger, gently squeeze the sides of the cap, and pull it straight off. - Before using FLONASE Sensimist, blow your nose gently to clear your nostrils. - Put the tip of the spray bottle into your nostril, and tilt your head forward while keeping the bottle upright. Only the tip should go inside. Be sure to aim slightly away from the center of your nose. -While sniffing gently, press the button all the way in twice. Breathe out through your mouth and repeat in the other nostril. - When used daily, FLONASE Sensimist Allergy Relief continues to provide powerful relief 24 hours a day. Review of Resident #72's Physician Order Sheet (POS), dated 4/9/25 showed: - Start date: 11/1/24 - Aspirin tab delayed release 81 milligrams (mg.), one tab daily for hypertensive heart disease; - Start date: 4/9/25 - Flonase Sensimist Nasal Suspension 27.5 microgram (mg.)/spray, two sprays in both nostrils daily for allergies. Review of the resident's Medication Administration Record (MAR), dated 4/9/25 showed: - Aspirin tab delayed release 81 mg., one tab daily for hypertensive heart disease; - Flonase Sensimist Nasal Suspension 27.5 mg./spray, two sprays in both nostrils daily for allergies. Observation on 4/9/25 at 10:34 A.M., showed: - Licensed Practical Nurse (LPN) G administered Aspirin 81 mg. chewable to the resident instead of the delayed release; - LPN G removed the cap from the Flonase Sensimist Nasal Spray and gave the resident one spray in each nostril; - LPN G did not have the resident blow his/her nose, did not close either side of the nostril and did not give two sprays. During an interview on 4/10/25 at 4:15 P.M., the [NAME] President of Operations said: - Staff should follow the manufacturer's guidelines for the administration of nasal sprays (have the resident blow their nose, close one side of the nostril). - If the order was for Aspirin delayed release, staff should not have administered Aspirin chewable. - Staff should administer what the physician has ordered.

Based on observation, interview and record review, the facility failed to store medications in a locked storage area to ensure medications were inaccessible to unauthorized staff and residents, when eye drops (Resident #26) and one blue pill (Resident #27) were left at bedside. This affected two out of 23 sampled residents. The facility census was 112. Review of facility policy, Medication Administration General Guidelines, revised August 2016, showed: - Residents are allowed to self-administer medications when specifically authorized by the attending physician and the interdisciplinary team and in accordance with procedures for self-administration of medications; - In the event a non-controlled medication is refused by the resident, the nurse is to waste the medication by placing it in the sharps container or a clearly labeled container or cabinet in a locked secured area designated for that purpose until destroyed; Review of facility policy, Medication Administration General Guidelines, revised August 2016, showed: - Residents are allowed to self-administer medications when specifically authorized by the attending physician and the interdisciplinary team and in accordance with procedures for self-administration of medications; - In the event a non-controlled medication is refused by the resident, the nurse is to waste the medication by placing it in the sharps container or a clearly labeled container or cabinet in a locked secured area designated for that purpose until destroyed; Review of facility policy, Medication Storage, revised November 2010, showed: - Medication supply must be accessible only to licensed nursing personnel, or staff members lawfully authorized to administer medications. All drugs, treatments, and biologicals must be stored securely and following the manufacture's labeled recommendations, or per facility policy. - Medications will be stored on the medication cart, or in other designated area for extra supply of medications, except for those requiring refrigeration. 1. Review of Resident #27's Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 3/6/25, showed: - He/She was cognitively intact; - He/She was independent for eating, oral hygiene, and upper body dressing; - He/She required nursing staff to administer medications; -Diagnoses: hypertension (high blood pressure) and schizophrenia (a chronic mental disorder characterized by disruptions in thought processes, perceptions, emotions, and social interactions); Review of physician's orders, dated April 10, 2025, showed: - No orders for self-administration of medications; - Physician order for Tramadol 50mg tablet as needed and an order for hydrocodone 325mg as needed. Observation on 4/07/25 at 9:06 A.M. showed the resident had one small blue pill in a plastic clear cup on the bedside table within the resident's reach. During an interview on 4/7/25 at 9:07 A.M., the resident said staff left the cup on his/her table when they came by with medications this morning. During an interview on 4/10/25 at 8:45 A.M., CMT A said: - When handing out medications they wait until the resident takes all medications administered before leaving the room. At no point, unless the resident had an order for self-medication, would he/she leave medications in the room with the resident unattended. During an interview on 4/10/25 at 4:15 P.M., the Administrator said residents with medications at bedside should have orders to self-administer. 47195 2. Review of Resident #26's Quarterly MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She had clear speech and he/she usually made self-understood and usually understood others; -He/She required nursing staff to administer medications; -Diagnoses included renal failure, stroke, dementia, depression, and glaucoma. Review of physician's orders, dated April 10, 2025, showed: -Ordered 9/10/24, Started on 11/1/24, Artificial tear 0.1-0.2-0.3%, Give 1 drop into eye every 6 hours as needed for instill 1 drop in both eyes every 6 hours; -Ordered 4/4/25, started 4/4/25, Timolol Maleate PF Ophthalmic solution 0.5%, Instill 1 drop in both eyes two times a day for glaucoma; -Ordered 4/4/25, started 4/4/25, Travoprost Ophthalmic Solution 00.4% (Benzalkonium Free), give 1 drop into eye at bedtime for instill 1 drop in both eye at bedtime daily related to unspecified glaucoma. Review of care plan, revised 12/4/24, showed: -Resident had impaired cognitive function/dementia, anxiety/depression, bipolar, and panic disorder. -Administer medications as ordered. monitor and document for side effects and effectiveness; -Resident had impaired visual function due to glaucoma Observation on 4/07/25 at 7:50 A.M., showed the resident had eye drops observed on his/her nightstand. Observation on 4/9/25 at 10:28 A.M,. showed the resident had a bottle of eye drops sitting on the nightstand beside the resident's bed. During an interview on 4/9/25 at 1:45 P.M., Licensed Practical Nurse (LPN) C said the resident should not have eye drops at his/her bedside and did not self administer any medications. During an interview on 4/10/25 at 4:15 P.M., [NAME] President of Operations said: -He/She expected residents with medications at bedside to have orders to self-administer; -He/She did not expect residents residing on memory care to have eye drops left at their bedside.

Based on observation, interview, and record review, the facility failed to provide acceptable accommodations for one non English speaking resident (Resident #104) and failed to provide one resident appropriate seating for meal times when his/her chair put his/her at face at table height (Resident # 26). This affected two of 21 sampled residents. The facility census was 103. Facility did not provide a policy on accommodation of needs. Review of Resident [NAME] of Rights, revised 1/23, showed: -Each resident had a right to dignified existence, self-determination, and communication with and access to persons and services and outside the facility in a manner and in an environment that promotes maintenance or enhancement of (his or her) quality of life, regardless of diagnosis, severity of condition. -Informed in a language he/she can understand of his/her total health status, including but not limited to, his/her medical condition. -Reside and receive services in the facility with reasonable accommodation of residents needs and preferences except when to do so would endanger the health or safety of the resident or other residents. -Communicate with individuals and entities within and external to the facility. 1. Review of Resident #104's minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 9/25/24, showed: -His/Her cognitive status was not measurable; -His/Her preferred language was Spanish; -He/She had no impairment to upper or lower extremities; -H/She was dependent on wheelchair; -He/She required substantial/maximal assistance with eating, oral hygiene; -He/She was dependent with toileting hygiene, bathing, dressing, mobility ; -Diagnoses included Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), Parkinson's Disease (a disorder of central nervous system that can cause symptoms of low movement, stiffness, and loss of balance) , repeated falls, headaches, and ototoxic hearing loss (inner ear damage that develops as a side effect of taking certain medications). Review of care plan, undated, showed: -Resident was Spanish speaking and staff were able to communicate with him/her through Google translate; -He/She enjoyed listening to music such as traditional Spanish music; -Offer picture communication book to allow resident a chance to point at what he/she needs; -Provide an activity calendar in his/her room; -Offer picture/word communication board to the resident to show signs for snacks and fluids to alert resident to know what is happening; -Offer cueing for toilet, pain, nurse with pictures due to lack of communication due to Spanish speaking only; -He/She had difficulty hearing due to hearing loss; -Staff should speak in low, clear voice to increase resident's chance of hearing; -He/She can understood simple direct communication; -Resident hears better in right ear. Review of daily care guide, dated 10/8/24, showed: -He/She spoke Spanish; -Keep communication board pages with pictures in English and Spanish at his/her side in the wheelchair when he/she was up so staff can assist with his/her needs. Review of electronic medical record showed: -On 9/26/24, Physical Therapist A documented a physical therapy evaluation was completed after family requested physical therapy screen, and physical therapy was not recommended. The resident was at baseline function and did not progress with therapy due to language barrier and refusing to perform tasks in therapy. During an interview on 10/8/24 at 10:51 A.M., family representative Interview said: -Resident spoke Spanish and did not understand English; -He/She had translated short cues for therapy department with cues such as stand up and walk; -Resident understood short cues; -Facility staff mostly communicated with resident in English; -Family member went to facility daily to provide cares and showers to resident; -Resident was the only Spanish speaking resident on the hall; -The facility staff did not make any accommodations for his/her language barriers. Observation on 10/7/24 at 10:07 A.M., showed resident was placed in alcove across from nurses station. Resident spoke Spanish to self. He/She was observed staring at the wall and pulling on his/her pants. He/She did not have a communication board with him/her in his/her wheelchair. Resident had no engagement items or Spanish music playing. Observation on 10/7/24 at 10:17 A.M. showed Licensed Practical Nurse (LPN) G obtained resident's foot pedals for wheelchair and applied to his/her wheelchair. LPN G talked to resident in English. Observation on 10/7/24 at 10:18 A.M. showed resident's room did not have any Spanish items. No activity calendar posted in room. Communication board observed in English was laying on a table in the resident's room. Observation on 10/7/24 at 2:35 P.M. showed resident was sat across from nurses station in an alcove. Resident was observed playing with his/her shirt. Resident did not have communication board with him. He/She had no engagement, no entertainment, and nothing in his/her hands. During continuous observation on 10/9/24 at 7:18 A.M.-9:04 A.M., showed resident was sat in alcove across from nurses station. He/She had no entertainment, no communication board, and no items in his/her hand. Observation on 10/9/24 at 9:11 A.M. showed Activity Director stopped and spoke to resident in English stating 'Papa are you okay?'. The staff member did not use a communication board, translator application or Spanish phrases when he/she interacted with the resident. Observation on 10/9/24 at 1:01 P.M. showed staff placed resident in alcove across from the nurses station with no communication board and no engagement activity. Observation on 10/9/24 at 1:12 P.M., showed Activity Director inquired with Shower Aide if resident has been provided incontinent care. Staff stated he/she did not know. Activity Director then said to resident in English 'come on, let's go'. The resident did not respond to the staff member and had blank stare. The staff member took the resident to his/her room. During a continuous observation on 10/9/24 from 6:55 P.M.-8:33 P.M. of B hall showed: -6:55 P.M. Facility staff wheeled the resident in his/her wheel chair to the alcove at the nurses station; - He/She tried to stand up; -7:02 P.M., Resident was speaking in Spanish and talking loudly, Certified Nurse Aide (CNA) E and CNA F talked to the resident in English and sat the resident back down in his/her wheelchair. Resident continued to talk loudly in Spanish. -7:10 P.M., resident was sitting in the alcove across from nurses station attempting to stand up. CNA G went to the resident and said to him/her in English 'Come on Poppy, let's go'. Resident did not have his/her communication board. -8:09 P.M., showed resident was back in the alcove across from nurses station. Resident was speaking in Spanish and showing signs of agitation when he/she began to raise the tone of his voice and started speaking more rapidly. Registered Nurse (RN) A went to resident and asked resident in English if he/she wanted to go to bed. He/She then asked resident in English if resident wanted water. The resident had a blank stare and looked from staff to staff member back and forth. Resident did not have his/her communication board. Observation on 10/10/24 at 1:42 P.M. showed resident was in the dining room alone and attempted to stand up. The resident was chanting loudly in Spanish in front of the television. Television was on playing the news in English. During an interview on 10/8/24 at 11:27 A.M., Therapy Director said: -He/She had screened resident for therapy and determined resident was unsafe; -His/Her family had requested therapy multiple times but resident was too impulsive. During an interview on 10/9/24 at 1:22 P.M., LPN G said: -He/She used Google translate to communicate with resident; -Resident's family always came in evening if they needed help communicating with resident; -Resident had been talking a lot in Spanish; -Resident could not participate in activities, but Activities Director will take him/her to activities if there was music. During an interview on 10/9/24 at 1:45 P.M., CNA J said: -He/She found it hard to communicate with resident; -He/She told resident what he/she was doing in English; -He/She did not know Spanish; -Resident's family was in facility a lot and they helped communicate with resident; -He/She was not aware of a communication board; -When family is in facility they can get resident to relax and do more; -Resident was provided fidget toys for activities and taken on walks around building; -Resident was sat at nurses station due to fall risk. During an interview on 10/9/24 at 7:14 P.M., RN A said: -It was his/her first time working on B-hall and his/her second day working in the facility building; -He/She was agency staff. During an interview on 10/9/24 at 8:13 P.M., CNA E said: -He/She had not been education about resident's communication board; -He/She did not know how to use Google translate; -He/She wanted to know how to communicate with resident; -He/She did not speak Spanish. During an interview on 10/9/24 at 8:15 P.M., CNA F said: -No staff members spoke Spanish that worked with resident; -He/She did not know resident had communication board; -He/She had not been taught how to communicate with resident. During an interview on 10/9/24 at 8:23 P.M., CNA G said: -He/She had not used resident's communication board to communicate with the resident; -He/She tried to communicate with resident in short phrases in Spanish; -He/She had tried using Google translate on his/her phone but it did not work with him/her. During an interview on 10/10/24 at 8:16 A.M., LPN G said: -He/She did comprehend some of what his/her family communicated to him/her in Spanish; -He/She had used Google translate with resident and Google translate only picked up one sensible thing from resident when he/she told him/her that he/she liked the music that LPN G had played. During an interview on 10/10/24 at 4:15 P.M., Activity Director said: -Resident did not appear he/she was interested in any activities; -He/She had not done activities for resident in Spanish; -He/She had not spoken to resident's families to find out resident's history of activities that brought him/her joy; -Resident would act out by raising his voice and yelling, would try to get up out if his/her chair; -Resident should have a Spanish activity calendar in his/her room. During an interview on 10/10/24 at 6:25 P.M., Director of Nursing said: -He/She expected staff to communicate with resident who didn't have English as their primary language by using a communication board or translation device; -He/She expected staff to be educated on how to use communication boards or communication devices; -He/She would expect communication board to be in resident's primary language; -He/She expected activities or entertainment to be offered in resident's primary language. During an interview on 10/10/24 at 6:56 P.M., Administrator said: -He/She would expect some sort of accommodation for staff to be able to communicate with resident who did not speak with English as primarily language; -He/She expected staff working with resident to be educated on those accommodations and how to use them. During an interview on 10/16/24 at 10:41 A.M., Physical Therapist A said: -He/She completed the resident's initial physical therapy screening assessment when the resident was admitted to the facility; - The resident's family requested a second assessment that he/she completed on 9/26/24; -He/She set up therapy times so family could be present during therapy sessions; -Language was a barrier even when family was present; -Resident did respond to some prompts provided by family members during therapy sessions; -He/She did not know if the facility had a way to communicate with the resident outside of utilizing family members; -Therapy department had family write down sayings like larger steps, higher steps to utilize with resident in Spanish; -Therapy department staff had a really difficult time getting resident to progress even with family present providing prompts in Spanish. 44395 2. Review of Resident #26's Quarterly MDS completed 8/9/24 showed: -BIMS of 4, indicated significant cognitive loss; -Substantial to maximum assistance of staff with Activities of Daily Living (ADL's: tasks completed in a day to care for oneself); -He/She is dependent on a wheelchair for mobility; -Height of 62 inches (in); -Diagnoses of osteoporosis (a disease that weakens bones), Dementia (a brain disease that causes loss of function such as thinking,remembering and reasoning that interferes with daily life), Ischemic Cerebral Infarction (damage to the brain from blocked blood flow). Review of the resident's comprehensive Care Plan showed no care plan for use of a wheelchair. Review of the resident's electronic medical record showed: -April 2024 the resident was seen by Skilled Therapy services for self feeding skills due to mobility and self propelling the w/c. -May 2024 the resident was seen by Skilled Therapy services for sitting balance and functional mobility. Observation on 10/07/24 at 11:05 A.M. showed the resident sitting in his/her w/c, slightly bent forward with a c shaped curve to his/her upper body. He/She was looking at a game card lying on the family style dining room table. His/Her w/c was very low to the ground. The table was at mid chest/breast height of the resident. The resident remained at the table for the noon meal. At 1:11 P.M. his/her meal was served . He/She attempted to raise his/her right hand from under the table, and picked up his/her fork from the table. He/She dropped the fork on the floor. He/She then began eating with his/her fingers. He/She did not complete his/her meal and staff removed the resident from the room. Observation on 10/08/24 at 6:41 AM the resident was sitting at the same dining room table. He/She had his/her head laid face down on the table. At 7:04 A.M. Certified Nurse Aide (CNA) H assisted the resident out of the dining room. During an interview on 10/8/24 at 6:45 A.M. CNA H said: -The wheelchair belongs to the resident. During an interview on 10/08/24 at 11:33 AM the Therapy Program Director said: -Skilled Therapy should measure each resident individually for wheelchairs; -She made recommendations for this resident to sit at an over bed table to eat, since he/she cannot reach the dining table; -She expects nurses to notify therapy if a wheelchair does not fit the resident, or if the resident has a problem with a chair, such as sitting chest height to a table. During an interview on 10/10/24 at 6:25 PM the Director of Nursing said: -He/She would expect staff to look into other options for a resident that sits chest height to the table; -She would expect Dietary and Skilled Therapy to be involved in care of Resident #26; -She was not aware that resident #26 sat at chest height to the dining room table.

Based on interview and record review, the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) form CMS - 10123, to Medicare beneficiaries at least two days before the end of a Medicare covered Part A stay. This affected two out of 21 sampled residents (Resident #1 and #93). The facility census was 103. The facility did not provide the requested policy for Notice of Medicare Non-Coverage (NOMNC) form CMS - 10123. CMS Guidlines: Form CMS-10123, is given by the facility to all Medicare beneficiaries at least two days before the end of a Medicare covered Part A stay or when all of Part B therapies are ending. The NOMNC informs the beneficiaries of the right to an expedited review by a Quality Improvement Organization. 1. Review of Resident #1's medical record showed: -The resident had a Notice of Medicare Non-Coverage (NOMNC) issued that showed Medicare Part A benefits were ending on 8/20/24; -The NOMNC was signed by the resident on 8/20/24; -The resident's record showed the facilty failed to ensure the resident received the NOMNC at least at least two days before the end of a Medicare covered Part A stay. 2. Review of Resident #93's medical record showed: - The resident had a NOMNC issued that showed Medicare Part A benefits were ending on 9/3/24; -The NOMNC was signed by the resident on 9/3/24; -The resident's record showed the facilty failed to ensure the resident received the NOMNC at least at least two days before the end of a Medicare covered Part A stay. During an interview 10/10/24 at 4:40 P.M. the Business Office Manager said: -He/she was unaware the residents #1 and #93 did not receive the NOMNC at least two days before the end of their Medicare covered part A stay; -Residents should receive the NOMNC at least two days prior to the end of a Medicare covered Part A stay. During an interview on 10/10/24 at 06:56 P.M., the Administrator said: -He/She could not recall the time frame for when the NOMNC form should be given to residents coming off of Medicare A; -He/She did not know who was responsible for providing the NOMNC form to the residents; -The NOMNC should not be given on the resident's last covered day.

Based on observation and interview, the facility failed to ensure noise levels were at an acceptable level for two sampled residents (Resident #35 and #77). Additionally the facility failed to ensure housekeeping and maintenance services were provided to maintain a sanitary, orderly and comfortable interior throughout the facility. and failed to provide an adequate supply of linens. The facility census was 103. Review of the facility provided policy Resident [NAME] of Rights dated 1/2023 showed: -The facility residents have a right to a safe, clean, comfortable and homelike environment. Review of the facility provided policy Housekeeping Cleaning Procedures dated 6/2018 showed: -Spot clean walls/ damp wipe vertical surfaces/counters/ledges/sills; -Wipe walls weekly. Review of the facility provided policy Floor Care Cleaning Procedures dated 6/2018 showed: -Dust mop floor-remove gum, etc. with a putty knife; -Scrub edges with utility pad holder and/or scraper. The facility did not provide a policy on sound levels. 1. Review of Resident #35 Quarterly Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff) dated 7/11/24 showed: -Brief Interview of Mental Status of 99, indicated significant cognitive loss; -Adequate hearing; -Able to understand others and make himself/herself understood; -Dependent on staff for Activities of Daily Living (ADL's: tasks completed in a day to care for oneself); -Used a wheelchair for mobility; -Diagnoses of Anxiety disorder (a mental illness that causes a person to experience excessive and uncontrollable feelings of fear and anxiousness), Depression (a serious mental illness that can affect a person's thoughts, feelings, behavior, and sense of well-being), Mood disorder (a mental health condition that primarily effects your mental state), Alzheimer's Dementia (a disorder of the brain that gradually destroys thinking, memory and eventually the ability to complete daily tasks). Observation on 10/07/24 beginning at 11:05 A.M. showed the Special Care Unit (SCU) dining room/sitting room patio door was propped open with a brick and potted plant. The door alarm was beeping. Certified Nurse Aide (CNA) A said the door was alarming because the it was open and residents were at the dining table near the door. Resident #35 was sitting at the table with one side of his/her body positioned toward the door and the alarm. He/She had her hand up over his/her ear closest to the alarm. At 12:45 P.M. CNA A assisted the resident from the table down the hall. At 1:06 P.M. Resident #35 returned to the table. The door alarm continued to sound. The resident put his/her hand back over his/her ear. He/She had a distressed look with furrowed brow, on his/her face. 2. Observations beginning on 10/08/24 at 7:58 A.M. on the SCU showed: -Nursery room: the carpet was stained with grey dusty color debris, light fixtures had dead bugs and debris and baseboards had gray/black debris at floor edge; -room [ROOM NUMBER]: the entry door had scratches and large paint chips exposing the wood underneath, and drug against the floor when opening/closing. The bathroom floor grout was gray/black in color. The bathroom door had large chips and gouges in the paint. The room sink baseboard was chipped; -room [ROOM NUMBER] had a sticky floor, the entry door had gouges and chips in the paint, and there was dirt and rust on a ceiling access panel; -room [ROOM NUMBER] entry door had paint chips that exposed the wood underneath. The bathroom had non skid strips in front of the toilet that were peeled up and partially away from the tile. The bathroom grout was gray/black in color; -room [ROOM NUMBER] the baseboard was peeling away from the wall. The bathroom grout was gray/ black in color. The bathroom door has chipped/scratched paint; -room [ROOM NUMBER] the privacy curtain had brown colored debris approximately 6 inches long on the front side; - room [ROOM NUMBER] the entry door had multiple paint chips exposing the wood underneath; -Dining/Sitting Room the baseboard had thick black gray crusty debris at the edge of the floor. There were multiple stained/scuffed floor tiles. The walls had multiple scuff marks. The ceiling light fixtures had dead bugs and debris. The door jam had scuffs and chips in the paint. The area rug had dust, debris and gray/brown stains. There were missing tile under the Packaged Terminal Air Conditioner (PTAC a type of self-contained heating and air conditioning system).The baseboard near the PTAC unit was peeling away from wall. The radio and radio stand had a layer of gray dust. There were pearl like beads on floor at edge of the wall. The windowsills had thick brown dust and debris. The chair rail mounted on the wall had a layer of dust at the top edge. The window blinds had dust and debris. The PTAC unit had black mold like substance in the vent, on the filter and the filter cover. An over bed table had laminate peeling off, with exposed pressboard; -room [ROOM NUMBER] had a large wall patch, unpainted. A large scuffed area at the door entrance. The baseboard was peeling away from the closet wall. The tile at the base of closet was cracked. The bathroom door had large scuffed areas with cracked laminate, exposing the wood underneath. The floor was sticky. The bathroom grout was gray/black in color; -room [ROOM NUMBER] the floor was sticky. The baseboard was peeling away from the wall and had crusty debris at the top of the board and wall. The PTAC had black mold like debris in the vent; -room [ROOM NUMBER] had dust and debris in the vent of the PTAC unit. There were two pencil sized holes in the bathroom door. The room entry door had scuffs and scratches in the paint. The baseboards had thick black/gray debris at the floor edge. 3. Observation on 10/09/24 at 8:16 P.M. showed the resident telephone room door had chipped finish exposing the wood underneath. There were multiple scuffs and gouges in the door. The floor was stained with brown/gray color. The baseboard was grimy with dust and dirt. There was dark crusty debris at the entry door threshold. During an interview on 10/10/24 at 4:13 PM Housekeeper A said: -There are floor technicians who are responsible for the hallways and general areas; -Housekeeping staff are responsible for cleaning the resident rooms, bathrooms and shower rooms; -Maintenance staff cleaned the lights, and completes high dusting in the hallways, such as the door corners; -Maintenance is responsible for patching and painting. During an interview on 10/10/24 at 4:42 P.M. the Maintenance Director said: -He worked in this facility for two years; -He was supervising the housekeeping department, but usually that department has their own supervisor; -The floor technicians are responsible for floor care, to include scraping debris off the floor, cleaning behind the doors and cleaning and/or scraping the baseboard edges; -Floors are stripped and waxed as resident rooms open up. General hallways and floors are done at night on a three week schedule; -Housekeeping staff are responsible for cleaning, and that included cleaning dead bugs and debris from the light fixtures; -Maintenance staff are responsible for upkeep of the building and repairs only; -PTAC units get cleaned twice a year; -Staff can fill out work orders for things that need repaired; -He did not have a list of repairs that need completed. During an interview on 10/10/24 at 6:25 P.M., the Director of Nursing (DON) said: -She expected the building to be clean, and residents to be comfortable. 31102 4. Review of Resident #77's Quarterly Minimum Data Set (MDS), completed by facility staff and dated 8/9/24, showed: - Cognitive skills intact; - Independent with transfers; - Diagnoses included anxiety and depression. Review of the resident care plan, dated 4/4/2022, showed:- The resident had an alteration in sleep pattern related to insomnia ( persistent problems falling and staying asleep); administer medications as ordered by the physician; observe for changes in sleep pattern inability to fall/stay asleep; provide a quiet restful environment. During an interview on 10/7/24 at 3:17 P.M., the resident said;- The staff take the smoking cart outside and roll it past his/her door and it is very loud; - There is something broken on it and it makes a loud clunking sound; - The smoking cart has been broken for over a month; - He/she has trouble sleeping at night and it has woken him/her up before. Observation on 10/8/24 at 7:14 A.M., showed: - Staff pushing the smoking cart down the hallway to the exit for the smoke break; - The front wheel looked like it was broken and it was made a very loud clunking sound. Observation on 10/8/24 at 10:05 A.M., showed:- Staff pushed the smoking cart down the end of the hall for the smoke break; - The smoking cart made a very loud clunking sound all the way down the hall. During an interview on 10/9/24 at 7:03 P.M., Licensed Practical Nurse (LPN) D said: - If something was broken he/she would call Maintenance and let them know and he/she would pass it on in report; - He/she was not for sure how long the smoking cart had been broken. During an observation and interview on 10/9/24 at 7:15 P.M., showed: - Staff brought the smoking cart back inside and it made a terribly loud clunking sound; - Certified Nurse Aide (CNA) C said he/she has worked at the facility for a month. The smoking cart was really loud and had been like that since he/she has worked there. He/she had not reported it but you could hear the staff coming with it. Observation on 10/10/24 at 9:55 A.M., showed: - The surveyor was inside resident #77's room with the door closed and you could hear staff pushing the smoking cart past the room and it made a very loud clunking sound as it went past. During an interview on 10/10/24 at 10:07 A.M., LPN C said: - If something needs to be fixed or repaired, he/she writes up a departmental slip and places it in the maintenance box up front in the copy room; - He/she also reported it to the unit manager; - If it was not repaired, he/she would stay on it until it and follow up. During an interview on 10/10/24 at 4:42 P.M., the Maintenance Director said:- He/she used a notepad and wrote down things of high attention and would take care of those first; - He/she was aware of the wheel on the smoking cart being broken; - He/she ordered the replacement wheel this week. During an interview on 10/10/24 at 6:25 P.M., the Director of Nursing (DON) said: - Staff should report broken equipment; - Staff should notify the unit manager; - She was not aware of the wheel on the smoking cart being broken. 47195 5. Observation on 10/07/24 at 12:01 P.M. showed dining room had area above the television had been dry wall patched and sanded but not painted. A second area had not been painted where the wall was patched and sanded where the television previously hung. 6. Observation of B-wing hall on 10/7/24 at 10:29 A.M., showed: -room [ROOM NUMBER] had dry wall patches above the bed that had not been painted; -In the hallway between room [ROOM NUMBER] and 45 there was two 1 inch holes in the wall and paint was missing; -room [ROOM NUMBER] had gouges to the wall where drywall and paint had been scraped away by furniture; -room [ROOM NUMBER] had a broken outlet cover in the middle of the room. 7. Observation on 10/9/24 at 8:39 A.M. showed floor technician using floor machine on B-hall. The machine was making a loud squealing noise. During an interview on 10/10/24 at 4:43 P.M., Maintenance Director said: -He/She was responsible for facility repairs and upkeep; -He/She became aware of items requiring repair via the facility system; -He/She checked computer every morning for work orders; -Staff notify him also via cell phone of facility repairs needed; -The floor machine just started squeaking noise due to a rubber seal; -The walls in dining room were just patched; -Once drywall is patched it, he allowed it to sit for two to three days to allow the mud to dry; -He/She then should sand and paint the drywall patches;

Based on observation, record review, and interview, the facility failed to evaluate and respond to a change in condition for two residents (Resident #152, and #72) when the facility failed to recognize one resident (Resident #152) was lethargic, difficult to arouse, and had minimal to no oral intake for over 24 hours which resulted in an emergency discharge to the hospital for severe dehydration, urinary tract infection and possible sepsis (a life threatening result of infection that could lead to tissue damage, organ failure and death). The facility staff also failed to identify and respond to one resident (Resident #72) who had a critically high blood glucose reading following blood glucose readings consistently over 200 milimoles per liter (mmol/l : the measurement for molecular blood sugar) since November 1, 2023, resulting in an emergency discharge to the hospital for hyperglycemia (high blood glucose: happens when the body has too little insulin. Hyperglycemia can lead to diabetic ketoacidosis, a serious complication of diabetes that can be life-threatening, coma and death). The facility census was 106. The administrator was notified on 11/16/23 at 5:01 P.M. of an Immediate Jeopardy (IJ) which began on 11/14/23. The IJ was removed on 11/20/23, as confirmed by surveyor onsite verification. Review of facility policy, notification of a change in resident's status, dated November 2017, showed: -Guideline for notification of physician and responsible party included: -Significant change in or unstable vital signs (temperature, blood pressure, pulse, respiration); -Symptoms of any infectious process; -5% weight gain or loss in 30 days; -Change in level of consciousness; -Abnormal complaints of pain, ineffective relief of pain from current regimen; -Unusual behavior; -Glucometer reading below 70 or above 200, unless specific parameters given by the physician; -Document in the Interdisciplinary Team (IDT) notes: -Resident change in condition; -Physician notification; -Notification of responsible party. 1. Review of Resident #152's Admission Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff), dated 11/3/23, showed: -Brief Interview for Mental Status (BIMS) of 0, indicated severe cognitive deficit. -One to three days of physical behaviors directed towards others such as hitting, kicking, pushing or pinching. -Four to six days of wandering over the past 7 days. -Maximum assistance with Activities of Daily Living (ADLs: refer to people's daily self-care activities such as bathing, using the toilet, eating, dressing and moving from one point to another). -Diagnoses of mild cognitive impairment, acquired absence of part of the lung, major depressive disorder, and dementia with psychosis (a general loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life, and may include: hallucinations (seeing/hearing/smelling things that are not real); delusional thinking (false beliefs); paranoia (being irrationally suspicious); agitation or aggression, and depression. -No weight loss. Review of the resident's Baseline Care Plan, dated 11/9/23, showed -He/She was confused, communicated verbally, needed incontinent care, and had a history of hallucinations of spiders and snakes; -Alert; -Used a wheelchair for mobility. Continuous observation on 11/13/23 at 10:55 A.M. until 1:59 P.M., showed the resident was in bed, in a gray t-shirt, snoring. He/She did not respond to verbal stimuli. His/Her face was flushed (the red color to the cheeks and face that can be caused from being too hot, having a fever, exercise or high emotions) and his/her skin was dry. At 1:59 P.M. the resident did not get up for the noon meal and remained in bed napping. Observation on 11/14/23 at 5:38 A.M., showed the resident in the same gray T shirt as the day before, in bed. He/She did not respond to verbal stimuli. His/Her face was flushed and his/her skin was dry. Observation on 11/14/23 at 12:38 P.M., showed the resident was in the dining room, asleep at the table, non-responsive to staff verbal cues. Staff encouraged him/her to wake up. His/Her meal went untouched. The resident was assisted back to his/her room and returned to bed. Review of the 24 hour report sheet, dated 11/14/23 and 11/15/23, showed the resident did not get up for breakfast and had no intake. Observation and interview on 11/15/23 at 9:42 A.M., showed Registered Occupational Therapist was performing passive range of motion (PROM: the extent of movement of a joint performed for a person by another person) to the resident's legs. The resident showed no response. He/She was in bed, eyes closed, face flushed, skin dry. The OTR said the resident was very sleepy the last two days. He/she said the resident usually works with them and is able to follow commands. During an interview on 11/15/23 at 9:54 A.M. the Special Care Unit Coordinator said the resident had no medication changes recently. The resident was really tired the past two days and had not eaten. Observation and interview on 11/15/23 at 11:10 A.M., showed the resident left via ambulance with Emergency Medical Services (EMS) staff. Registered Nurse A said the Nurse Practitioner (NP) completed rounds and noticed the resident's altered mental status and gave orders for the resident to be sent to the hospital. During an interview on 11/15/23 at 11:34 A.M., the Charge Nurse, Licensed Practical Nurse (LPN) A said the resident did not eat yesterday and only ate a bit of breakfast that morning. The resident had been lethargic for two days and he/she did not call the physician, because the NP would be in the building on 11/15/23. Review of the resident's progress notes, dated 11/13/23 to 11/16/23 showed no documentation of the resident's change in condition, decreased intake, assessment after the change in condition, or attempts to contact the resident's physician. During an interview on 11/15/23 at 3:49 P.M., NP A said she had seen this resident on Monday (11/13/23) and he/she was slow to arouse. That morning (Wednesday 11/15/23) the resident was not acting right, his/her pulse was very fast, and he/she would not wake up. She gave an order to send the resident to the hospital. She was not notified the resident's condition had changed over the day Monday or Tuesday. She was not notified the resident did not eat. During an interview on 11/16/23 at 8:29 A.M., Hospital Nurse A said he/she was responsible for Resident #152. The resident was admitted to the hospital for severe dehydration, urinary tract infection, and possible sepsis. 2. Review of Resident #72's quarterly MDS, dated [DATE], showed: -BIMS of 4, indicated severe cognitive deficit. -No behaviors -Maximum assistance of staff with ADLs. -Frequently incontinent of bowel and bladder. -Diagnoses of Type 1 Diabetes Mellitus, chronic kidney disease, vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain), and mood disorder with depressive features (general emotional state or mood is inconsistent with circumstances and interferes with the ability to function and causes significant distress or impairment in social, occupational, or other important areas of functioning). Review of the resident's Comprehensive Care Plan, dated September 2023, showed: -He/She was at risk for complications of diabetes. Observe him/her for signs and symptoms of hyperglycemia such as increased thirst, fatigue, poor concentration, headaches, blurred vision, and frequent urination. Monitor labs and report results to the physician and/or NP. Review of the physician order sheet, dated November 2023, showed: -Order date of 5/30/23 for Accuchecks before meals and at bedtime. Notify the physician if blood sugar less than 60 or greater than 400. -Order date 7/5/23 for Humalog (short-acting insulin that lasts 15 minutes to 4 hours) 100 units/ml administer 15 units, subcutaneously before meals three times a day. Do not hold meal time insulin. -Order date of 9/20/23 for Lantus solostar (long-acting insulin that lasts 24 to 36 hours )100 units/milliliter (ml) give 16 units subcutaneously (under the skin) every morning. Review of the resident's Diabetic Administration Record, dated November 2023, showed accucheck results of: -On 11/3/23 at 8:00 A.M., a result of 421 milimoles per liter (mmol/l: the measurement for molecular blood sugar); -On 11/4/23 at 12:00 P.M., a result of 450 mmol/l; -On 11/10/23 at 8:00 A.M., a result of 530 mmol/l; -On 11/13/23 at 8:00 A.M., a result of 510 mmol/l. Observation on 11/13/23 at 11:09 A.M., showed the resident was in the activity room, sitting up in his/her wheelchair, playing with blocks. smiling, then helping hang laundry. He/she was talking nonsensically. He/she used a wheelchair to propel from the table to the clothes line. Review of the resident's Diabetic Administration Record, dated November 2023, showed accucheck results of: -On 11/13/23 at 12:00 P.M., a result of 525 mmol/l; -On 11/13/23 at 6:00 P.M., a result of 341 mmol/;l -On 11/13/23 at 8:00 P.M., a result of 355 mmol/l; -On 11/14/23 at 8:00 A.M., a result of High. -On 11/14/23 at 12:00 P.M. a result of High. Review of the resident's progress notes, dated November 1 to November 16, 2023, showed: -No documentation of physician notification of glucose readings above 400 mmol/l on 11/3/23, 11/4/23, 11/10/23, and 11/13/23. -No nursing assessment documented at the time of, or after the High glucose readings. -On 11/14/23 at 2:12 P.M., the resident was sent to the hospital due to high reading blood sugar. The on call physician was notified and orders were received for 10 units of Humalog insulin. Blood sugar was still high after 15 minutes and one hour. The on call nurse was notified and orders were received to send the resident to the hospital. Review of the physician order sheet, dated November 2023, showed: -Humalog 100 units/ml give 10 units one time only for high blood sugar with an order date of 11/14/23. Review of the resident's progress notes, dated November 12, 2023 to November 15, 2023, showed: -The resident was alert and disoriented with no complaints. Observation on 11/14/23 at 1:32 P.M., showed EMS was on the special care unit with Resident #72. He/She was in his/her wheelchair, alert, leaning forward, not talking, eyes open, smiling at EMS staff, sitting in the dining room doorway. The resident had an intravenous line in the right forearm. EMS staff was seen squeezing the bag of saline fluid. EMS staff asked LPN A when the resident had a normal blood glucose. LPN A said it was last week. Review of the resident's hospital record showed the resident was treated in the emergency room for hyperglycemia (high blood sugar: If not treated, hyperglycemia can become severe and cause serious health problems: such as damage to the blood vessels, heart, kidneys, eyes, including a diabetic coma, that require emergency care) of 455 mmol/l. The resident was treated and discharged back to the facility 11/14/23. During an interview on 11/15/23 at 11:32 A.M., LPN A said he/she only calls the physician or NP if the resident's blood sugar is above 400 to 450 or below 60. He/She called the NP due to a reading of high on the blood glucose monitor. He/She gave the resident extra insulin as ordered. He/She waited 15 minutes and the Accuchecks read high so he/she waited an hour then notified the NP again. He/She was the nurse on Monday (11/13/23) and did not notify the NP or physician of any other Accuchecks for resident #72. If the physician or NP is notified it should be charted. During an interview on 11/15/23 at 3:49 P.M., NP A said staff do not inform her of daily blood glucose levels. Staff did not call her or notify her the resident's blood glucose was high for 2-3 days. She would expect staff to follow the orders the resident has. She was in the facility on Monday 11/13/23, but did not see Resident #72. The resident has a do not hold insulin order because he/she is a brittle diabetic (hard-to-control diabetes (also called labile diabetes). It is characterized by wide variations or swings in blood glucose (sugar) in which blood glucose levels can quickly become too high.) During an interview on 11/16/23 at 12:49 P.M., CMT A said: -When a resident has change of condition the protocol was to grab a nurse and have the nurse complete an assessment; -Some nurses are agency and did not know residents; -Everyday that he/she worked the charge nurse was new and did not know the residents baseline; -If a resident's blood sugar was low he/she would grab a glass of orange juice and notify the nurse; -He/she would recheck the resident in an hour or maybe shorter time and contact the physician if blood sugar was bad; -He/she would not let a resident go three days with a change of condition without notifying the physician; -The physician should be notified right away. During an interview on 11/15/23 at 11:57 A.M., the primary care physician said he was not called daily about changes in condition or elevated blood sugars for Resident #72. There are 2 NPs who go to the facility every other day and staff tend to notify them of changes. The NP should be notified of high glucose readings or if someone was not eating or drinking well. The NP should be notified of any change in condition. If the staff are unable to get in touch with the NP then he would expect a call. He/She would expect the facility to follow physician orders. 47195 NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visits, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation.

Based on observation, interview, and record review, the facility failed to manage pain for one resident, (Resident #10), when staff failed to assess and document resident's pain, administer pain medication timely and provide non-pharmacological (non medication ways to prevent pain such as ice, positioning, meditation, etc) pain relief measures, in a review of 20 sampled residents. The facility census was 96. The facility did not provide a policy on pain control. Review of Resident #10's quarterly Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff), dated 4/13/23, showed: -Brief Interview of Mental Status (BIMS) of 15, indicated no cognitive deficits. -Independent for Activities of Daily Living (ADL's: tasks completed in a day to care for yourself such as bathing, eating, dressing, getting up from a chair or bed and using the toilet). -Pain marked as none. Review of the resident's face sheet showed diagnoses of hemiplegia (paralysis of one side of the body), syncope ( a loss of consciousness for a short period of time) and collapse, orthostatic hypotension (a condition in which your blood pressure suddenly drops when you stand up from a seated or lying position), acquired absence of the right leg above the knee (amputation of the leg above the knee joint), and arthritis of the knee. Review of the resident's undated comprehensive care plan showed no care plan for pain. Review of the resident's progress notes showed: -5/8/23 at 11:12 P.M., x-ray completed on left knee with results of acute distal femur fracture. Staff called and left a message for the physician. Director of Nursing (DON) notified and she gave an order to send the resident to the hospital. -5/10/23 at 11:16 A.M., the resident was reviewed in fall/safety meeting after recent fall. The following day the resident complained of knee pain, an x-ray was completed and the resident was sent to an area hospital. Review of the resident's hospital medical record showed: -5/8/23 at 10:55 P.M., x-ray of left knee completed with results of acute comminuted (producing multiple bone splinters.) displaced (the bone snaps into two or more parts and moves so that the two ends are not lined up straight) fracture of the left femur. -5/10/23 at 4:46 P.M., operative report showed the resident had intermedullary nailing (a metal rod that is inserted into the cavity of a bone and across the fracture to provide a solid support for the fractured bone) of the left femur. -5/12/23 at 10:18 A.M., discharge order was given for Percocet 10 milligram (mg)/325mg, one tablet every four hours as needed for pain. Review of the resident's May 2023 physician order sheets showed: -Percocet, (a medication used to treat moderately severe pain) 10 mg/325 mg, one tablet every four hours as needed for pain. Ordered 5/12/23. -Acetaminophen (Tylenol) 650 mg every six hours as needed for pain. Ordered 5/12/23. -Ibuprofen 600 mg twice a day as needed for pain. Ordered 12/2/21. -Tramadol 100 mg twice a day for pain. Ordered 2/8/22. -Document Pain Assessment every shift with pain scale. Ordered 11/17/20 Review of the resident's progress notes showed: -5/15/23 at 3:38 A.M., the resident continued to complain of pain of 8 of 10. Pain medication was administered. -5/16/23 at 2:27 P.M., the resident had poor appetite and complained of some pain. -5/16/23 at 7:57 P.M., the resident complained of pain at a 9 of 10. Pain medication relieved pain to a level of 5 of 10. -5/18/23 at 2:32 A M., the resident complained of pain of 9 of 10. -Staff did not document any attempts of pain relief with non pharmacological interventions. Review of the resident's medication administration record for May 2023 showed: -Tramadol 100 mg twice a day for pain; given twice May 1st through 19th. -Ibuprofen 600 mg twice daily as needed for pain; was not given to the resident after the fall. -Acetaminophen 650 mg every 6 hours as needed for pain given once on 5/12/23; -Percocet 10 mg/350 mg every 4 hours given on: 5/13/23 at 12:00 A. M. , 2:00 P.M., and 6:15 P.M.; 5/14/23 at 10:00 A.M.; 5/15/23 at 8:15 P.M.; 5/16/23 at 3:30 A.M., 7:30 A.M., 12:15 P.M., 5:30 P.M. and 8:00 P.M.; 5/17/23 at 10:00 A. M., 3:15 P.M., 7:45 P.M.; 5/18/23 at 12:00 A.M., and 5:00 A.M. -Pain assessments were not documented every shift as ordered. During an interview and observation on 5/16/23 at 9:49 A.M., the resident said he/she fell two weeks ago and busted up his/her leg. The pain medication was not helping for more than 30 minutes at a time. He/she rated his/her pain at 9 on a 0-10 scale (0 is no pain, 10 is worst pain ever). He/she was not able to get up to shower or eat at times, because the pain was too bad. He/she was having muscle spasms at times. He/she had told the nurse he/she was in pain that morning. Staff told him/her he/she could not have pain medication unless he/she asked for it; staff don't always let him/her have it when he/she asks. Observation showed the resident was writhing and twisting in bed, eyes closed, facial grimacing, and groaning. Observation and interview on 5/16/23 at 4:17 P.M., showed the resident moaning, writhing and twisting in bed, eyes closed, facial grimacing, he/she rated pain at 10 and had not had pain medication for awhile. He/she had told the nurse but had not gotten anything for pain. Observation showed no staff in immediate area and unable to locate staff to notify of the resident's pain. During an interview on 5/22/23 at 4:55 P.M., Orthopedic office nurse A said the facility had called the office on 5/16/23 at 1:34 P.M. about the resident's pain. No new orders were given. Observation and interview on 5/17/23 at 5:27 P.M., showed the resident was wheeled down the hall by staff, moaning, and said so much pain repetitively. He/she rated pain at 9. During an interview 5/17/23 at 5:27 P.M., Licensed Practical Nurse C said the resident had a pain pill about 30-45 minutes ago and he/she could not have another one. During an interview on 5/18/23 at 9:34 A.M., Registered Nurse (RN) A said the residents's fall occurred when he/she came back in from outside after smoking. The resident went to his/her room and tried to transfer him/herself to his/her bed from the electric scooter. The scooter was not turned off, and it moved away causing the fall. He/she had several conversations with the resident about the need to ask for assistance The resident's pain was not well controlled. He/she had sat with the resident for hours and observed the resident moaning and crying, but there was not much to do because the resident has a history of alcohol abuse. He/she called the physician yesterday about dressings for wounds caused from the fall and the surgical procedure. The physician had not returned the call. He/she would ask about pain medication when the doctor called back. During an interview on 5/18/23 at 10:45 A.M., RN A said he/she called the surgeon's office, and the physician said with the resident's history of alcohol abuse he/she would not change the medication and staff should have used ice and non-pharmacological (non-medication) pain relief measures. During an interview on 5/22/23 at 4:22 P.M., the Director of Nursing (DON) said she was aware the resident was having some pain. The Charge Nurse had been in contact with the physician about the resident's pain. She was not aware those attempts were not documented. She would expect all attempts to reach a physician to be documented. During an interview on 5/22/23 at 4:33 P.M., the Administrator said she was aware the resident had been complaining of pain. The Charge Nurse had been in contact with the physician's office several times. She would expect the nurse to follow the physician's orders and follow up with the physician if no return call. She would expect attempts to reach the physician to be documented in the medical record. She would expect the nurse to respond to the resident complaints of a 9 on the pain scale. If the resident was in so much pain she would expect him/her to want the acetaminophen or ibuprofen offered in addition to the as needed Percocet that he/she was taking. During an interview on 6/8/23 at 3:53 P.M., the Orthopedic Surgery Nurse said the surgeon was not notified of the resident's continued pain issues. The facility physician should address the pain issues. The resident's surgeon only sends out the first prescription for pain medication when a person was done with surgery. There are no notes in Resident #10's chart the facility tried to call. His/her physician or the facility physician should manage the pain. Facility staff had told him/her the resident did drugs or alcohol. Regardless of alcohol or drug use the house physician or the resident's physician, should be the one to manage his/her pain. During an interview on 5/22/23 at 2:23 P.M., the Medical Director said he had not been in the building for a couple of weeks. He reviewed all incidents in weekly meetings. He would expect to be notified by nursing staff if a resident was having uncontrolled pain.

Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #84) out of 18 sampled residents, was not ordered and administered medications which were not required to treat medical symptoms and resulted in altering the resident's behavior, such that the resident required a lesser amount of effort or care. Observations showed the resident sleeping for prolonged periods of time, had difficulty keeping eyes open when talking, speech was slow and soft with words slow and elongated during enunciation and incontinent. The facility failed to ensure the resident used the least restrictive dosage of medication to treat a medical symptom; failed to address the underlying causes of the distressed behavior; and failed to develop and implement non-pharmalogical individualized interventions prior to administering medications. The facility census was 89 residents. Review of the facility provided Resident Bill of Rights, dated 11/2017, showed in part: -The right to be free of physical and chemical restraints. Review of the facility provided policy; Behavior Management and Psycho-Pharmacological Medication Monitoring Protocol, dated 3/2018, showed in part: -Residents who receive antipsychotic, antidepressant, sedative/hypnotic or anti-anxiety medication are to be maintained at the safest lowest dosage necessary to manage the resident's condition. Residents will be reviewed routinely for effectiveness and monitored for side effects of these medications. Residents with behaviors that are displayed routinely, that effect the resident's psychosocial well-being or that of other residents, or behaviors that can have potential for harm to self or others will be assessed with development of a behavior program. Definitions: -Behavioral Interventions are individualized non-pharmacological approaches to care that are provided as part of a supportive physical and psychosocial environment, and are directed toward understanding, preventing, relieving, and/or accommodating a resident's distress or loss of abilities as well as maintaining or improving a residents mental, physical and psychosocial well-being. Established resident with new onset of adverse behaviors: -The admitting physician will be notified to rule out medical causes, which may be contributing to the behavior. 1. Review of Resident #84 Admission Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 9/1/22, showed: -BIMS of 99: indicates the resident's inability to complete the assessment, or severe cognitive defect -Independent for ADLs -Always continent of bowel and bladder -Physical behaviors (such as hitting, kicking or spitting) 1-3 days. -No rejection of cares -Wanders (traveling aimlessly place to place: a typical behavior with dementia diagnosis) 4-6 days -Reading books/magazines, music, current news,going outside, and religious practices are somewhat important to the resident. -Diagnoses: Alzheimer's (a brain disorder that affects the ability to remember, think clearly, communicate, and perform daily activities and may cause changes in mood and personality) and Hypertensive Heart Disease (heart problems that occur because of high blood pressure). Review of the resident's Initial Care Plan, dated 10/20/22, showed: -No behaviors noted. Review of the resident's undated Care Plan showed: -Risk for elopement; wanderguard in place, redirect from exits, encourage activities of choice; -Potential to strike out at staff, poor impulse control; Administer medications as ordered, give choices,when becoming agitated intervene, guide away from source of distress, engage calmly in conversation, if no response walk away and approach later. Review of family written undated Care Plan posted on the resident's wall showed: -Please show him/her anything while talking. Point at stuff while talking/explaining things to help him/her get a full understanding and if there are different options involved; -If he/she is not responding or understanding - show him/her; -He/she doesn't need much done for him/her, but explain what he/she is doing and how it will help him/her or you; -We have to follow the rules; -For women- project loudly as he/she has a hard time hearing women's voices; -Go slow, be patient; -Do one thing at a time; -Say things in ways that he/she is helping others by doing what you are having him/her do; -Any way you can say it to help you or him/her, NOT a demand; -He/she had a pool table and likes to play; -He/she enjoys: -Music: 80/90s country, Beach Boys and Monkeys; -TV: Historical, crime/police,comedy, sports events; -He/she does not like westerns or basketball; -Signs of frustration include: -Scratching back of head and slowly becomes more intense; -Looking around, straightening out and not making eye contact - means he/she wants you to go away or stop having him/her do what it is; -Grinding teeth; -A straight blank focused stare; -Shaking of head - like he/she is shaking off what you're telling him/her; -Tight squeezing of hands in and out; - Hitting his/her own head with his/her hands or against something; -This is when he /she is very overwhelmed and peak frustration/anger. During an interview on 11/15/22 at 11:53 A.M., the resident family member said: -prior to coming to the facility, the resident went to the gym three times a week, he/she liked walks, and to watch sporting events; -he/she had specific television shows programmed on the TV for the resident, but the staff will not turn them on for the resident; -staff should not tell the resident what to do. The resident has to be talked to, and the resident will not do something if he/she is told to do it; -the resident is now incontinent, has a shuffling walk, and needs help he/she did not need prior. Review of the resident's medical record showed: -Progress noted dated 8/27/22 at 2:56 P.M.: The resident admitted with a diagnosis of Dementia. He/she was alert and oriented x 2-3, only uses 1-2 words to answer. He/she wanders and is exit seeking. He/she is not aggressive. Review of the Physician Order Sheet (POS), dated 8/27/22, showed: -Donepezil Hcl (a medicine that helps with some types of dementia and can improve memory, attention, the ability to interact with others, speak, think clearly, and perform regular daily activities) 10 milligrams (mg) 1 tablet daily for Alzheimer's, ordered 8/27/22; -Depakote DR (a mood stabilizer that decreases the excitability of brain cells and can cause sedation) 125 mg sprinkle caplets, take 2 tablets three times a day ordered 8/27/22; -Vistaril (a medication used to treat anxiety or itching and may be used as sedation) 25 mg every 8 hours as needed for anxiety, ordered 8/27/22. Record review of the manufacturer's prescribing guidelines for Vistaril showed: -Sedating drugs may cause confusion and over sedation in the elderly; elderly patients generally should be started on low doses of Vistaril and observed closely; -The effectiveness of hydroxyzine as an antianxiety agent for long-term use, that is, more than 4 months, has not been assessed by systematic clinical studies. The physician should reassess periodically the usefulness of the drug for the individual patient. Record review of the manufacturer's guidelines for Depakote DR showed it has been approved for the following uses: -to treat manic episodes associated with bipolar disorder -alone or with other medicines to treat: complex partial seizures in adults and/or simple and complex absence seizures, with or without other seizure types -to prevent migraine headaches. Review of the resident's medical record showed the resident did not have any of the above indications for use. Record review of the manufacturer's guidelines for Depakote DR showed it can cause drowsiness or sleepiness in the elderly. Review of the resident's medical record, dated 8/27/22 to 9/1/22, showed no documented behaviors, no exit seeking behaviors, and no aggression towards staff or other residents. Review of the resident's medical record showed: - Progress notes, dated 9/1/22 at 5:37 P.M., showed Charge Nurse reported the resident was noted to be agitated, insisting to go home and balled his/her fist as if he/she was going to attempt to strike the 1 to 1 staff member. Attempted to calm the resident and explain the Public Administrator would have to give permission. Resident continued to state he/she wanted to go home. Again explained that leaving the facility was not safe, this seemed to increase residents agitation. He/she smacked him/herself in the head several times, approached the writer and slapped him/her with an open palm in the side of the head. Staff members began to gather to assist and resident slapped his/her own head with open palm, then charged at the writer. 911 called for assistance. Resident transported to area emergency room (ER). - 9/1/22 at 6:22 P.M. The resident was sent out, after he/she balled up fist in 1 to 1 staff members face and demanded for door to be opened and him/her let out. Explained he/she needed to talk with social services and he/she began getting agitated. The resident was then taken to the supervisor office. -Progress note on 9/2/22 at 12:49 A.M., showed: The resident returned from ER with no new orders. Review of the POS, dated 9/6/22, showed: -Buspirone Hcl (a medication used to treat anxiety) 5 mg three times a day for anxiety, ordered 9/6/22; administer as ordered. The resident's record did not include details on why the medication was ordered or who ordered it. -Wanderguard (a bracelet and alarm system used to monitor when someone wearing the bracelet is close to a door or attempting to exit a door): check placement and function every shift, ordered 9/6/22. Review of the POS, dated 9/9/22, showed: -Depakote DR order increased to 375 mg three times a day. The diagnosis listed for treatment was agitation, however, there was no documentation to show the reason for the increase. Review of the resident's medical record dated 9/2/22 to 9/11/22 showed no documented behaviors, no exit seeking behaviors, and no aggression towards staff or other residents. Review of the residents medical record showed: -Progress notes, dated 9/12/22 at 11:08 A.M., the resident tested positive for COVID and placed in isolation unit. Review of the POS, dated 9/12/22, showed: -Zyprexa (an antipsychotic used to treat schizophrenia, bipolar disorder) 5mg every 8 hours for agitation/aggression, ordered 9/12/22, administered as ordered. The resident's record did not show documentation as to why the medication was ordered. Review of the manufacturer's guidelines for Zyprexa showed: - it is used to treat certain mental/mood conditions (such as schizophrenia, bipolar disorder); - it may also be used in combination with other medication to treat depression; -side effects include drowsiness -elderly patients with dementia-related psychosis treated with olanzapine are at an increased risk of death compared to placebo. Zyprexa is not approved for the treatment of patients with dementia-related psychosis. Review of the resident's medical record, dated 9/13/22 at 1:51 A.M., showed: -The resident refused vital signs. Resident will not stay in his/her room and becomes agitated with staff when encouraging him/her to stay in his room. Resident tried to push past staff and was threatening. Nurse Practitioner called and order received to send to ER. He/she was given Zyprexa medication in the ER and returned to the facility. Returned at 11:58 P.M. He/she remains 1:1 and resting in his/her new room in isolation. Nurse practitioner called and order for Zyprexa received. Review of the resident's medical record, dated 9/13/22, showed no documentation to address the underlying causes of the distressed behavior; or any non-invasive individualized interventions prior to administering medications, or sending the resident to the hospital. Review of the resident's medical record, dated 9/14/22 to 10/7/22, showed no documented behaviors, no exit seeking behaviors, no aggression towards staff or other residents. Review of Behavior Intervention Monthly Flow Record showed: -No behaviors noted for September 2022; -No documentation of interventions to address the underlying causes of the distressed behavior or any non-invasive individualized interventions prior to the administration of the antipsychotic medication. Review of the POS, dated 10/7/22 to 10/21/22, showed: -Depakote DR order increased to 500mg three times a day ordered 10/7/22, administered as ordered. The resident's record did not contain documentation to support the use or increased dosage of the medication. Review of resident's medical record, dated 10/12/22 to 10/15/22, showed: -Progress notes dated 10/12/22 at 1:29 A.M., The resident was walking and pacing during later evening. Given Vistaril. He/she was sleeping most of this time. -Progress notes, dated 10/14/22 at 12:17 A.M., The resident was pacing the halls most of the evening. Vistaril given. -Progress notes, dated 10/15/22 to 10/21/22, showed no behaviors noted. -No documentation to address the underlying causes of the distressed behavior or any non-invasive individualized interventions. Review of the POS dated 10/22/22 to 10/28/22 showed: - Ativan 0.25mg at 4 PM daily, ordered 10/21/22. The resident's record did not include documentation to support the use of the medications. The order was received verbally, however, there was no physician signature on the order. Review of the manufacturer's guidelines for Ativan showed: -Should be used with caution in elderly due to the risk of sedation and/or musculoskeletal weakness that can increase the risk of falls, with serious consequences in this population; -Elderly or debilitated patients may show a more sensitive response to the effects of Ativan; therefore, these patients should be more frequently monitored and given a reduced dose; -Side effects of sedation, drowsiness, dizziness, ataxia (impaired balance and coordination) Review of the medical records showed no documentation to address the underlying causes of the distressed behavior or any non-invasive individualized interventions prior to the order of the Ativan on 10/21/22. Review of the resident's medical record, dated 10/22/22 to 10/27/22, showed no behaviors documented. Review of the resident's medical record, dated 10/28/22 at 11:47 P.M., showed: -The resident had increased pacing, given Vistaril as ordered. -No documentation to address the underlying causes of the distressed behavior or any non-invasive individualized interventions prior to the administration of the Vistaril. Review of the resident's medical record showed no consultation with psychiatry or psychology to address the behaviors prior to the administration of the antipsychotic medications. No documentation of the resident or the administration of the antipsychotic medication in the weekly risk management meetings. Review of Behavior Intervention Monthly Flow Record showed: -Continuous pacing and striking out noted on October 25, 27, and 30, 2022; with intervention of medication. -No other interventions noted for times of pacing/striking out. -No documentation to address the underlying causes of the distressed behavior or any non-invasive individualized interventions prior to the administration of the antipsychotic medication. Review of the resident's Medication Administration Record showed Vistaril was given without documentation to address the underlying causes of the distressed behavior or any non-invasive individualized interventions prior to the administration of the antipsychotic medication: -10/11/22 at 8:30 P.M. for anxiety, follow up showed resident was resting; -10/18/22 at 8:30 P.M. for anxiety, follow up showed resident was asleep; -10/25/22 at 7:30 P.M. no indication for use; -10/27/22 at 7:30 P.M. no indication for use, follow up showed resident was resting; -10/29/22 at 7:30 P.M. for anxiety; -10/30/22 at 7:30 P.M. for anxiety, follow up showed resident was resting; -10/31/22 at 1:30 P.M. for anxiety; Observations on 11/01/22 beginning at 8:44 A.M., showed: - Resident was lying in bed, on top of covers, head to the far left corner and feet toward the far right corner; one shoe off and one shoe on, snoring with mouth open, staff sitting at bedside. -At 10:54 A.M., the resident remained in bed in the same position and continued to snore with mouth open. -At 1:21 P.M., The resident was in bed, remained in same position, continued to snore with mouth open. -Staff sitting at bedside with no resident interaction. During an interview on 11/1/22 at 1:21 P.M., Certified Nurse Aide (CNA) F said: -Staff stay with the resident all the time. -He/she sleeps a lot and does not get up much. -He/she sleeps more in the last couple of weeks. -There have been no behaviors today; he/she has only slept today. -He/she was 1:1 for trying to leave. -Staff are to call the nurse if behaviors occur. -No other interventions, call nurse for assistance. Observation on 11/02/22 at 10:51 A.M., showed: -The resident was in bed, on his/her back. -One side half covered by sheet. -Staff sitting at bedside no with resident interaction. When asked about the resident still being in bed, staff replied he/she was sleeping in. Observation on 11/02/22 at 12:01 P.M., showed: -CNA D in room. -The resident was physically assisted to stand and sit in a bed side chair by CNA D. -The resident was having difficulty keeping eyes open when talking. -The resident's speech was slow and soft, words are slow and elongated during enunciation. -Resident's bottom sheet noted to have multiple and varying brown rings of dried urine. -CNA D assisted the resident to the restroom with fresh clothing. During an observation and interview on 11/02/22 at 12:09 P.M., showed: -The resident was in bed, lying on his/her back. -CNA D said: -The resident had not been up today. -The resident had been sleeping a lot recently. -He/she calls the nurse if behavior occurs. -There are no other interventions for behaviors, except calling the nurse. During an interview on 11/03/22 at 8:55 A.M., CNA G said: -The resident has never had behaviors with him/her. -If the resident starts patting his/her head staff need to back away, and give him/her some space. -The resident's behaviors are about how he/she was approached. -When staff introduce themselves and start kindly it all goes well, and he/she has no behaviors. -Staff can't tell him/her what to do, that does not work. -His/her family made this care plan (indicating the care plan on the wall) and it was very helpful, if it's used. -He/she would notify the nurse if behaviors occurred. During an interview on 11/03/22 at 9:21 A.M., Licensed Practical Nurse (LPN) E said: -If the resident has any behaviors the CNAs will yell for help. -When staff call for help, the resident is assessed and redirection is attempted by him/her. -Medication is administered if needed. -Only nurses can administer as needed medication. -If that doesn't work then the Police are called for assistance. -The resident only hit staff one time, early in his/her stay in the facility. -The resident had never been away from his/her family so it's very hard for him/her. -If the resident was having a bad day he/she calls the family. They have a very good relationship. Observation on 11/3/22 at 3:30 P.M., showed: -The resident was up walking in the hall. -Steps are slow and shuffling. -He/she answers questions with one word answers. -Resident requested to dance, then walked back to his/her room. During an interview on 11/03/22 at 3:46 PM the Social Service Director (SSD) said: -The resident was currently 1 on 1 with CNAs. -He/she did not have 1 on 1 visits with the resident. -He/she does rounds every morning to ensure the resident has his/her wanderguard bracelet on. -The resident was not seen by psychologist. -The resident had an order for a Psychiatry consult, then got COVID. -The resident has been seen by Psychiatry. -He/she was unsure why the Psychiatry notes aren't in the residents chart. -There are no other interventions to deal with the resident's behaviors besides those that are listed in the care plan. During an interview on 11/03/22 at 3:50 P.M., the Social Service Aide said: -He/she does not sit or visit with the resident. -He/she waves or says hello only. During an interview on 11/03/22 at 3:45 P.M., the Director of Nursing (DON) said: -He/she expects staff to follow the care plan for any resident specific needs prior to medication use. -He/she expects staff to notify the Charge Nurse to handle behaviors. -He/she expects staff to have ongoing training and education about behaviors and interventions. -Medications are ordered by the nurse practitioner or physician and adjusted as needed. During an interview on 11/03/22 at 4:05 P.M., the administrator said: -He/she expects staff to attempt redirection for behaviors. -He/she expects staff to notify the Charge Nurse of behaviors. -He/she expects the resident care plan to be followed. -Medications are adjusted after behavior meeting every week if needed. During an interview on 11/23/22 at 9:03 A.M., the facility Medical Director/Primary Care Physician (PCP) A said: -Behavior meetings are conducted every week, which includes discussions of behaviors and medications. He/she does attend these meetings. -He/she does not remember discussing this particular resident at the weekly meetings. -Zyprexa should not have been started without an approved diagnosis. -Agitation is not an approved diagnosis for use of Zyprexa. -Shuffling gait, slow speech and sleeping long amounts of time are considered extrapyramidal side effects (a group of symptoms that can occur in people taking antipsychotic medications which can include slower thought processes, slower movements, rigid muscles, difficulty speaking, feeling restless, or muscles to involuntarily contract and contort). -The use of antipsychotic medications with for a dementia diagnoses only is unacceptable. -Psychotropics should be added one at a time to determine the effectiveness of each medication. -He/she was not aware the resident was on all of the medications.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #55) out of 45 sampled residents was free from mental abuse when a staff member used his/her cell phone to record the resident as he/she was out in the hallway, on the floor with his/her legs extended in front of him/her and his/her night gown was above the top of his/her legs exposing his/her thighs and hip area. The staff member, who was present in the video, posted the video to social media to share it with others and included a demeaning comment about the resident who he/she described to have fallen multiple times and had just fallen again. The resident, who had dementia, was unaware the he/she was being recorded. The facility census was 86. Review of the facility Abuse Prevention Policy, dated 11/2017, showed: -The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. -Mental abuse is defined as the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation including staff taking or using photographs or recordings in any manner that would demean or humiliate a resident. -All facility staff shall be in-serviced upon initial employment regarding Resident's Rights, including freedom from abuse, neglect, mistreatment, misappropriation of property, and exploitation and the related reporting requirements and obligations. -Train employees, through orientation and on-going sessions on issues related to abuse prohibition practices such as: What constitutes abuse, neglect, exploitation and misappropriation of resident property. -Training will also include prohibiting staff from using any type of equipment (e.g., cameras, smart phones, and other electronic devices) to take, keep, or distribute photographs and recordings of residents that are demeaning or humiliating. Review of the facility's Personal Cellular Phone Usage policy, dated 1/2012, showed: -Personal cell phone must be shut off and are not to be carried during the work day. Review of the facility's Social Media Policy, dated 4/2012, showed: -Personal use of social media on Company time and/or equipment, including but not limited to computers, servers, other electronic systems, is strictly prohibited. -Employees may not share information online regarding the Company's confidential or proprietary information. This includes, but is not limited to, information about nursing home residents, employees or vendors. -When using social media, the Company expects employees to be respectful and professional. You may not post discriminatory, defamatory, libelous, or slanderous comments when discussing the Company, managers, supervisors, co-workers, facility residents, vendors or our competitors. 1. Review of Resident #55's Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff , dated 12/23/21, showed a Brief Interview for Mental Status (BIMS), a structured evaluation aimed at evaluating aspects of cognition in elderly patients score of 11. This indicates mildly impaired cognition. Review of the resident's quarterly MDS, dated [DATE], showed: -Adequate hearing and vision, understands others and able to make self understood -BIMS was not assessed. -No behaviors noted; -Extensive assistance with all transfers and toileting; -Limited assistance with personal hygiene. -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident comprehensive care plan, dated 4/14/22, showed: -Due to my cognitive impairment and impaired thought processes I am forgetful and make exaggerated comments. Review of the undated video recording provided by the facility on 5/9/22 10:10 A.M., showed: -The video posted to Snapchat on 5/7/22 was 16 seconds long. -The text across the video screen showed, Y tf I pick up this double maneeee this lady fell 2 times in 30 mins now she tryna fight us, followed by three laughing emojis. A banner with Tonights Vibe was visible in the lower portion of the video. -At 0:00 seconds, the video starts with an image of a person wearing a light blue mask, dark shirt, and an animal print headband/headwrap. -At 0:02 seconds, the video then shows the resident sitting on the floor, legs extended in front of him/her. He/she was wearing a dark blue night gown that was pushed up to the top of his/her legs. There was a piece of red clothing/fabric and a pair of black and white shoes between the resident's legs. He/she was waving a silver and blue grabber in the air. -The resident and staff member are speaking in the video, but not unable to be determined what was being said. Review of the resident's Progress Notes showed: -5/9/22 at 11:35 A.M., signed by Social Worker B: Attempt made to notify the resident's guardian regarding the resident being posted on a social media outlet. Message left for guardian to return call. -5/9/22 at 1:36 P.M., signed by Social Worker B: This writer spoke with the resident's guardian, public administrator deputy, informed deputy of social media incident. Let the deputy know the facility did an inservice on abuse, neglect and social media policy on 4/29/22 and was doing a complete house in-service today and tomorrow on abuse, neglect, and social media policy. Deputy will talk to the public administrator to determine if law enforcement will be contacted. During an interview on 5/10/22 at 9:03 A.M., the resident said: -The staff have their cell phones with them a lot. -Staff have their phones out in his/her room, because they know he/she will not tell on them. -There was a staff member who had his/her phone out in the resident's room this past weekend. The staff must have been new as the resident had not seen him/her many times. -The resident did not know the staff member's name. -The resident did recall falling over the weekend. -He/she did not know if the staff took any pictures or video of him/her. During an interview on 5/10/22 at 1:45 P.M., the resident said: -He/she was aware of social media, such as Facebook. -The resident was not aware of what Snapchat was. -Did not know a staff member took a video of him/her on the floor over the weekend. -The resident would not have consented to this. -This made the resident angry, hurt his/her feelings, and made him/her sad that someone would do that to him/her. During an interview on 5/10/22 at 2:45 PM, the deputy of the [NAME] County Public Administrator said: -The resident is not his/her own person. The [NAME] County Public Administrator is the resident's legal guardian. -The [NAME] County Public Administrator contacted law enforcement and filed a police report regarding the incident. -The deputy says he/she knows the resident well and the resident would not consent to having the video taken or posted to a public platform. During an interview on 5/10/22 at 9:46 A.M., CNA B said: -He/she worked the morning shift, 6:00 A.M. to 2:00 P.M., Monday through Friday. CNA A worked the weekends. -CNA B was at home on Sunday, 5/8/22, in the evening, looking at Snapchat on his/her phone. -CNA B was friends with CNA A on Snapchat and sees what he/she posts. -The video came up on Snapchat and CNA B recognized the resident from the facility. -CNA B saved the video to his/her cell phone. During an interview on 5/11/22 at 1:45 P.M., CNA B said: -He/she first saw the video on Snapchat on Sunday, 5/8/22 at 2:44 A.M. -The timestamp on the video showed it had been posted 12 hours prior, at approximately 2:44 P.M. on Saturday, 5/7/22. -CNA A posted the video on his/her story, did not send it directly to CNA B. -CNA B arrived at work on Monday, 5/9/22 at 6:00 A.M. He/she began getting residents up for the day, and then assisting residents with breakfast. Breakfast was served at 7:30 A.M. -After finishing assisting with breakfast, CNA B went to speak with the SDC. The SDC instructed CNA B to immediately go and inform the Administrator of the video. -CNA B had not received training on abuse, neglect and exploitation, and when to report. During an interview on 5/12/22 at 8:20 A.M., CNA B said: -Confirmed the staff member in the video posted to Snapchat was facility staff member CNA A. During an interview on 5/13/22 at 12:12 P.M., CNA B said: -He/she did not have service or minutes on his/her phone at home, and could not call the office on Sunday, 5/8/22, so he/she saved the video to his/her cell phone. -He/she would not have called on Sunday, but would have waited until Monday morning. -He/she had worked with the resident previously. -No one from the facility had spoken to CNA B previously or this week about resident abuse. -CNA B was not sure that he/she was a mandated reporter. -CNA B knew the video was wrong, he/she did not like it and knew the resident would not like it. -CNA B again confirmed the staff member in the video was CNA A. During an interview on 5/11/22 at 11:33 A.M., the SDC said: -He/she was made aware of the video on Monday, 5/9/22. It was later in the morning, between 9:00 A.M. and 10:00 A.M. -He/she had not watched the video, but was aware of its contents. -When CNA B informed the SDC of the video, the SDC instructed CNA B to go directly to the Administrator to report the video. -There is a no cell phone usage policy at the facility. Staff cannot use cell phones when working on a hall or in a room. Staff cannot have earbuds in either. -He/she conducted an inservice on 4/29/22 for all staff about abuse and neglect and cell phone usage. This inservice was conducted as part of training that are conducted every pay day. -It was difficult to ensure training of all staff, with agency staff frequently working in the building. -Agency staff do not receive the facility's policies or procedures before working in the facility. During an interview on 5/11/22 at 3:50 P.M., the SDC said: -He/she confirmed the staff member in the video was CNA A. During an interview on 5/11/22 at 2:34 P.M., CNA A said: -He/she worked Saturday, 5/7/22, the 2:00 P.M. 10:00 P.M. shift, then the night shift, 10:00 P.M. to 6:00 A.M. into Sunday 5/8/22. -CNA A worked on F hall, then C hall, then back to F hall for the night shift. -He/she did help out on B hall. -CNA denied taking the video of the resident. -CNA denied having a Snapchat account. -The aide in the video was an agency aide who was working at the same time and looks similar to CNA A. CNA A did not know this agency staff's name. -CNA A had worked with the resident before. -CNA A had not received training from the facility on abuse, neglect, and misappropriation, cell phone usage, or social media usage. -When asked why the name of the Snapchat account the video was posted from contained CNA A's first name, he/she again denied he/she had a Snapchat account. During an interview on 5/11/22 at 10:10 A.M., the Administrator said: -It was his/her expectation staff should report suspected abuse immediately. However, the staff who reported the incident was not working at the time he/she saw the video. -Abuse reporting timelines are covered in the abuse and neglect training all staff receive, but he/she was unsure if the training specifically covers reporting when the employee was not working. -He/she did not have documentation that CNA A received training on social media or cell phone usage. -It was his/her expectation staff follow facility policy, not use their cell phones while working, and not take pictures/video of the residents, and not post images of residents to social media. During an interview on 5/12/22 at 3:23 P.M., the Administrator said: -He/she did consider this incident abuse and was investigating it as an act of abuse. MO 2

Based on observations, interviews, and record review, the staff failed to ensure residents remained free from accident hazards, and failed to provide adequate supervision and assistance devices to prevent accidents. Staff failed to initiate their elopement protocol timely when one sample resident (Resident #36), identified as being at risk for eloping, left the facility through a window in the dining room, and staff did not notify administration for 1 hour and 45 minutes after the resident was unable to be located. The resident was found 3 hours and 15 minutes later, was intoxicated, and was 2.8 miles away from the facility. Staff failed to use proper transfer techniques to reduce the possibility of accidents and injuries when staff did not use a mechanical lift properly to transfer two residents (Residents #27 and #5). Staff failed to fully complete smoking assessments, provide adequate supervision for residents identified as needing supervised smoking, and failed to supply smokers' aprons for residents who required them for three sampled residents (Residents #3, #47 and #81). The facility census was 126. 1. Review of the facility's undated Missing Resident/Elopements policy showed: - The unit charge nurse is responsible for knowing the location of their residents. When residents are participating in various programs, such as physical therapy, recreational activities, dining, etc., the staff in these programs will be responsible for the location of their participants. - Should an employee discover that a resident is missing from the facility, he/she should: -Determine if the resident is out on an authorized [NAME] or pass. If not; -Initiate Dr. Wander code and make a thorough search of the building and premise. -If not located; -Notify the Executive Director and the Director of Nursing Services (DON); -Notify the resident's legal representative; -Notify the attending physician; -Notify law enforcement officials; -If necessary, notify volunteer agencies; -Provide search teams with resident identification information; -Make an extensive search of the surrounding areas. - At any time at which a resident is determined missing, the following procedures will be strictly followed: -Alert: the supervisor/charge nurse will alert all other personnel by all-paging Dr. Wander and location (including unit, floor and room number); -Search: A search of the immediate area (buildings) will be initiated under the shift supervisor/charge nurse. All rooms will be searched (including locked rooms). The shift supervisor/charge nurse will designate staff to search the area surrounding the building, as appropriate (patio, parking lot, etc.) -Contacts: If the search of the immediate area is unsuccessful, the shift supervisor/charge nurse will immediately contact the -Executive Director and DON; -Local Police Department; -Family/responsible party; -Vice President of Operations; -Attending Physician/Medical Director; -Department of Health & Senior Services. 1. Review of Resident #36's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/1/20, showed: - Resident unable to complete a brief interview for cognitive status; had short- and long-term memory problems; moderately impaired, poor decision-making, needs cues, supervision required; did have evidence of an acute change in mental status from baseline; suffered from inattention and staying focused; - No evidence of [CONDITION(S)], no behaviors, no wandering; - Independent with bed mobility and transfers; supervision with walking, moving on and off the nursing unit, eating, toilet use and personal hygiene; limited assistance with dressing and bathing; used a walker and wheelchair for mobility; - Diagnoses included high blood pressure, diabetes, [CONDITION(S)] (loss of ability to understand or express speech, caused by brain damage), [CONDITION(S)], non-traumatic intracerebral hemorrhage (brain bleed), alcohol dependency and repeated falls; - Had falls prior to admission. Review of the resident's hospital discharge records, dated 6/24/20, showed: - Chief complaint: bilateral subdural hemorrhage (a type of bleeding that often occurs outside the brain as a result of a severe head injury); - Patient dropped off at the emergency department (ED) by a family member secondary to altered mental status and confusion. Patient unable to provide history as he/she is confused. History obtained from chart review and ED staff. Per report, has been confused for 3 days, apparently abuses alcohol and has had frequent falls. In ER, code stroke was activated, imaging showed acute left subdural hemorrhage and right intraparenchymal hemorrhage (a brain bleed that accounts for 8-13% of all strokes). Review of the resident's Risk of Elopement Evaluation, dated 6/24/20, showed: - admitted [DATE]; - Alert and oriented to person only; - Ambulates independently; - Not at risk of elopement; - A line drawn through the page and discontinued 7/10/20 written at the bottom. Review of the care plan showed: - Problem onset 6/24/20: I have impaired mobility related to traumatic brain injury (TBI); I am able to propel myself in my wheelchair; - Problem onset 6/24/20: I am at risk for falls related to history of falls and TBI; - Problem onset 6/24/20: I have had a TBI and at risk for showing behaviors. Handwritten underneath this staff wrote I am impulsive and get agitated easily; I will yell and curse at peers; - Problem onset originally left blank but 6/24/20 had been handwritten in: I am at risk for elopement. I have tried to leave the facility and have made comments about leaving. Staff handwrote I will take my wanderguard (used as a device to sound an alarm if the device goes past a door with the alarm equipped) off. Elopement assessment quarterly and with any changes; wanderguard in place, calmly redirect away from exit doors; 10/13/20 engage in conversations; discuss safe discharge plans; 12/11/20 wanderguard to wheelchair. Review of the resident's departmental notes showed: - 6/25/20 at 4:31 P.M., ambulates him/herself down the hall; confused as to where he/she is and wanted to leave. Called son which seemed to calm him/her down. Unable to make needs known; uncertain how much he/she understands what is said to him/her. Can propel self in wheelchair very fast with legs; has made several attempts to leave the unit. Review of the Social History / Psychosocial Assessment, dated 7/2/20, showed: - admitted : 6/24/20; - Parents are unable to care for him/her at home, lived with parents previously; - History of substance abuse: yes, alcohol; - Restless and anxious; - Behaviors Yes: Attempts to leave - exit seeking; wanders; wants to leave; - What helps to calm the resident? 1:1 supervision; - Recent changes in cognition: TBI; - Can the resident make medical decisions for self? Yes, has not been deemed incapacitated, recovering from brain injury. Review of the resident's departmental notes showed: - 7/10/20 at 9:38 A.M., resident approached this nurse stating that he/she was leaving, that his/her dad was coming to get him/her. The resident had all of his/her belongings gathered on his/her bed. Elopement assessment updated by social services (SSW) and wanderguard placed on right ankle. Review of the Risk of Elopement Evaluation, dated 7/10/20, showed: - Non-traumatic intracerebral hemorrhage; alert to person and place; - Recent move of room or facility; statements such as I'm going home, how do I get out of here or have to catch a bus; - Ambulates independently with assistive devices; - Yes, resident is at risk for elopement, monitoring bracelet applied, door alarms; - Care plan completed and reviewed with family; - Diversional activities: watching TV, conversations, adult coloring. Review of departmental notes showed: - 7/14/20 at 6:19 A.M., unable to verbalize wants and needs effectively. New order for speech therapy to evaluate. No mention of exit seeking behaviors. - No departmental notes written until 7/18/20 at 2:54 A.M., the resident is alert with some confusion at times. Continues on every 15 minute checks related to exit seeking. The resident had one episode this shift that he/she was found at the rotunda, seemed like he/she was lost and was looking for ice water. The resident was easily redirected and gave him/her ice water. He/she went to his/her room; no acute changes at this time. Review of the handwritten interdisciplinary progress notes, showed: - 7/18/20 6:00 A.M. to 6:00 P.M., the resident continues on behavior monitoring; is alert with mild confusion noted. Up in wheelchair and wandering around on the hall. The resident continues to have exit seeking behaviors but is easily redirected by staff. Staff continue to check on the resident every 15 minutes to ensure safety. Review of the departmental notes dated 7/19/20 at 1:24 A.M., showed: - The resident is alert with confusion at times; - Continues to be on every 15 minute checks related to exit seeking; - No exit seeking exhibited this shift. Review of the handwritten interdisciplinary progress notes for 7/19/20 showed: - 6:00 A.M. to 6:00 P.M.: continues on 15 minute checks; alert and mild baseline confusion noted. He/she stayed in his/her room during the morning time, then came out during lunch time and wandered around. Staff easily redirected back to room and activities. Staff check on the resident every 15 minutes to ensure safety and reassure the resident; - 6:00 A.M. to 6:00 P.M., the resident pushed on entrance door and set off alarm. He/she went out the door at approximately 1:45 P.M. and oncoming staff was able to bring him/her safely back into the building. The resident is responsible for self and mother notified. Administrator and Director of Nursing (DON) notified, physician notified and given new orders for lab work including a drug screen. The resident has a history of confusion and could not answer where he/she was going. The resident has a new order for 1:1, staff member remains with the resident. Review of the SBAR (Situation, Background and Resident Evaluation) Communication Form, dated 7/19/20 at 1:45 P.M., showed: - Change in condition is: exit seeking; - This started on 7/19/20; since this started it has gotten: Better; - Primary diagnoses: non-traumatic intracerebral hemorrhage, multiple localized. - No changes observed. Review of the departmental notes showed: - 7/20/20 at 2:54 A.M.: the resident is alert with confusion at times, remains on every 15 minute checks due to exit seeking behaviors. The resident has not exhibited any signs of exit seeking thus far this shift, has been in his/her room sleeping on and off; - 7/21/20 at 1:28 P.M.: the resident continues on 24 hour one on one monitoring related to elopement risk, wandering and agitation. The resident is somewhat compliant with this arrangement but is argumentative with every attempt at care; - 7/21/20 at 4:44 P.M.: a psychiatric evaluation was completed today; resident has 1:1 supervision due to exit seeking behaviors. Wanderguard bracelet is being worn; - 8/7/20 at 4:12 A.M.: The resident remains on 15 minute checks related to removing his/her wanderguard; - 8/8/20 at 1:49 P.M.: Resident doing well with room move and has voiced no complaints. Resident able to make most wants and needs known with baseline confusion and forgetfulness at times. No noted behaviors on this shift thus far and has not attempted wandering on shift. The resident has been transferring without assistance; - 8/9/20 at 12:24 P.M.: Resident is continuing on every 15 minute checks; has not attempted to remove wanderguard or leave facility; - 8/17/20 at 1:10 P.M.: Resident continues on every 15 minute checks with no exit seeking behaviors noted. Resident is verbalizing that he/she is leaving this week however no exit seeking; - 8/19/20 at 2:57 P.M.: Resident on 15 minute checks, has had no elopement attempts, no falls noted, resident up as desired (ad lib), gait (walking) steady, has been in room and hallway during this shift; - 9/5/20 at 9:43 P.M.: Continues on behavior monitoring, states he/she is stir crazy and wants to get outta here but has not displayed any exit seeking behaviors thus far on shift; - 9/6/20 at 9:56 P.M.: Resident removed wanderguard anklet this evening, do not have replacement bracelet so did not attempt to replace at this time, SSW notified; - 9/7/20 at 3:53 P.M.: has had no overt behaviors this shift, pleasant and cooperative with staff, resident refused to allow this nurse to replace wanderguard, stated I'm not going to go anywhere; - 9/18/20 at 5:02 P.M.: resident mentioned of an unnoticeable fall he/she had yesterday while getting out of wheelchair; - 10/8/20 at 1:48 P.M.: no plan for discharge, homeless prior to admission and is recovering from a traumatic brain injury. Speech has improved, alert and oriented to person, place and time. He/she has had verbal outbursts at times and has punched the B-wing TV. He/she speaks about wanting to leave but does not have a discharge destination. He/she is able to transfer and ambulate independently but uses wheelchair when out of his/her room. - 12/10/20 at 7:32 P.M.: nurse went to check placement and function of wanderguard and noted that the resident did not have one on. When asked what happened to it, the resident said he/she took it off. Notified appropriate parties and SSW attempted to apply and resident refused. Waited approximately 15 to 20 minutes and went to attempt placement. Resident immediately became upset and started yelling, NO, NO, you are not going to put that thing on me! I already told them I ain't wearing that! DON notified and resident placed on 15 minute checks. Review of the resident's risk of elopement evaluation showed staff reviewed this on 12/11/20 and made no changes, still stating the resident was at risk for elopement and wore a wanderguard. Review of the departmental notes showed no nursing notes regarding completion of 15 minute checks after 12/10/20 and no notes between 12/10/20 and 12/31/20 when the registered dietitian wrote a note. No other departmental notes written until 1/5/21. Review of the quarterly MDS, dated [DATE], showed: - A BIMS score of 15, which indicted no cognitive impairment; - A score of zero on the resident mood interview to indicate no evidence of depression; - No behaviors noted, which included physical and verbal behavioral symptoms toward others, wandering, and refusal of care; - Independent with all activities of daily living. Review of the resident's risk of elopement evaluation showed staff reviewed this on 12/30/20 and made no changes, still stating the resident was at risk for elopement and wore a wanderguard. Review of the resident's January 2021 physician's order sheet (POS) showed: - [MEDICATION(S)] 25 milligrams (mg) take one capsule by mouth four times a day as needed (PRN) for anxiety and agitation, order date 7/20/20; staff marked through the order and wrote D/Ced (discontinued) 1/7/21; - [MEDICATION(S)] 25 mg capsule, give one capsule every six hours, hold for sedation; order date 1/7/21; - 1/21/21 D/C [MEDICATION(S)] 25 mg every six hours; start [MEDICATION(S)] 25 mg every eight hours. - Check Function and placement of wanderguard every shift; order date 10/21/20. Review of the departmental notes showed: - 1/5/21 at 3:51 A.M.: Resident is alert and oriented, able to voice needs to staff, currently on behavior monitoring related to an altercation with another resident, no behaviors noted. Resident has been staying on E-hall and goes to the main dining room off and on, stated that his/her room was called, he/she wants to be discharged from the facility. The resident was being redirected and encourage him/her to keep face mask to cover both nose and mouth, placed on 15 minute checks; - 1/5/21 at 10:37 A.M. Noted 1/4/21: noted to have increased verbal aggression towards resident. Nursing staff redirected resident, effective. Nursing staff removed resident from hallway and all stressors. Nursing staff will continue to monitor for behaviors and frequent checks to prevent any further incidents; - 1/6/21 at 2:13 A.M.: in bed at this time. Has informed this nurse that he/she is unhappy with new room and new roommate. Stated that he/she is back in a room located by the outside door, which causes him/her to be cold. Was found in dining room watching a movie at this time; - 1/7/21 at 6:02 A.M.: In good spirits but continues to request another room/roommate. Stayed in dining room watching TV until he/she decided to go to bed; - 1/7/21 at 4:00 P.M.: Behavior Meeting: reviewed for recent behaviors, increased agitation and a confrontation with a peer. Review of the resident's care plan showed: - Problem onset 1/7/21; - Resident hopes to discharge to the community to a group home or assisted living facility; Review of the departmental notes showed: - 1/12/21 at 12:12 A.M.: resident continues to refuse [MEDICATION(S)] (given for anxiety and agitation) at midnight. Resident informed this writer to not come to his/her room with 6:00 A.M. [MEDICATION(S)] because he/she was not going to take it; - 1/13/21 at 1:30 A.M.: resident refused 6:00 A.M. [MEDICATION(S)]; - 1/14/21 at 3:27 A.M.: Continues to refuse [MEDICATION(S)] during night; - 1/15/21 at 5:59 A.M.: refused [MEDICATION(S)] during this shift; - 1/19/21 at 8:29 P.M.: Took [MEDICATION(S)] this morning, but refused noon dose; - 1/20/21 at 3:01 A.M.: continues to refuse [MEDICATION(S)], teaching was provided with no success; - 1/22/21 3:44 A.M.: Refused [MEDICATION(S)] during this shift; - No nursing notes indicated staff notified the physician of the resident's continued refusal of [MEDICATION(S)]; no nurses' notes between 1/22/21 and 1/26/21 at 1:56 A.M. Review of the departmental notes for 1/26/21 showed Licensed Practical Nurse (LPN) E documented the following: - 1:56 A.M., resident was unable to be found to get accucheck, insulin and medication at 8:45 P.M. and 9:00 P.M. Resident was seen in hallway going toward the dining room at 8:30 P.M. by this nurse. Resident's wheelchair was observed in dining room area by certified medication technician (CMT), who informed this nurse that the resident was not in the wheelchair in dining area. This nurse went to observe and look for the resident. When this nurse could not find the resident, nurse manager LPN G was informed of the resident missing and a Dr. Wander was announced over page at 10:00 P.M. Staff continued to search for the resident and were unable to find him/her. Administration, physician, resident's mother and policed notified of resident not being in the facility. This nurse was informed that the resident had been apprehended by police and that the resident was requesting to go to the hospital. Will continue to monitor and report. Review of the facility's initial report/investigation completed by the Administrator showed: - On 1/25/21 at approximately 8:30 P.M., the resident was seen using his/her wheelchair to ambulate down the hallway toward the dining room by LPN M. At approximately 8:45 P.M., staff were looking for him/her to dispense medication and initially noted he/she was not in his/her room or visiting with other residents on C-wing where he/she resided. LPN M checked but did not see the resident in the dining room and then staff checked on other halls and could not located him; - At approximately 10:00 P.M., staff initiated Elopement Protocols. At approximately 10:05 P.M., the DON was notified and she notified the Administrator. Staff continued to search rooms, bathrooms and perimeter of the building. DON reported to the facility at approximately 10:30 P.M. and began providing direction to facility personnel. At approximately 10:41 P.M. the administrator called the Director of Social Services (DSS) who said the resident had not been behaving in any unusual manner earlier in the day. DSS suggested that the resident might have been trying to get to his/her parents' house. At approximately 10:56 P.M., the police department was contacted. At approximately 10:59 P.M., the resident's parent was contacted. He/She reported that the resident had been asking to come home, and that he/she thought the resident may be headed that way and would let the facility know if he/she showed up. Administrator reported to the facility at approximately 11:00 P.M. Police were provided with a picture and description of the resident. The picture was also faxed to local emergency room s. Since staff had searched the immediate area around the building, the police and Administrator searched several walkways and local 24-hour businesses; - Administrator told the police that the resident might be trying to get this his/her parents' house and provided the address. At approximately 12:30 A.M. (on 1/26/21), the administrator told DSS (who was in route to the facility) to go the address and see if he/she could find the resident in route. Administrator told police about the parents' address being a possible destination. The police expanded the search by notifying the adjoining city's police department; - At approximately 12:13 A.M., Administrator received a call from the police department stating that the resident had been found approximately 2.8 miles from the facility. He/she had no apparent injuries and was being taken to a local hospital. Report from the hospital showed the resident had an elevated alcohol level. At approximately 12:52 A.M., the medical director was notified. The resident's mother was notified via voicemail; - At approximately 2:00 A.M., Administrator went to the local hospital emergency room . The resident was being belligerent and uncooperative with staff. He/she would not say how he/she left the building or why. The resident was admitted for observation; - Conclusion: unsubstantiated for deficient practice. The resident has a BIMS of 15 and is capable of making his/her own decision to leave the facility. He/she is his/her own person, with no guardian or durable power of attorney. He/she chose to circumvent active measures the facility had in place to learn if a resident was leaving the building without authorization. He/she did not follow the protocol for signing out of the building; - Action Plan: -Resident has been re-educated on letting staff know when he/she is going to leave the building and signing out; -The resident has signed a contract that he/she will sign out of the building; -Staff have been educated on having the resident sign out or having him/her notify before going outside; -The resident's family members have been educated on the need to let the facility know if the resident is voicing that he/she plans to leave the facility; -The resident's care plan was updated regarding leave of absence without signing out or notifying staff; -Pocket care guide was updated regarding leave of absence without signing out or notifying staff. During an interview on 4/8/21, at 3:54 P.M., LPN M said the night the resident left the building he/she did the usual things. He/she ate dinner then roamed the building. Staff noticed they were not able to locate him/her but found his/her wheelchair empty in the dining room and he/she noticed a screen out of one of the windows. He/she began a search of the whole building and he/she did not think it took too long. He/she located the nurse manager on duty, LPN G and Dr. Wander was paged. He/she could not remember who made the page but thought it might have been LPN G. Staff were looking for him/her before the Dr. Wander page went out, but did not look downstairs. They were just having a problem finding him/her. During an interview on 3/25/21 at 2:35 P.M., LPN G said he/she was in the building the night the resident eloped and was working the floor as a charge nurse. LPN M did not officially notify him/her that the resident was missing. They met in the rotunda at about 10:00 P.M., and LPN M asked in passing if he/she had seen the resident, that he/she was looking for the resident for medication pass. LPN G questioned LPN M if it was just looking or really gone to which LPN M said really gone. Once he/she knew the resident was really gone, he/she paged Dr. Wander, called the DON and Administrator and continued to search for the resident. At that point, it was out of his/her hands. LPN G said LPN M should have notified him/her as soon as they began the search for the resident and they found his/her wheelchair in the dining room with the wanderguard still attached. He/she did not know why there had been such a delay in implementing the missing resident protocol. During an interview on 3/24/21, at 12:45 P.M., the Administrator said staff notified him at about 10:00 P.M. that the resident was not found in the building. He started the protocol immediately after he was notified. He contacted the police department and had DSS drive by the resident's mother's home in case the resident had been headed that way. The police department found the resident and took him/her to the hospital where he/she was found to be intoxicated. The resident had a tendency to take off the wanderguard so they placed it on the wheelchair, where they found it after he/she left the building. He completed the investigation and the times listed in the report were accurate. Review of the departmental notes for 1/26/21 showed: - 5:29 A.M., this nurse called local hospital to inquire about resident's status. Was informed by ER nurse that the resident was admitted . No other information would be given at this time; - Entered by the DON on 1/26/21 5:15 P.M., late entry to reflect 1/26/21 at 2:00 A.M., at 10:05 P.M. on 1/25/21, this writer was notified by a nurse at the facility that the resident could not be located and Dr. Wander had been called. This writer arrived at the facility at approximately 10:30 P.M. and spoke with charge nurse who had last seen the resident at 8:30 P.M. Nurse reported that the resident was not able to be found when he/she went to administer insulin. The writer began to look in the resident room, down C-hall, then moved search to the dining room and outside of building to the perimeter of the building. At 10:59 P.M., attempted to reach the resident's parent, left voicemail. At 11:00 P.M. called resident's parent back and informed him/her of the situation. He/She had reported that the resident had been asking to come home and that he/she thought the resident may be headed that way. He/She would call if he/she showed up there. Resident's parent also stated that he/she did not hold the facility responsible if anything happened while the resident was out of the facility. Police were notified by administrator and arrived at approximately 11:00 P.M. Police were here taking information to help search for resident. Resident was found by police approximately 2.8 miles from the facility at 12:35 A.M. and was taken to the hospital with no apparent injuries. Report from hospital indicated that the resident's alcohol level was elevated at 262.6. Resident was admitted , physician was notified at 12:52 A.M., of elopement and finding of resident. Attempted to notify the resident's parent that he/she had been found, left voicemail. Review of the hospital discharge summary, dated 1/29/21, showed: - Chief Complaint: Altered mental status, history of brain injury, alcohol intoxication; - Admission 1/26/21 at 12:50 A.M.; discharged on [DATE]; - Discharge diagnoses: uncontrolled diabetes, left knee pain; alcohol dependency, history of TBI; - [MEDICATION(S)] (blood alcohol level, which means that one tenth of a percent of a person's blood volume is alcohol or that a person has 1 part alcohol per 1000 parts blood. At a blood [MEDICATION(S)] level of less than 50 mg/dL, or 0.05% concentration, an individual is not considered to be intoxicated) 262.6 milligrams per deciliter (mg/dL); [MEDICATION(S)] 0.263% at 1:31 A.M. - Has a history of subdural hematoma status post craniotomy in June 2020, uncontrolled diabetes, [CONDITION(S)], alcohol abuse was brought in by emergency medical services (EMS) for agitation. The patient escaped the nursing home and drank alcohol. Patient is repetitive and a poor historian unable to answer questions surrounding his/her hospitalization . Unclear as to how much alcohol patient consumed. Unclear as to when patient last took insulin. At the time of the evaluation, the patient was agitated and not easily redirected. - Patient was placed on Clinical Institute Withdrawal Assessment (CIWA) protocol for alcohol dependence as he/she had drank prior to admission. Blood sugars became controlled. Was very reluctant to return to nursing home and very much wanted to discharge to the care of family, however are unable to care for him/her at this time as he/she does require 24-hour supervision. During an interview on 3/25/21 at 11:30 A.M., CMT A said if they notice a resident is missing, staff notify the charge nurse and should immediately start the search of the building. The charge nurse will announce Dr. Wander so everyone knows to look for the resident. Staff have access to the Elopement Book, which is kept at each nurses' station. Review of the facility's elopement book, found on each of the nurses' stations on 3/25/21 showed the books contained a picture of every resident who resided in the facility with a box to indicate if the resident was an elopement risk or not. The book included Resident #36's picture, even though he/she discharged on [DATE] to another facility. The book did not include three residents' pictures who were new admissions; Resident #121 admitted on [DATE], Resident #75 admitted on [DATE] and Resident #107 admitted on [DATE]. During an interview on 3/25/21 at 12:10 P.M., the DON said the DSS and her department updated the Elopement book when residents were admitted . During an interview on 3/25/21 at 12:10 P.M., the DSS said the medical records department updated the Elopement Book with new admissions or changes to a resident's status. They have a color printer so they print the pictures out. During an interview on 3/25/21 at 12:17 P.M. and 3:50 P.M., the DON and the Consultant Nurse said: - They were not sure why medical records updated the Elopement Book. They are not sure how often the book was updated; - Staff should have implemented the elopement protocol as soon as they noticed the resident was not there then notified the DON; - She expected that call to come relatively quickly, like five to ten minutes after they've discovered the resident missing. - Their policy really did not say a time frame, but they waited until they were certain the resident was not in the building; - She completed in-services, elopement drills, made sure exits were all secure and that the Elopement Book was up to date; - Keeping the book up to date was a group effort. Admissions completed the elopement assessments, then notified the DSS for a wanderguard; medical records prints out pictures and updates the book; - Wish they would have notified someone sooner that the resident was missing as he/she had time to go to the store, buy a pint of whiskey and was intoxicated when the police found him/her. During an interview on 3/25/21 at 4:46 P.M., the Family Nurse Practitioner who worked with the resident's primary care physician said they did know the resident left the facility in the middle of the night. She felt staff acted appropriately when he/she left. Staff should implement the Missing Resident Protocol within an hour of realizing the resident is missing. She did not feel staff could have done anything to stop him/her from leaving. 2. The facility did not provide a policy for transfers and how to determine the appropriate methods of transfers for residents. Review of Resident #5's quarterly MDS, dated [DATE], showed: - Staff attempted to complete the BIMS interview but the resident could not answer; short- and long-term memory loss; - Total dependence on staff for bed mobility, bathing and transfer

Based on observations, interviews, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice when: the facility failed to notify the physician when Residents #377 and #1 sustained a change in condition; failed to obtain physician ordered labs and notify the physician and the responsible party when Resident #377 refused to have labs drawn and failed to ensure an indwelling catheter was maintained and free from infection for Resident #377; and failed to obtain and complete physician ordered treatments to bilateral lower extremities for Residents #24 and #93. The facility census was 126. Review of facility policy, Notification of a Change in a Resident's Status, dated 11/17 showed: -The attending physician/physician extender and the resident representative will be notified of a change in a resident's condition, per standards of practice and federal and/or state regulations. -Guideline for notification of physician/responsible party includes: significant change in/or unstable vital signs, change in level of consciousness, abnormal lab findings, unusual behavior, symptoms of any infectious process, repeated refusals to take prescribed medication (for two days), onset of pressure sores, emesis/diarrhea; -Document in the Interdisciplinary Team (IDT) notes: resident change in condition, physician/physician extender notification, notification of responsible party. 1. Review of Resident #377 MDS dated [DATE] showed: -Alert and oriented; -Extensive assistance with ADL's; -Indwelling catheter (a tube inserted into the bladder to drain urine), incontinent of bowels; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . [CONDITION(S)] symptoms usually begin gradually and get worse over time. As the disease progresses, people may have difficulty walking and talking.), and [CONDITION(S)] (a long-term mental disorder of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation.). Review of the care plan for indwelling catheter dated 7/10/20 showed: -Indwelling catheter related to Stage 3 Pressure Ulcer (PU - involves full-thickness skin loss potentially extending into the subcutaneous tissue layer) to the coccyx; urinary tract infection (UTI) added 7/31/20 -Goal: Show no signs of infection and UTI will resolve; -Approaches: secure catheter with device to prevent injury; catheter care every shift and as needed (PRN); wound care plus to evaluate and treat (7/17/20); Cefdinar (is used to treat a wide variety of bacterial infections.) daily for seven days (7/31/20). Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -Cefdinar 300 mg capsule, take one capsule daily for seven days, order date of 7/31/20 with no documentation of medication administered. Review of the nurse's notes showed: -7/11/20 at 7:42 P.M. resident remains on COVD-19 (COVID-19 is a disease caused by [CONDITION(S)]-CoV-2 that can trigger what doctors call a respiratory tract infection. It can affect your upper respiratory tract (sinuses, nose, and throat) or lower respiratory tract (windpipe and lungs). Tracking due to COVID-19, on droplet precautions; 7/12/20 at 3:02 A.M. signed by the Wound Nurse, continues COVID-19 positive with resident resting quietly with no complaints of cough or dyspnea (difficulty breathing). Dressing intact to coccyx; -7/17/20 at 6:20 A.M. signed by the Wound Nurse, wound care plus to evaluate and treat and nurse practitioner will see today on wound rounds, cleanse coccyx wound with wound cleanser, pat dry, gently pack with calcium alginate type dressing and cover with protective dressing, change daily and PRN -7/17/20 3:25 P.M. signed by the Wound Nurse, resident resting quietly will continue to educate staff regarding positioning related to wound on coccyx and will look at providing food in a manner that makes feeding self easier. Wound measures 2.0 cm by 2.0 cm by 0.6 cm. -7/27/20 4:26 P.M. signed by Registered Nurse (RN) B, called to the residents room to assess. Resident was ice cold to touch. Resident was making comments on seeing [NAME] the Pooh in the mirror and saying he/she was seeing things that were not there. Resident was extremely weak and unable to lift arm. Lethargic and sleepy. Vital signs: blood pressure (BP) 90/50 (normal 120/80), pulse 92, oxygen saturation at 90%, temperature 93.4 degrees (normal 97 to 99 degrees). Called Director of Nursing (DON) and she advised to recheck the temperature, reposition and call the doctor. Doctor called with orders to send the resident to the hospital for evaluation. Called the DON and she called the doctor to get an order to do labs. Fluids and urinalysis at this time. PICC nurse (a nurse trained to insert intravenous (IV) (a line inserted into a vein) lines for medication and fluids) arrived at approximately 4:00 P.M. with an IV and stat (immediately) of CBC (complete blood count, the red blood cells, white blood cells, and platelets are counted. The CBC is used to test for, diagnose, and monitor many different conditions) and CMP (A comprehensive metabolic panel (CMP) is a test that measures 14 different substances in your blood. It provides important information about your body's chemical balance and metabolism.). Will continue to monitor and follow up as needed. (Staff did not document the resident was sent to the hospital as ordered by the physician.) Review of the medical record showed: -UA collected on 7/27/20 showed positive for UTI (urinary tract infection). -Orders received for Cefdinar 300 mg daily. Review of the medical record showed no results for the stat CPC or CMP. Review of the nurse's notes showed: -7/30/20 at 5:20 P.M. resident transferred to the unit on 7/29/20, alert and oriented, resident IV line flushed, indwelling catheter care given, peri area red and smells, urine is red and cloudy. Unit manager and DON notified of catheter, and encouraged to keep catheter in place; -7/31/20 at 1:46 P.M. resident received new order per the DON for [MEDICATION(S)] (Infusion is used for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . It is used in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .) 0.9%, 100 millimeters (ml) per hour times one liter via IV. Lung sounds diminished. Catheter draining with brown urine with sediment. Vital signs: BP 110/65, pulse 88, respirations 17, temperature 96.9 and oxygen saturation 94%. Review of the Physician Order Sheet (POS) dated July 2020 showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record showed no laboratory results for the CBC or CMP ordered on 7/31/20. Review of the medical record showed no documentation of the physician notification for the CBC or the CMP not done on 7/27/20 or 7/31/20. Review of the nurse's note dated 8/1/20 at 4:22 P.M. showed: -Vital signs BP 109/59, pulse 100, respirations 19, temperature 99.2, oxygen saturation 90%. Resident started on seven day course of antibiotic today. Resident is sleepy on this shift but able to rouse easily. Reported fever to physician on call. Labs were drawn this morning with results pending. Catheter draining yellow urine with sediment. One plus [CONDITION(S)] (swelling) in both lower extremities (BLE). Wound treatment completed to coccyx. Old dressing had no date written and there was a foul odor when removing the dressing. Review of the nurse's notes dated 8/4/20 at 1:44 P.M. showed: -At 12:16 P.M. BP 89/66; at 1:16 P.M. BP 152/122. Review of the nurse's note dated 8/4/20 at 6:36 P.M. showed: -Nurse Practitioner in to see the resident, new orders received to hold Losartan (a medication used to treat high blood pressure) and Metopropol (used to treat chest pain (angina), heart failure, and high blood pressure) for three days. STAT CBC and BMP (this panel measures the blood levels of blood urea [MEDICATION(S)] (BUN), calcium, [MEDICATION(S)], chloride, creatinine, glucose, potassium, and sodium). Resident refused for labs to be drawn. Review of the medical record showed no documentation of the physician or the responsible party being notified of the resident's refusal for the labs to be drawn on 8/4/20. Review of the nurse's note dated 8/5/20 at 1:40 P.M. showed: -Lab was here to draw labs again today. The resident refused to let the lab tech draw the labs. Review of the medical record showed not documentation of the physician or the responsible party being notified of the resident's refusal for the labs to be drawn on 8/5/20. Review of the nurse's note dated 8/5/20 at 7:09 P.M. showed: -The resident was sent to the hospital this shift. BP 90/55, pulse 121, temperature 97.9, respiration of 17, oxygen saturation 92%. The resident has a wound that is not healing on the bottom. Review of the nurse's note dated 8/6/20 at 1:55 A.M. showed: -BP 80/49, temperature 100.7, pulse 134, respirations 22. It was noted around 2:00 P.M. that the resident had a change in condition. Resident had a low BP, a high temperature and a change in level of consciousness. The physician was notified and gave an order to send the resident to the hospital. Review of the hospital emergency room records dated 8/5/20 at 4:41 P.M. showed: -Sent to the hospital by facility staff due to fever and altered mental status; -The resident is unable to give any history. According to the facility staff, the resident has been having a fever. Report that the resident has been tested for COVID-19. They state that he/she is typically alert and communicating. The resident is bedridden; -Temperature 102.0, pulse 129, respiration is 14, BP 157/90.; -Skin is warm and dry, the resident has a very large coccyx PU; -Diminished breath sounds in lung bases with some rhonchi (a whistling or snoring sound heard on auscultation of the chest when the air channels are partly obstructed), poor catheter care. The resident has bilateral boots on, to help with heel wounds. There is some breakdown on his/her heels. -The resident presents for a care facility, with fever, altered mental status. Concerned about possible [CONDITION(S)] ([CONDITION(S)] is a potentially life-threatening condition that occurs when the body's response to an infection damages its own tissues.); -Nursing staff made aware that there is a very large PU that their fist can get into, there was foul purulent drainage noted. The resident has some sloughing of the skin. Poor indwelling catheter and perineum (abdominal folds) care; -The resident having a large PU, coming in with altered mental status, and fever, concerned about [CONDITION(S)]. The resident also has evidence of a urinary tract infection; -Assessment/Final Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] .), [CONDITION(S)] UTI, COVID-19, large PU. Review of the lab results from the hospital dated 8/5/20 showed: -RBC (red blood cells) 2.66 (normal 4.7 to 6.1); HGB (hemoglobin) 8.6 (normal 12.0 to 15.5); WBC (white blood cells, indicator of infection) 19.5%; BUN (blood urea [MEDICATION(S)], indicator of infection in the urine) 25 (normal 7 to 20) and CRP (c-reactive protein, [CONDITION(S)] marker) 25.6 (normal 10). Review of the history and physical from the hospital dated 8/5/20 showed: -Assessment and Plan: [CONDITION(S)]: fever, leukocytosis (a condition in which the white cell (leukocyte count) is above the normal range in the blood. It is frequently a sign of an [CONDITION(S)] response, most commonly the result of infection), altered mental status. Potentially due to bacterial infection from stool in the PU. Indwelling catheter appeared very dirty in the ER, consideration for UTI and positive for COVID-19. Review of the surgery consultation report from the hospital dated 8/7/20 showed: -The resident was brought in with septic shock. He/she had blood cultures positive for Gram-positive rods and the UA was positive for Gram-negative rod and [MEDICATION(S)]. He/she had extensive stage 4 PU over his/her sacrum and heels; -Assessment: septic shock secondary to massive stage 4 PU involving the sacrum, multiple PU involving his/her bilateral heels and feet; -Plan: There is a massive amount of soft tissue loss as well as a massive amount of exposed bone, debridement is necessary, but given his/her underlying severe neurological condition from which there is not recovery from, serious consideration should be made to involve palliative care. Review of the discharge summary from the hospital dated 8/13/20 showed: -Discharge diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -The resident was started on broad spectrum antibiotics with multiple consultants. The resident was admitted to the intensive care unit and received aggressive IV fluid hydration. All consultants were in agreement that the resident would likely require a large debridement of the sacral PU. Given his/her medical comorbidities and poor nutritional status the resident would not likely recover from surgery. This was discussed with the resident's family and the resident was placed on hospice. During an interview on 3/19/21 at 2:30 P.M. the Medical Director said: -He does not recall the resident or the circumstances involving the resident, but the nursing personnel at the facility have been trained and educated on treating residents with IV fluids and monitoring for changes of condition and it would have been acceptable to keep the resident at the facility and treat the resident with IV fluids. During an interview on 3/19/21 at 8:30 A.M. RN B said: -He/she remembers the resident's name, but he/she does not recall the circumstances of 7/27/20. He/she remembers that the resident did have a change of condition, but does not remember if the resident was sent to the hospital; -If a resident had a change of condition, and the physician gave orders to send the resident to the hospital, he/she would send the resident to the hospital. During an interview on 3/23/21 at 9:10 A.M. the DON said: -She called the lab responsible for the labs ordered by the facility, there was no labs drawn on the resident on 7/27/20 or 8/4/20; -She was not the DON in 7/20 or 8/20, but she would expect the nurses to notify the physician and the responsible party of any changes of condition, refusal of treatments or medication and if labs were unable to be drawn; -She would expect the nurses to document if a resident had any new PU or change in the skin, complete a skin assessment and document, notify the wound nurse of any PU or worsening of a existing PU, the wound nurse should notify the physician, document in the medical record and complete a skin assessment and wound notes; -She would expect the nurses to send a resident to the hospital if the physician gave the order to send to the hospital. 2. Review of Resident #1's admission minimum data set (a federally mandated assessment completed by facility staff), dated 11/19/2020, showed: - Active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Resident is alert and oriented to person, place and time; -Able to understand and be understood; -Needs moderate to extensive assistance with Activities of Daily Living (ADLs: such as but not limited to: bathing, brushing teeth, combing hair, washing face, using the toilet,) Review of Laboratory Tests Policy dated 11/2017 shows: The licensed nurse or designee will forward lab results to the appropriate IDT nursing and dietary staff for review. The physician or physician extender will be promptly notified of abnormal results. Review of Current Physician orders sheet showed: -Kidney, Ureter and Bladder (KUB) X-ray related to nausea and vomiting, and a Complete Blood Count ((CBC) a group of tests that evaluate the cells that circulate in blood) draw ordered 3/12/2021 for 3/15/2021. -CBC in AM call doctor with results ordered on 3/17/2021. -Oxygen at 2.5 to 5 liters per nasal cannula (a nasal device used to deliver oxygen to a person): 2.5 to 3.5 liters during the day and 5 liters at night with [CONDITION(S)] (continuous positive airway pressure therapy ([CONDITION(S)]) uses a machine to help a person who has obstructive sleep apnea. Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops and starts) ordered 1/21/2021: Review of Nurse's Notes showed: -Vital signs on 1/3/2021: Blood pressure 136/74, Pulse 73, Respirations 18, Temperature 97.3 and Oxygen Saturation 98%. (Oxygen saturation is the amount of oxygen-rich cells in the blood. The human body requires and regulates a very precise and specific balance of oxygen in the blood. Normal blood oxygen saturation levels in humans are 95-100 percent). These are within normal limits or standards for vital signs; -Vital Signs on 1/17/2021: Blood pressure 131/77, Pulse 89, Respirations 20, Temperature 97.7, Oxygen saturation not obtained (Oxygen saturation is a standard vital sign and should be monitored with every Vital sign check.); -Vital signs 2/18/2021 : Blood pressure 107/62, Pulse 63, Respirations 18, Temperature 97.5, Oxygen saturation 93%; -Vital signs on 3/9/2021: Blood pressure 115/64, Pulse 78, Respirations 20, Temperature 97.8, Oxygen saturation 85%. No note indicating that physician was notified of low Oxygen saturation or any action taken to increase oxygen saturation; -Vital signs on 3/10/2021: Blood pressure105/58, Pulse 78, Respirations 20, Temperature 96.7, Oxygen saturation 85%. No note indicating physician notified of low Oxygen saturation or any action taken to increase oxygenation; -Vital signs on 3/13/2021: Blood pressure 92/53, Pulse 83, Respiration 20, Temperature 97.1, Oxygen 96% at 3 liters of Oxygen. No notes indicating call to physician for low blood pressure. - Vital signs on 3/17/2021: Blood pressure 112/59, Pulse 80, Respirations 20, Temperature 98.3. No Oxygen saturation charted/obtained, No note that blood was drawn or physician notified. - Vital signs on 3/19/2021: Blood pressure 108/57, Pulse 69, Respirations 18, Temperature 97.7, Oxygen saturation 93% dropping to 87%. Oxygen increased to 3 liters. - 3/19/2021 lab results were reviewed and Hemoglobin (a protein in red blood cells that carries oxygen to your body's organs) was noted to be 5.8 (a critically low number. Normal levels are 12 -15.5), Emergency Medical Services was called and resident was sent to North Kansas City Hospital where he/she was admitted with obscure GI bleeding per NKCH medical records. It is not noted if the physician was notified and there is no physician's order for transfer to the hospital. During an interview and observation on 3/22/2021 at 3:20 P.M., LPN F said: -Lab results come in on the fax machine; -If the results are critical the doctor Dr is called and orders obtained obtain orders; -Call the family and note the lab; -Report goes into the doctors' Dr's book at the nurses station; -LPN F produced the doctors' Dr's communication book, which showed a note: Please address Hemoglobin Hgb 5.8 on 3/18/21. Family reported appears more confused. During an interview on 3/22/2021 at 4:05 P.M., LPN A said: -The lab calls the Charge Nurse with critical labs; -If unable to reach Charge Nurse, a message is left. -Lab reports come in on the fax machine and are reviewed by the nurse, staff notify the doctor Dr notified and report is placed in doctors' Dr's book. During an interview on 3/22/2021 at 4:21 P.M., Lab Assistant A said: -He/she attempted to contact the facility at 5:15 P.M. and 6:14 P.M. without success; -The lab results were lab faxed to the facility. 3. Review of Resident #93's quarterly MDS dated [DATE] showed: -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Alert and oriented with BIMS (a quick test to get a snapshot of how well you are functioning cognitively at the moment )of 14 out of 15; -Required supervision with transfers; -Weight 300 pounds; -No skin issues. Review of the resident's Care Plan for skin showed: -At risk for altered skin integrity; -Has a history of venous ulcers due to bilateral lower [CONDITION(S)]; -Goals of skin remaining intact with no reddened or open areas; -Approaches include treatments as ordered and reapproach several minutes later if resident refuses. Observation on 03/15/21 at 10:02 A.M. showed the resident: -Sat up in bed with both legs hanging off the side of the bed; -Bilateral Lower Exremities (Bilat LE) were dark pink in color, edematous, and scaly; -Left leg wept clear fluid onto his/her socks; -Both legs hung off the side of the bed and were not elevated. Observation on 03/16/21 at 11:10 A.M. of the resident showed: -Resident sitting up in bed with legs hanging off the side of the bed; -Bilateral Lower Extremities (BLE) were red in color, edematous, and scaly; -Left leg weeping clear fluid onto his/her socks; -Both legs hanging off the side of the bed and were not elevated. During an interview on 3/16/21 at 11:25 A.M., the resident said: -His/her legs and feet were hurting and swollen; -His/her legs and feet keep getting bigger; -A doctor came into his/her room last week; -The doctor told him/her that staff would be putting something on his/her legs to help the swelling; -No staff have been in to put anything on his/her legs; -He/she has not refused any treatment on his/her legs since the doctor visited; -He/she would like for someone to put something on his/her legs to help the swelling and pain. Record review on 3/16/21 at 11:45 A.M. of the resident's Treatment Administration Record (TAR) showed: -Physicians order on 3/7/21 to apply zeroform to BLE, wrap with curlex -then ace wrap, and change daily for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Staffs initials marked in the areas of the form for 3/7, 3/8, 3/9, 3/10; -Blank areas with no initials on 3/11, 3/12, 3/13, 3/14, 3/15, and 3/16; -The TAR showed refusals of the treatment by the resident on 3/7, 3/8, and 3/9. During an interview on 3/17/21 at 9:25 A.M., the Wound Care LPN said: -The resident refused every day he/she worked; -He/she asked the resident one time to complete the treatment and left the room after the resident refused; -He/she did not make any other attempts to complete the treatment because he/she was very busy; -He/she did not look at the care plan for the resident. During an interview on 3/16/21 at 12:20 P.M., the facility's DON said: -Staff should have followed physician orders; -He/she was not aware the TAR had not been filled out; -Staff should have initialed the TAR to indicate the treatment was completed and circled the initials if the resident refused; -Staff should have informed the DON if the resident had refused treatments; -He/she had not seen the residents Bilat LE; -He/she was not aware the resident had been complaining of pain in his/her lower extremities; -The resident should have a care plan for refusals and the staff should follow the careplan; -No staff was assigned to follow up and make sure that the nurses were completing or attempting to compete treatments for the residents. 4. Review of Resident #24's annual MDS, dated [DATE], showed: - A BIMS score of six (6) which indicated moderate cognitive impairment; - No behaviors, including wandering, during the assessment period; - Independent with bed mobility; limited assistance with transferring from bed to wheelchair and with dressing; did not walk in room or corridor; moved independently in room and corridors; extensive assistance with toilet use and personal hygiene; - No limitations in range of motion for lower extremities and used a wheelchair for mobility; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - Received a diuretic medication (water pills used to expel excess water from the body). Review of the resident's face sheet, printed on 3/19/21, showed: - admitted [DATE]; - admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] - Additional current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plan located in the front of the resident's medical records, showed: - Problem onset 3/12/19; I do have a history of small bowel obstruction and [CONDITION(S)] (a common, potentially serious bacterial skin infection. The affected skin appears swollen and red and is typically painful and warm to the touch; usually affects the skin on the lower legs) to my lower legs; Approaches included: weigh me for four weeks. If my weight is stable weigh me monthly and as needed. Report major changes to my physician. - Problem onset no date listed: I have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . - Problem onset no date listed: I am at risk for dehydration related to use of diuretics related to cardiomegaly, high blood pressure and [CONDITION(S)]. I have [CONDITION(S)] to BLE (bilateral lower extremities); my [CONDITION(S)] will remain stable through next review on 9/30/19. Approaches included tubigrips (provides [MEDICATION(S)], effective support for the management of strains, sprains, and swelling, comes in different sizes and can be cut to fit) as ordered; encourage me to elevate BLE while in bed. - Problem onset 3/13/19: I have impaired mobility related to dementia, cardiomegaly and [CONDITION(S)]. Approaches included non-skid footwear and tubigrips as ordered. - Problem onset 3/12/19: I am at risk for altered skin integrity related to impaired mobility related to dementia, cardiomegaly and [CONDITION(S)]; my skin will remain intact with no reddened or open areas through next review on 9/30/19. Approaches included tubigrips as ordered and encourage me to elevate legs in bed. Review of the physician's monthly progress note, dated 9/16/20, showed the physician noted on his assessment the resident had pitting [CONDITION(S)]. Review of the resident's March 2021 POS showed: - An order dated 3/22/19, for tubigrips, apply to BLE every day, on in the morning and off at bedtime for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . - [MEDICATION(S)] (a diuretic) 20 milligrams (mg), one tablet by mouth every day for [CONDITION(S)]; - Potassium chloride 10 milliequivalents (meq), one table by mouth every day as a supplement; - [MEDICATION(S)] Cream (seals in moisture to help heal very dry, sensitive skin) to BLE daily and as needed (PRN) for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident's weight change history, printed on 3/22/21, showed: - 11/5/20 148 pounds (lbs); - 12/9/20 150lbs; - 12/22/20 149.4lbs; - 12/29/20 149.0lbs; - 1/7/21 149.0lbs. Review of the resident's departmental notes showed: - 1/13/21 at 10:58 A.M. Quarterly registered dietitian (RD) note: current weight 149lbs., weight well maintained, has limited mobility to bed and wheelchair. Review of the resident's weight change history showed: - 2/2/21 132.6lbs - 2/10/21 138.2lbs. Review of the resident's departmental notes showed: - 2/5/21 at 4:04 P.M. RD note: current weight 132.2lbs. Resident weight loss 11.01% in one month and 10.41% in three months. - 2/12/21 at 4:11 P.M.: RD note: Current weight 138.2lbs. Resident weight gain 5.6lbs in one week; weight loss 11.01% in one month. Review of the resident's weight change history showed: - 2/15/21 136.4lbs; - 2/24/21 148.6lbs; - 3/3/21 149.2lbs; - 3/9/21 148.0lbs. Review of the resident's departmental notes showed: - 3/9/21 at 4:50 P.M.: resident has bilateral [CONDITION(S)] +3-4 (pitting [CONDITION(S)]) in both legs. Tubigrips were applied this morning for circulatory support. Physical therapy (PT) noticed it also and is massaging legs to increase circulation in both BLE. Will continue to monitor and report any further changes in resident. - 3/11/21 12:11 P.M. RD note: current weight 149.2lbs on 3/3/21. Resident weight gain 12.52% in one month and weight loss of 12.44% in six months. Review of the resident's March treatment administration record (TAR) showed: - Tubigrips, apply to BLE every day, on in the morning and off at bedtime for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] - Staff documented they applied the tubigrips every morning between 3/15/21 and 3/23/21. - Staff documented they removed them in the evenings on 3/15/21, 3/17/21, 3/19/21 through 3/22/21; and did not initial to show they removed them on 3/16/21 and 3/18/21. - Eucrin Cream to BLE daily and PRN for dry skin, to be done on the day shift; - Staff documented they applied the cream ever day of March except 3/22/21. Observation and interviews on 3/17/21 showed: - At 9:23 A.M., the resident trying to ambulate in hallway in his/her wheelchair. He/she did not appear to be moving very quickly and did not have any leg rests on his/her wheelchair. The resident wore ballerina-type black shoes which had come off his/her feet. The backs of the shoes were folded underneath his/her heels. The resident's legs were red and appeared swollen. Wound Care LPN knelt in front of the resident to try to put his/her shoes on. He/she said the shoes were too small and he/she would tell the social services department. - At 2:24 P.M., the resident still wearing shoes that did not fit his/her feet. The resident wore black socks on over the tops of tubigrips, which had slid down his/her legs and were bunched up around his/her ankles. His/her legs were swollen above tubigrips. - At 4:22 P.M., the resident sat in his/her wheelchair in the front lobby of the facility with his/her feet sitting on the floor. The resident still wore the same black shoes and his/her legs remained swollen with a distinct line along the mid-thigh where the legs appeared to be swelling over tubigrips, which appeared to have been pulled back up to cover the resident's thighs and calves. The resident said his/her feet and legs hurt. - At 7:00 P.M., the resident sat up in his/her wheelchair on the hall where he/she resided. His/her legs remained swollen and were now red. His/her upper thighs appeared more swollen than previously noted. Review of the resident's departmental notes for 3/17/21 at 3:52 P.M., showed staff documented the resident was alert and oriented and

Based on observation, interview and record review, the facility failed to prevent skin breakdown and implement interventions to prevent and treat scabbed areas, moisture associated skin damage (MASD), multiple Stage II pressure ulcers (partial thickness loss of dermis or living tissue below the epidermis, or top layer of tissue, presenting as a shallow open ulcer with a red pink wound bed without slough or dead tissue that forms the true skin and contains blood capillaries, nerves, sweat glands, hair follicles, and other structures) and a Stage III pressure ulcer (full thickness skin loss, exposing the subcutaneous tissues, presents as a deep crater with or without undermining adjacent tissue), for four of 26 sampled residents (Resident #27, #108, #113 and #532) and failed to obtain a wound vac (a vacuum-assisted closure (VAC) is a method of decreasing air pressure around a wound to assist the healing) for Resident #376. The facility census was 126 Review of the undated facility policy for Pressure Ulcer/Injury Skin conditions Guide for Wound Evaluation and Documentation showed: -It is the practice of this facility to ensure residents with pressure ulcers (PU) receive necessary evaluation and treatment to promote healing, prevent infection and prevent new ulcers from developing; -PU injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A pressure injury will present as intact skin and may be painful. A PU will present as an open ulcer, the appearance of which will vary depending on the stage and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by skin temperature and moisture, nutrition, perfusion, co-morbidities and condition of the soft tissue. Review of the undated facility policy for Guide for Wound Evaluation showed: -Wound (surgical, arterial, venous neuropathic, etc.): surgical may be any size, shape location, etc. Partial thickness wound: confined to skin layers; damage does not penetrate below dermis and may be limited to the [MEDICATION(S)] layers only (the outermost three layers that make up the skin). Full thickness wound: ulceration extending through dermis to involve subcutaneous tissue and possible muscle/bones. Arterial ulcers: ulceration that occurs as the result of arterial occlusive disease when non-pressure related disruption or blockage of the arterial blood flow to an area causes necrosis (dead tissue). Venous: open lesion of the skin and subcutaneous tissue of the lower leg. Diabetic neuropathic ulcers: lower extremity neuropathic foot ulcers usually occur because of peripheral [CONDITION(S)] and peripheral vascular disease; -Procedure: Upon identification of a pressure ulcer/injury (arterial, venous or neuropathic), regardless if developed in-house or upon admission, the area is to be documented on the Wound Evaluation form or in electronic record. Non-ulcers are to be documented weekly on a Skin condition form or in electronic format; -Contact physician, interdisciplinary team, family members, and significant others as indicated; -Initiate appropriate treatment per treatment protocol and physician order; -Evaluate further interventions that may be indicated to promote healing and prevent infection; -Documentation of wound status will occur at least once a week. This weekly evaluation will be documented electronically or on the Wound Evaluation Form/Skin condition Form as appropriate; -The physician is to be notified if there is no improvement in the area, signs and symptoms of infection or signs of deterioration; -The Unit Manager/Charge Nurse are to be responsible to ensure PU or injury/wound/skin condition treatment plan is addressed on the resident's plan of care; -The Director of Nursing Services and/or designated Licensed Nurses will make PU rounds on a weekly basis. Documentation of the area will be addressed. Resident progress or lack of progress will be evaluated. Directives may be given for further interventions and changes in plan of care. The resident's current care plan will also be reviewed; -When a pressure area heals, a preventative plan of care should be initiated. Review of the undated facility policy for Wound Care Treatment Protocol showed: -Evaluate the wound daily for signs and symptoms of infection and for signs of healing. Document/Report findings. Provide treatment as per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -All licensed nurses are responsible. 1. Review of Resident #27's care plan for skin dated 10/10/20 showed: -At risk for skin breakdown related to refusing to change position in bed and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Goal: will not have any more open areas; -Approaches: pressure reduction mattress; turn and reposition every two hours as resident allows; protein and calories needs met through diet; pressure reduction device on chair; treatments as ordered; if new areas develop notify wound nurse and doctor to report findings; take supplements as order. Review of the quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 11/2/20 showed: -The resident is alert and oriented and able to answer questions appropriately; -Dependent upon two staff members for Activities of Daily Living (ADL's); -Stage 2 PU, and MASD present; -Has an intermittent catheter (a tube placed into the bladder to drain the urine as needed); -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Braden Scale (a tool used for predicting pressure sore risk) dated 1/5/21 showed the resident was at high risk for the development of PU. Review of the Physicians Order (POS) for March 2020 showed: -Left pannus (an area of excess skin and fat that hangs over the pubic region) skin fold: cleanse, apply Venelex ( topical ointment used in the management of chronic and acute wounds) twice a day (BID) and as needed (PRN), fold an ABD pad (a large dressing) and place under skin fold (dated 1/8/21); -Clean wound to left posterior thigh with normal saline (NS) and apply [MEDICATION(S)] (a soft and antimicrobial foam dressing). Change dressing every three days or PRN if dressing is soiled or missing (dated 3/4/21); -Clean wound to right posterior thigh with NS and apply Venelex ointment and [MEDICATION(S)] border, change dressing every three days or PRN if dressing is soiled or missing (dated 3/4/21); -Cleanse right lower leg open areas with wound cleanser, apply [MEDICATION(S)] dressing, change every three days and PRN. Review of the weekly skin assessment dated [DATE] showed: -Diabetic ulcer to the right thigh and right calf. Excoriation of the left buttock. Abrasion to the right foot. Scabbed area to the right lower leg proximal to the ankle. Open area identified as an ulcer to the left upper thigh. Review of the weekly skin assessment dated [DATE] showed: -Excoriation to the left buttock, abrasion to the right foot resolved and scab to the right lower leg proximal to the ankle as resolved. Review of the wound notes signed by the Wound Care Licensed Practical Nurse (LPN) showed: -3/1/20 at 11:51 A.M.: noted small scabs to the posterior of lower right leg and healing ulcer to the lower posterior leg, open area to the posterior right thigh with a new open area Stage 2 noted to the posterior left thigh with macerated (occurs when the skin is in contact with moisture for too long) and excoriated (when the skin has been scratch or picked or rubbed off) tissue. 3/14/21 at 12:01 A.M. showed no documentation of the wounds characteristics or what wounds were on the resident's body. Observations and interviews on 3/18/21 at 9:32 A.M. with the Wound Care LPN showed: -The left side of pannus was very irritated with bloody drainage; -The Wound Nurse stated he/she was unaware of the wound; -The resident stated that the nurses had been putting a 4 x 4 dressing under the pannus for the drainage; -The entire surface of the buttocks and upper thigh excoriated with multiple open areas with bloody drainage. A line, measuring five inches by a half inch to an inch to the back of the right leg, that wrapped around the back of the calf of the right leg with various stages of healing, from red to black tissue; -An indentation to the left side of hip area with an open area to the bottom of the indentation, measuring two inches by an half inch to three quarters of an inch; -The Wound Nurse stated he/she was unaware of the open area to the left side of the hip and unaware of the area to the back of the right leg; -The resident stated that the area was very painful. During an interview on 3/18/21 at 9:45 A.M. the Wound Care LPN said: -The Certified Nurse Aides (CNAs) should report any open areas to the nurses and complete a skin assessment on the bath sheet upon showers; -The Nurses should complete a weekly skin assessment. If a nurse finds a new wound, the nurse should notify the physician, obtain a treatment order, document in the electronic medical record and notify him/her of the wounds; -Agency licensed staff do not have access to the electronic wound documentation, they should notify him/her verbally of any new wounds; -He/she has not been notified of any new wounds for the resident. 2. Review of Resident #108's face sheet showed the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Review of the baseline care plan dated 11/12/20 showed the resident's skin was intact. Review of an undated baseline care plan showed the resident's skin was intact. Review of the quarterly MDS dated [DATE] showed: -The resident was alert and oriented and able to answer questions; -Required extensive assistance of two staff for ADL's; -Incontinent of bowel and bladder, no indwelling catheter (a tube inserted into the bladder to drain urine); -Not at risk for PU, with MASD present; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record showed no care plan for the MASD or skin integrity care plan. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the bath sheets completed by the CNA's showed: -3/1/21- wound to bilateral buttocks and redness to the groin; -3/3/21 - redness to the bilateral buttocks and abdomen area -3/8/21 - wound to the bilateral buttocks and redness to the groin; -3/11/21 - bottom raw and sore; -3/16/21 - wound to the bilateral buttocks and redness to the groin. Review of the weekly skin assessments completed by the Wound Nurse showed: -3/4/21- Incontinence [CONDITION(S)] (a chronic [CONDITION(S)] that develop from exposure to urine or liquid stool) to the left buttock, rash to left and right groin area; -3/11/21 - Incontinence [CONDITION(S)] to the left buttock and rash to the left and right groin. Review of the resident's medical record from 1/1/21 through 3/17/21 showed no documentation of any skin issues in the nurses notes in the electronic medical record. During an interview on 3/15/21 at 3:35 P.M. the resident said: -He/she has a rash on his/her groin that is on fire. Observation on 3/16/21 at 1:34 P.M. showed: -Two CNAs stood the resident up from his/her wheelchair, Agency LPN H wiped bowel movement from his/her buttock. The nurse applied [MEDICATION(S)] to the excoriated left buttock and multiple open areas to the right buttock. During an interview on 3/16/21 at 1:34 P.M. CNA A said: -The open areas to the right buttock have been there for several days; -He/she reported the open areas to the nurses. During an interview on 3/16/21 at 1:34 P.M. Agency LPN H said: -He/she is an agency nurse and this is the first time he/she has taken care of the resident; -He/she was unaware that the resident had any open areas to the buttocks; -He/she will notify the wound nurse as he/she does not have access to the electronic medical record (EMR) to document the open areas. Observation and interview with the Wound Care LPN on 3/18/21 at 9:07 A.M. showed: -The Wound Care LPN said that he/she was unaware of any open areas to the right buttock. The areas are a Stage 2 PU. He/she was aware of the contact [CONDITION(S)] with maceration to the right and left buttock. During an interview on 3/22/21 at 1:00 P.M. the Director of Nursing said: -CNAs should always notify their charge nurse with any new areas or concerns with the resident's skin. The charge nurse should go assess the area, document it in nurse's notes, notify the physician and get a treatment ordered, notify the responsible party and the wound nurse; -She would expect the Wound Care LPN to assess the area, document in the EMR, obtain a treatment and monitor the area. 3. Review of Resident #113's medical record showed: - February and March coccyx Stage III pressure wound reports dated: - 1/28/21 = 4 centimeter (cm) x 1.2 cm x .5 cm; - 2/5/21 = In hospital; - 2/19/21 = 1.2 cm x 1.2 cm x 2.2 cm with undermining of 0.7 cm from 9:00 to 2:00; - 3/5/21 = 3 cm x 2.2 cm x 1.2 cm with undermining from 9:00 to 2:00; - 3/12/21 = 3 cm x 2.2 cm x 1.2 cm with undermining of 0.4 cm from 9:00 to 2:00. Review of the resident's MDS, dated [DATE], showed: - Able to make daily decisions; - Required extensive assist with bed mobility, toilet use and personal hygiene; - Dependent on transfers; - Indwelling Foley catheter and incontinent of bowel; - One Stage III pressure ulcer and moisture associated skin damage. Review of the resident's care plan, date onset 3/16/21, showed: - I have a skin breakdown related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - Encourage me to reposition frequently; - Skin assessment weekly and as needed; - Use supportive and pressure reducing devices as needed; - Encourage me to allow treatment as ordered by physician; - Treatment as ordered. The care plan did not direct staff how to provide care to the coccyx wound other documentation showed the resident was admitted to the facility with. Review of the resident's current March 2021, physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's current March 2021, treatment administration record (TAR) showed staff documented every other day treatment as follows: - Cleanse coccyx wound with wound cleanser, pat dry, apply skin prep to periwound tissue, gently pack wound with Hydrafera blue (provides wound protection and addresses bacteria and [MEDICATION(S)]. It provides a moist wound environment, as it addresses swelling in the wound by providing negative pressure, pulling exudate from the wound environment) and cover with [MEDICATION(S)] (absorbent foam) dressing. Change every other day and as needed if soiled, order and start date is 2/17/21. Observation and interview on 3/1/5/21 at 3:18 P.M., showed the resident lay on his/her bed on a low air loss mattress. Certified Medication Technician (CMT) D was at the resident's bedside taking the resident's vital signs. The controls to inflate and set the low air loss mattress hung over the foot of the resident's bed. The lights on the machine were off. The electrical cord to the low air loss mattress was loosely hanging from the outlet on the wall, the low air loss mattress was deflated. The resident said the mattress was not too comfortable, but he/she had a sore on his/her bottom. Observation on 3/16/21 at 8:27 A.M., showed the resident sat upright in bed, the mattress was inflated. The resident stated the bed was so much more comfortable after they plugged it in last night. He/she kept telling them he/she was sitting in a hole. During an interview on 3/16/21 at 8:46 A.M., RN A said he/she did not notice the resident's low air loss mattress wasn't up yesterday. He/she did not think there was a place to document in the MAR/TAR that staff had checked that the mattress was up and working. Observation on 3/16/21 at 10:18 A.M., showed the Wound Care LPN administered a treatment to the resident's Stage III coccyx wound while RN A stood on the other side of the resident and assisted the resident to stay rolled over. Wound Care LPN stated the resident needed a clean paper chux and left the room to get one. RN A reached over the resident and rolled the soiled chux under the resident, The resident had had about a two inch line of small red open areas about the size of the top of a pen, from the center crease outward on the left buttock. Wound Care LPN re-entered the resident's room and placed the clean paper chux under the resident. Observation and interview on 3/17/21 at 9:12 A.M., showed Certified Nurse Aide (CNA) H provided partial peri care and catheter care for the resident. He/she turned the resident over and cleaned fecal material from the resident's backside. The resident continued to have the dotted line of small open areas on the left buttock and another opened line slit on the left gluteal fold area. During an interview on 3/22/21 at 9:44 A.M., the Agency RN (Unknown) said nothing came through report about the resident having any new open areas on his/her bottom. He/she did not have access to the facility's software program and could not check to see if any new open areas had been reported. Review of the facility's documentation for progress nurse's notes showed no entry of the new areas to the resident's left buttock and or gluteal areas. During an interview on 3/22/21 at 10:00 A.M., LPN A said: - Staff should report any new open areas to the nurse; - The nurse should assess the new areas, contact the physician, put a treatment in place, and leave notification for the wound nurse. During an interview on 3/23/21 at 2:00 P.M., CNA H said he/she reported the resident's new open areas to the Wound Care LPN the same day he/she first saw them. During an interview on 3/23/21 at 12:00 P.M., the Director of Nurses (DON) said: - The facility did not have any policy about what staff responsibilities were when the resident used a low air loss mattress; - CNAs and nurses should be looking at the low air loss mattress each time they are in the room to make sure it is inflated; - CNAs should always notify the nurse when they see any open area or if they have any concerns about the resident's skin; - The charge nurse should then go assess the area, document it in nurse's notes, notify the resident's physician, get a treatment ordered, and notify the responsible party and the wound nurse. 4. Review of Resident #532's face sheet, showed: -admitted on [DATE]. -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Treatment: Left abdomen wound, cleanse with wound cleanser, cover with calcium alginate (a highly absorbent dressing that maintains a moist wound environment that promotes wound healing), then cover with ABD pads (absorbent dressing used of heavily draining wounds). Secure with [MEDICATION(S)] tape (soft, highly [MEDICATION(S)] tape). Change daily and as needed if soiled; start 3/7/21; -[MEDICATION(S)] (a cream used to treat fungal infections) - apply to left abdomen three times daily for 10 days; start 3/3/21; -[MEDICATION(S)] powder (a powder used to treat fungal infections) - apply twice daily to bilateral groin areas and pannus (lower abdomen) folds; start 2/4/21; -Venelex Ointment (a topical medication used to treat skin wounds) - apply to buttocks and perineum every shift and as needed; start 2/5/21; -[MEDICATION(S)] 0.1% cream (a medication used to treat topical [CONDITION(S)] skin conditions) - apply topically to left abdomen and right below the knee amputation stump twice daily; start 2/5/21; -Encourage resident to turn every two hours while in bed and to shift weight every 15 min and reposition hourly while in the wheelchair; start 3/6/21; -Treatment: Right buttock wound, cleanse with wound cleanser, pat dry; Apply calcium alginate to wound bed and cover with [MEDICATION(S)] foam border after applying skin prep to surrounding skin. Change every other day and as needed if loose/soiled; start 3/7/21; -[MEDICATION(S)] HCL 125 mg - Give one capsule by mouth twice daily for [CONDITION(S)]; Start 3/14/21; Stop 3/20/21 Review of the resident's care plan for incontinence, dated 2/16/21, showed: -Resident has frequent episodes of urinary incontinence; -Goals: Resident will ask for assistance as needed with toileting; -Approaches: Toilet every two hours during the day and every four hours during the night and as needed; -Answer call light promptly; -Change soiled clothing after every incontinent episode; -Cleanse skin with soap and water after each incontinent episode; -Monitor skin condition for signs of breakdown or redness. Review of the resident's care plan for skin breakdown, dated 2/16/21, showed: -Resident has potential for skin breakdown related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Goals: Resident will have no new open areas of skin integrity issues through the next review date; Approaches: -Pressure reduction mattress; -Turn and position every two hours; -Protein and calories needs met through diet; -Pressure reduction device on chair; -Between meals supplements as ordered; -Complete treatments as ordered by physician; -Notify physician of any changes in skin integrity; -Encourage resident to allow treatments to be completed as ordered; -Registered Dietitian consult as needed; -Therapy to evaluate and treat, as needed. Review of the resident's care plan for Activities of Daily Living (ADLs), dated 2/16/21, showed: -Resident has impaired mobility related to bilateral below the knee amputation (surgical removal of limb) and requires a wheelchair for mobility and requires assistance with ADLs and transfers; -Goals: Resident will have no decline in mobility or ADL function through the next care plan review date; -Approaches: Assist the resident with ADL's and transfers as needed; -Resident prefers two showers per week; -Per Resident preference offer shower after return from [CONDITION(S)] or at bedtime; -Resident requires moderate assistance with ADL's; -Resident requires a mechanical lift for transfers; Review of the resident's admission skin assessment, dated 2/4/21, showed: - Resident has bilateral below the knee amputation with ulcers. Resident has a blister on the right side of bottom and a tumor like bulge to his/her abdomen. Review of the resident's weekly skin assessments for the month of February, showed: 2/5/21 - Right upper thigh - blisters; still present; present on admission; Left clavicle port, still present, present on admission; Bilateral below knee amputation, open lesion other than ulcer, rash or cut, still present, present on admission; 2/10/21 - Right upper thigh - blisters; still present; present on admission; Left clavicle - port, still present, present on admission; Bilateral below knee amputation - open lesion other than ulcer, rash or cut, still present, present on admission; 2/19/21 - Right upper thigh - blisters; still present; present on admission; Left clavicle - port, still present, present on admission; Bilateral below knee amputation - open lesion other than ulcer, rash or cut, RESOLVED. 2/24/21 - Right upper thigh - blisters; still present; present on admission; Left clavicle - port, still present, present on admission. 2/27/21 - Right upper thigh - blisters; still present; present on admission; Left clavicle - port, still present, present on admission; Right buttock - open lesion other than ulcer, rash or cut; still present, indescribable lesion with blister on top, not present at time of admission; Left lower quadrant - callus, still present, not present at time of admission; Review of an undated, resident readmission skin assessment, showed: - Resident has bilateral legs amputated with left lower extremity [CONDITION(S)], groin excoriation, rash and Stage II pressure ulcer to R buttock. Review of the resident's weekly skin assessments from 3/1/21 to 3/14/21, showed: 3/6/21 - Right buttock - cyst, still present, not present at the time of admission; Coccyx - rash, still present, not present at the time of admission; Left and Right groin - excoriation, still present, not present at the time of admission; Left lower quadrant - bruise, still present; weeping and [CONDITION(S)], not present at the time of admission; Left above the knee amputation - [CONDITION(S)], still present, not present at the time of admission. 3/13/21 - Right buttock - cyst, RESOLVED, not present at the time of admission; Coccyx - rash, RESOLVED, not present at the time of admission; Left and Right groin - excoriation, still present; not present at the time of admission; Left lower quadrant - bruise, RESOLVED; weeping and [CONDITION(S)], not present at the time of admission; Left above the knee amputation - [CONDITION(S)], RESOLVED, not present at the time of admission. 3/14/21 - Right buttock - cyst, still present, not present at the time of admission; Coccyx - rash, still present, not present at the time of admission; Left and Right groin - excoriation, still present; not present at the time of admission; Left lower quadrant - bruise, still present; weeping and [CONDITION(S)], not present at the time of admission; Left above the knee amputation - [CONDITION(S)], still present, not present at the time of admission. During an interview on 3/16/21, at 7:37 A.M., Resident #532 said: -He/she has a wound on the side of his/her abdomen and another wound on his/her right buttock. He/she believes that the foul odor identified in the resident's room is from his/her wounds. -He/she cannot remember the last time this dressing was changed; -Staff are not changing his/her dressings or providing treatment per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Although he/she is unable to reposition on his/her own, staff do not provide assistance in his/her repositioning in bed; -He/she has only received 3 bed baths since being admitted to the facility in February. He/she told staff that he/she would prefer to take a shower at least twice weekly but this has not happened yet. Review of the resident's Treatment Administration Record (TAR) for the right buttock wound from 3/7/21 through 3/16/21, showed: -3/7/21 - No wound treatment performed; -3/15/21 - No wound treatment performed. During an observation and interview on 3/16/21, at 4:53 P.M., the Wound Care LPN said and did the following: -The resident has a small raised area to the right buttock but there are no open areas so there is nothing for him/her to measure and he/she has not been documenting much for this area on the resident's weekly skin assessments. - Due to the resident having [CONDITION(S)] three times weekly on Monday, Wednesday and Friday, he/she changed the wound treatment time from the dayshift to the evening shift. Nurses on the evening shift have not been changing the dressing as ordered. Often he/she will come in on his/her days off on the weekend and find that nursing staff have not provided dressing changes. - He/she does not know when the dressing has been changed last as there is not date on the dressing. -Upon removing the resident's dressing to his right buttock, an odor could be identified and increased tan drainage was noted to the resident's dressing. He/she stated that although the wound had not been previously, the wound was now open and that the wound would need to be measured. He/she called out to another staff member and asked that they bring him/her a paper measuring tape to the resident's room. Using wound cleanser, he/she cleaned the wound and found the wound bed pink in color with approximately 15% of the wound bed covered in tan/yellow slough (a soft yellow/white material in the wound bed that consists of dead cells that accumulate in the wound) per his/her assessment. The wound measured 2.0 cm. x 1.5 cm. x 0.1 cm. Review of the residents' weekly skin assessments for 3/16/21, showed: - Right buttock - open lesion, other than ulcer, rash or cut, change in condition, not present at the time of admission; Coccyx - rash, RESOLVED, not present at the time of admission; Left and Right groin - excoriation, still present; not present at the time of admission; Left lower quadrant - bruise, RESOLVED; weeping and [CONDITION(S)], not present at the time of admission; Left above the knee amputation - [CONDITION(S)], RESOLVED, not present at the time of admission; Right upper thigh - open lesion other than ulcer, rash or cut, still present, Open area noted measuring 2x1.5x0.1, moderate amount of yellowish drainage noted, no redness or warmth to peri-wound tissue and this tissue is intact. Review of the resident's nurses notes for provided by the facility for 3/9/21 through 3/19/21, showed: -3/16/21 at 6:52 P.M. - Open area noted on upper right thigh where resident previously had a raised red area. Open area measure 2 centimeters (cm.) x 1.5 cm. x 0.1 cm. with epithelial cells 80% and sough 20% with moderate amount of yellowish drainage. Provided treatment as directed. Resident stated pain level was at a 3/10. Continues on antibiotic treatment as directed without adverse effects. Call light within reach. - 3/17/21 at 2:23 P.M. - New order noted to change right buttock/hip treatment to: cleanse with wound cleanser, apply calcium alginate and cover with ABD pads and secure with Medifix type (soft, highly [MEDICATION(S)] tape) tape. Change daily and as needed. Order processed and resident is aware of this. -3/19/21 at 2:26 P.M. -Right buttock/hip wound bed noted to have 20% slough and 80% epithelial with yellowish drainage noted. Some odor noted. Peri-wound tissue cobble stone appearance and raised. Continue treatment as directed and staff continue to provide cares and positioning. Open area measures 2.0 cm. x 1.5 cm. x 0.2 cm. Review of the resident's TAR for the right buttock wound from 3/17/21 through 3/23/21, showed: -3/19/21 - No wound treatment performed; -3/20/21 - No wound treatment performed; -3/21/21 - No wound treatment performed; -3/22/21 - No wound treatment performed; -3/23/21 - No wound treatment performed. During an interview on 3/22/21, at 4:27 P.M., the Director of Nurses (DON) said: - Nursing staff should follow physicians' orders for wound treatments. Wound care should be performed as written including the frequency of treatments. -If a resident is resistant to cares or wound treatments, or if a resident refuses treatment, staff should educate the resident on the possible complications of wounds not being treated such as increased risk of infection or worsening of the wound. 5. Review of Resident #376 face sheet showed the resident was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] -Wound vac to perineal wounds @125 mmhg (millimeter of mercury per pressure) change every Monday, Wednesday, Friday and PRN for necrotizing (a serious bacterial infection that destroys tissue under the skin) wounds to the perineal area. Review of the Admission/Readmission Evaluation dated 9/18/20 showed: -Resident is alert and oriented; -Assist of two staff members for transfer; -Pain in the perinea

Based on observation, interview, and record review, the facility failed to implement the Centers for Disease Control (CDC) and Centers for Medicare & Medicaid Services (CMS) recommended infection control practices to prevent and control the potential spread of COVID-19 (a highly contagious [MEDICAL CONDITION] illness, that is easily spread from person to person), and the facility failed to ensure that all staff and visitors were thoroughly screened prior to having contact with the residents. This failure resulted in 20 residents and 8 facility staff members to test positive for COVID-19. The facility reported a census of 132 residents. It was determined that the facility's non-compliance with one or more requirements of participation placed all residents in the facility in Immediate Jeopardy. The non-compliance began on 10/15/20. On 11/04/2020 at 11:52am, the Executive Director was notified of the Immediate Jeopardy (IJ) at F880, Infection Prevention and Control. The IJ was removed on 11/05/20, after the surveyor verified the implementation of a removal plan. The scope and severity was lowered to an F. Findings include: An observation on 11/3/20, at 8:30am showed a visitor entered the facility. The screener took the visitor's temperature, and instructed the visitor to write their temperature on the screening form and answer the questions listed, then placed the paper face down in the paper tray. The screener did not review the screening form prior to allowing the visitor to proceed into the resident care area. An observation on 11/3/20, at 8:31am showed a visitor entered the facility. The screener took the visitor's temperature, and instructed the visitor to write their temperature on the screening form and answer the questions listed, then placed the paper face down in the paper tray. The screener did not review the screening form prior to allowing the visitor to proceed into the resident care area. An observation on 11/3/20, at 2:14pm showed a visitor entered the facility. The screener took the visitor's temperature, and instructed the visitor to write their temperature on the screening form and answer the questions listed, then placed the paper face down in the paper tray. The screener did not review the screening form prior to allowing the visitor to proceed into the resident care area. An observation on 11/3/20, at 3:47pm showed a visitor entered the facility. The screener took the visitor's temperature, and instructed the visitor to write their temperature on the screening form and answer the questions listed, then placed the paper face down in the paper tray. The screener did not review the screening form prior to allowing the visitor to proceed into the resident care area. An observation on 11/3/20, at 3:58pm showed two visitors entered the facility. The screener took the visitor's temperature, and instructed the visitors to write their temperature on the screening form and answer the questions listed, then placed the paper face down in the paper tray. The screener did not review the screening form prior to allowing the visitors to proceed into the resident care area. An observation on 11/4/20, at 8:04am showed a visitor entered the facility. The screener took the visitor's temperature, and instructed the visitor to write their temperature on the screening form and answer the questions listed, then placed the paper face down in the paper tray. The screener did not review the screening form prior to allowing the visitor to proceed into the resident care area. During an interview on 11/3/20, at 10:05am, Licensed Practical Nurse (LPN1) indicated that all staff entered through the front door, completed the screening questions for COVID-19, and had their temperature taken. If there was no one to screen at the front door, staff were to go to the B Hall nurse's station to have their temperature taken, fill out the screening questions, then put the form in the book at one of the nurse's stations. She worked on different units throughout the facility so she would go to the B Hall nurse's station to have her temperature taken, and then proceed to her assigned unit, where she would complete her screening form, and then place it in the book for the Assistant Director of Nursing Services (ADNS) to pick up when she arrived for work. There was a book for forms at each nurse's station because sometimes people would take their temperature on B Hall and then go to their assigned unit to finish filling out the screening form. Staff did not always complete their COVID-19 screening form before going to their assigned work area. During an interview on 11/4/20, at 8:55am, LPN2 indicated that all staff were to come to the B Hall nurse's station to be screened if no one was at the front desk. There was no one at the front desk to screen staff and/or visitors until 8:00am during the week, and not at all on weekends. Staff would have their temperature taken, and then answer the questions on the screening form and place them in the book to be picked up. There were books for the screening forms at each nurse's station. She had not received actual training on the screening form but had been told to fill it out each time she came to work. Staff was to notify their supervisor immediately if they were not feeling well, or had symptoms of COVID-19. During an interview on 11/4/20, at 9:11am, Housekeeper (H1) indicated that each morning when she came to work, she had to have her temperature taken, and fill out the Employee Screening form. She had not been trained on the form, other than to make sure she filled it out each morning. She was sure she answered all the questions each morning. During an interview on 11/4/20, at 9:15am, Medication Aide1 (MA) indicated that she comes to work at 6:00am and proceeds directly to the B Hall nurse's station to have her temperature checked, and to complete the COVID-19 screening form. After she completed the form, she placed it in the book to be picked up. She did not know if anyone reviewed the forms to see if they were completed. During an interview on 11/4/20, at 9:39am, the ADNS indicated that staff were to come in the front door, have their temperature taken, and complete the screening form. If no one was at the front desk to screen, the employees were to go to the B Hall nurse's station to have their temperature taken and complete the screening form. The staff were to place their screening form in the book at one of the nurse's stations, so that she could pick them up and review them. Staff were supposed to answer all the questions on the form. She was supposed to review the forms, but did not really have time to review them, as there were so many and she was busy. She did the best she could to review them but it may be several days before she would get to look at them. It was a big job just trying to keep them organized by date, and she assumed the nurses had checked to see that the forms were completed before the forms were put in the book. During an interview on 11/4/20, at 10:45am, the Staff Development Coordinator (SDC) indicated that she was responsible for providing most of the training for staff in the facility. She indicated she had provided training to staff on COVID-19, Infection Control Practices, donning and doffing personal protective equipment (PPE), COVID-19 screening form and completion of the form for staff and visitors. She only provided education to nursing department employees and not any other department. The other department managers were responsible for educating the staff in each department. During an interview on 11/4/20, at 1:28pm, the Receptionist/Screener for staff and visitor entry door, indicated that she worked from 8:00am until 4:30pm, Monday through Friday. The Business Office staff screen staff and visitors entering the facility, from 4:30pm when she leaves, until 7:30pm. She first checked to see if the person was authorized to come into the facility, she then checked their temperature and had them fill out the screening form, before they could proceed into the facility. Vendors, contractors, physicians, and any other person entering that was not employed by the facility, completed the same screening questionnaire as the staff. She was instructed by the Regional Nurse to take temperatures when staff or visitors entered the facility, make sure the screening questionnaire is filled out, and then have them turn the papers upside down and place it in the paper bin. One of the Physician's, who comes to the facility to see residents, refuses to complete the screening form. The Physician told her that he is a physician and does not need to complete the screening, and that he had his temperature taken already one time today. She had not said anything to the Executive Director about the physician refusing to complete the screening. She did not review the forms to see if they are completed, but she thought the Executive Director or the Director of Nursing Services looked at them. During an interview on 11/4/20, at 11:40am, the Executive Director (ED) indicated that all staff and visitors were to complete the required screening at the front door of the facility, prior to proceeding to any resident care area. There was an assigned screener at the front reception area, Monday through Friday, from 8:00am until 7:30pm. Evenings after 7:30pm, weekends, and holidays the staff were to enter the facility and go directly to the B Hall Nurses station to have their temperature checked, and to complete the screening form. It was the expectation that all questions are answered on the screening form. He expected the receptionist/screener to review each form, to ensure its completion, prior to allowing staff or visitors to proceed to a resident care area. Staff and visitors, including Physician's, to the facility were to have their temperature checked, and complete that screening form questions. If a staff member or visitor refused to complete the screening then they would not be allowed entrance to the facility. The ADNS was responsible for reviewing all of the screening sheets to ensure they are completed. He was ultimately responsible to ensure the screenings were completed, as required. Record review of CMS guidance, dated 3/4/20, documented the following: How should facilities monitor or limit visitors? Facilities should screen visitors for the following: 1. International travel within the last 14 days to restricted countries. For updated information on restricted countries visit: https://www.cdc.gov/coronavirus/2019- ncov/[MEDICATION NAME]/index.html 2. Signs or symptoms of a respiratory infection, such as a fever, cough, and sore throat. 3. Has had contact with someone with or under investigation for COVID-19. The guidance then stated: How should facilities monitor or restrict health care facility staff? The same screening performed for visitors should be performed for facility staff (numbers 1, 2, and 3 above). Record review of the facility's Staff and Visitor Screening forms showed: All individuals (visitors, government officials, etc.) entering the building each day are to answer the following questions: showed a visitor entered the facility. Have you washed your hands or used alcohol based hand rub (ABHR) on entry? __Yes __No-do so now and upon every re-entry 1) Have you had any of the following symptoms in the last 3 days? Check all that apply: __Fever greater than 100 degrees No___ Yes___ (Temp upon entry____________) __Sore throat __Cough __New shortness of breath or difficulty breathing __Chills or repeated shaking with chills __Muscle pain __Headache __New loss of taste or smell __Diarrhea or vomiting IF YES to any, Immediately notify the screener and do not go any further into the building. You may or may not have COVID-19, and the potential consequences to COVID-19 entering the building is serious enough not to enter even though you may not have it. If NO to all proceed to Question #3. 2) Have you: -Been exposed to someone confirmed or suspected to have COVID-19? No___ Yes___ -Worked in any facilities or locations with recognized COVID-19? No___ Yes___ -Have you been tested for COVID-19? No___ Yes___ When:_______ Results:_________ If YES to any, do not enter the building (immediately notify the screener). If NO to all, proceed to question #4 3) For visitors/contractors indicate the resident you are visiting or purpose for your visit: _____________________________________________________________________ 4) Your name, address, telephone number and name of company (if applicable): _____________________________________________________________________ 5) Do you have a face mask or face covering? No___ Yes___ if no, notify screener before entering the building. Record review of the facility's Staff and Visitor Screening forms revealed that from 10/15/2020-11/03/2020, over 200 staff members, visitors, and contractors failed to complete the required screening. Record review of the facility's policy for Pandemic Protocols showed: The facility was to follow CDC recommendations for screening staff and visitors, and all individuals (visitors, government officials, etc.) that entered the building each day was to complete the Covid Screening Form and to answer all the required questions. Record review of the Staff, Visitor, and Contractor COVID-19 Screening forms showed: On 10/15/20, 12 staff members, and 1 physician failed to complete the required screening. On 10/16/20, 11 staff members, one physician, one mobile x-ray contractor, and one visitor, failed to complete the required screening. On 10/17/20, two staff members failed to complete the required screening. On 10/18/20, two staff members failed to complete the required screening. On 10/19/20, 12 staff members, four visitors, and two physicians failed to complete the required screening. On 10/20/20, 18 staff members, one Hospice provider, and one physician failed to complete the required screening. On 10/21/20, 15 staff members and one physician failed to complete the required screening. On 10/22/20, 20 staff members failed to complete the required screening. On 10/23/20, 13 staff members, three family members, one pest control contractor, and one physician failed to complete the required screening. On 10/24/20, four staff members failed to complete the required screening. On 10/25/20, three staff members failed to complete the required screening. On 10/26/20, 12 staff members, and one physician failed to complete the required screening. On 10/27/20, nine staff members failed to complete the required screening. On 10/28/20, eight staff members failed to complete the required screening. On 10/29/20, six staff members and one equipment contractor failed to complete the required screening. On 10/30/20, 10 staff members failed to complete the required screening. On 10/31/20, four staff members failed to complete the required screening. On 11/1/20, one staff member failed to complete the required screening. On 11/2/20, 10 staff members failed to complete the required screening. On 11/3/20, 20 staff members, one Hospice contractor, one lab contractor, and one physician failed to complete the required screening. Record review of the Employee and Visitor Screening forms showed H1 failed to complete the required screening on 10/15, 10/16, 10/19, 10/20, 10/21, 10/22, 10/24, 10/25, 10/26, 10/30, 11/2, and 11/3, prior to performing her duties in the resident care area on B Hall. Record review of the Employee COVID-19 testing on 11/3/20 showed H1 tested positive for COVID-19.

Based on observation, interview and record review the facility failed to prevent resident access to the steam table in the dining room that was turned on to the highest setting with steam rising from the water in the five pans. The pans did not have a cover over them to prevent direct access to the hot water that ranged from 138 degrees (°) Fahrenheit (F) to 164° F. Residents were observed in the dining room or traveled independently through the dining room without staff present, to go to the bookcase or to a room off the dining room to watch TV. This failure had the potential to cause serious injury to cognitively impaired residents. The facility identified 23 cognitively impaired independently mobile residents. The facility reported a census of 132 residents. The facility's noncompliance with one or more requirements of participation had the potential to affect all 23 residents identified as cognitively impaired and independently mobile and resulted in an immediate jeopardy (IJ). The Administrator of the facility was notified of the IJ on 11/3/20 at 2:12pm related to the unsupervised steam table that was turned on to the highest setting to heat the water and reached a temperature of 164°F. Findings include: During an observation on 11/3/20 at 11:03pm, steam was rising from the water in the five separate pans placed in the steam table located in the dining room. The five pans of water did not have covers which allowed full access to the hot water. Residents were observed traveling through the dining room to go to another room off the dining area where one resident was watching TV, or to the bookcase located in the dining room. Down the hall from the dining room R1 sat in a chair and had a Wanderguard (an alarm device to prevent exit from the facility) ankle bracelet on. R1 was cognitively impaired and independently mobile. On 11/3/20 at 11:16am, the dietary manager (DM) verified the steam table temperature was set on the highest setting to heat the water in preparation of the noon meal. The DM indicated the pans of water should have been covered with lids. The DM verified there was one lid available at the table, then requested dietary staff bring additional lids to cover the pans. The DM indicated staff turned on the steam table approximately 30-45 minutes prior to the meal to heat the water to keep the food warm during meal service. The DM indicated that when the water was heated with the lids on, the lids would be hot to touch and would require hand protection to remove them. The DM checked the temperature of the water and it was 138°F. When asked if the steam table should be monitored by staff when turned on, the DM indicated that due to COVID-19, all residents ate in their rooms, so it did not need to be secured. During this interview a resident self-propelled into the dining room and went to the bookcase along with several other residents that passed through the dining room to go to the other room. The DM indicated the nursing department was responsible for monitoring residents for safety. Observation on 11/3/20 at 11:38am, all of the steam table pans were covered with lids. A resident sat at a table in the dining room with a staff member. Observation on 11/3/20 at 11:49am, revealed the steam table remained on with the lids covering the pans of water. The lids were very hot to touch. There was not any staff present in the dining room. Several residents traveled in and out of the dining room independently. At this time the Director of Nursing Services (DNS) was notified and came into the dining room. The DNS indicated the steam table should be secured to prevent any access by residents when it was turned on. Dietary aide (DA1) came into the dining room. This surveyor requested a temperature check of the water and it recorded a temperature of 164°F. The DNS indicated that residents were encouraged to stay in their rooms due to COVID-19, but were allowed to go to the dining room or other areas as desired which included residents who were cognitively impaired and independently mobile. According to http://www.the-med.org/media/Scald%20Burns%20Flyer.pdf, a water temperature of 140°F caused a 3rd degree burn (affects all three skin layers, destroys hair follicles, sweat glands, and may damage nerve endings) in three seconds and at 155°F in one second. The facility's 2016 Policy and Procedure titled Use of Steam Table in Dining Areas under the title Procedure: 3. Once the steam table is in the serving location, it is plugged in to help maintain food temperatures and must be continually staffed by an employee. The IJ was removed on 11/3/20 during the survey after surveyors' verified implementation of an acceptable removal plan. The scope and severity was lowered to an F.

Based on observations, interviews, and record reviews, the facility staff failed to assess and treat in a timely manner, a skin condition of one resident (Resident #1). Staff did not communicate the residents refusal of wound care, bathing and the condition of the resident's skin to the physician and responsible party. Staff failed to effectively communicate the resident's skin condition and interventions for the refusal of cares to assure that all staff provided care and services to prevent a wound infection and the infestation of maggots in the resident's wounds. This had the potential to affect all residents. The facility census was 116. 1. Review of the facility policy for Weekly Skin Audits dated 11/12 showed: -A skin audit will be documented on residents weekly. Any identified skin conditions will be documented and a treatment initiated; -Every resident will have a head-to-toe skin evaluation performed and documented on a weekly basis. The evaluation will be documented electronically or on the weekly skin audit form; -Any skin abnormalities identified during this review can be documented in the interdisciplinary notes; -The physician and family will be notified of any abnormalities; -Treatments will be initiated per the physician's orders; -The Unit Manager/Charge Nurse will review and sign all weekly skin audits if documented manually. This signature indicates appropriate follow-up documentation and care plan interventions have been implemented; -Manual Weekly Skin Evaluations are to be kept with the treatment record and filed monthly in the medication/treatment section of the medical record. 2. Review of the facility policy for Pressure Ulcer and Skin Conditions dated 11/12 showed; -Non-ulcers are to be documented weekly on a skin condition form or in the electronic format; -Contact physician, interdisciplinary team, family members, and significant others as indicated; -Initiate appropriate treatment per treatment protocol and physician order; -Evaluate further interventions that may be indicated to promote healing and prevent infections; -Documentation of wound status will occur at least once a week; -The physician is to be notified if there is no improvement in area, signs and symptoms of infections or signs of deterioration; -The Unit Managers/Charge Nurses are to be responsible to ensure pressure ulcer/wound/skin condition treatment plan is addressed on the resident's plan of care; -The Director of Nursing (DON) and/or designated licensed nurses will make pressure ulcer rounds on a weekly basis. Documentation of the area will be addressed. Resident progress or lack of progress will be evaluated. Directives may be given for further interventions and changes in the plan of care. The resident's current care plan will also be reviewed. Review of the facility policy for Behavior Management dated 10/09 showed: -Residents with behaviors that are displayed routinely, that affect the resident's psychosocial well-being or that of other residents, or behaviors that can have potential for harm to self or others will be addressed with the development of a behavior program. Interventions developed in this program will only include the use of medications when the appropriate assessment by the physician and interdisciplinary team members have validated that non-chemical interventions alone are not successful, that these behaviors were persistent and were not caused by preventable reasons; -The Interdisciplinary Care Team will update the care plan to include the problem behavior, goals and approaches; -The planned interventions for each individual resident's behavior will be communicated to the appropriate staff members. Interventions and response will be documented; -The DON or designee will make the referral to the Behavior Management committee; -The committee will establish a behavior program and review behavior monitoring documentation. Appropriate updating and/or revisions to the care plan will be done; -The committee will continue to routinely review the resident as long as the resident has an established behavior program. 2. Review of Resident #1's face sheet showed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Responsible party and Power of Attorney (POA) listed as Family Member A. Review of the care plan for skin breakdown dated 12/1/15 showed: -Actual skin breakdown on bilateral lower extremities related to [MEDICAL CONDITIONS], hypertension, A-Fib and diabetes; -There was no goal for the care plan listed; -Approaches included the following: perform treatment per physicians orders: supplements as ordered; whirlpool three times a week on Monday, Wednesday and Friday; due to refusal of cares, staff will educate the resident on adverse effects of refusing care; dietician to evaluate resident's nutritional status as needed; use supportive/protective and/or pressure reducing devices as needed; instruct resident/family on consequences of noncompliance with therapeutic regime; incontinence care following incontinent episodes. Review of the quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 3/16/17 showed: - Unable to make decisions; -Has long and short term memory problems; -Decision making poor requiring cues and supervision; -Has delusions; -Verbally aggressive one to three days a week; -Does not reject cares; -Limited assistance of one person for Activities of Daily Living (ADL's); -Incontinent of bowel and bladder; -Has no wounds; -Receives no medication for behaviors. Review of the care plan for verbally abusive behaviors dated 3/16/17 showed: -Goal was to converse with others without swearing or berating; -Approaches included the following: reinforce with resident unacceptability of resident's verbal abuse; do not argue with the resident; remove the resident from public area when behavior is disruptive; talk with the resident in calm voice when behavior is disruptive; praise the resident for demonstrating desired behavior. Review of the care plan for potential for skin breakdown dated 3/17/17 showed: -Maintain intact skin integrity; -Activities included the following: offer snacks as appropriate; provide diet as ordered.; Monitor food intake at each meal, dietician to evaluate resident nutritional status as needed, reposition resident as needed; incontinence care following incontinent episodes; continue treatment per order with wound care plus; encourage elevation; resident non-compliant with ADL cares. Review of the undated Daily Care Guide (a tool used by the Certified Nurse Aides (CNA) to give care) showed: -Approach in a warm, calm positive manner; if resident refuses care, inform the charge nurse for education on adverse effects of refusing care; shower days are Tuesday and Friday; whirlpool three times per week on Monday, Wednesday and Friday. Review of the Physician Order Sheet (POS) dated June 2017 showed: -[MEDICATION NAME] (a medication used to treat anxiety and panic disorder) 0.25 milligrams (mg) by mouth (po) four times a day (QID) as needed (prn) for anxiety; -[MEDICATION NAME] (a medication used for pain) HCL 50 mg, one tablet po every six hours prn for pain; -Santyl Calcium (CA) alginate (a medication used to clean dead tissue from wounds) to left lower extremity (LLE) wound, cover with foam dressing, change Monday, Wednesday and Friday; -Compression wraps to both lower extremities (BLE) change Monday, Wednesday and Friday. Review of the Behavior/Intervention monthly flow record dated June 2017 showed no approaches or interventions for refusal of care. Review of the initial weekly wound report dated 6/1/17 showed: -Venous ulcer (wounds caused by improper functioning of the blood vessels in the leg) to left calf, with pink, serosanguineous (drainage that contains blood) with no complaints of pain. Review of the nurses' notes for June 2017 showed no documentation of the wound to the left calf, no documentation of any wounds to the right lower leg and no documentation of any wounds or problems with the toes. Review of the shower sheet dated 6/3/17 showed the resident refused a shower. Review of the nurses' notes for June 2017 showed no documentation of the refusal of the shower, no documentation of any interventions for the refusal of the shower or any documentation of the responsible party or physician notification for the refusal of the shower. Review of the shower sheet dated June 6, 2017 showed: -No reddened areas or bruises; -Open [MEDICAL CONDITION], cuts, lacerations, abrasions or skin tears not marked; -Blisters or open ulcers not marked. During a telephone interview on 6/12/17 at 2:05 P.M. CNA A said: -He/she gave the resident a shower on 6/6/17; -He/she did not wash the resident's toes or legs due to the resident had dressings on the lower legs; -The nurses put plastic bags over the lower legs to protect the dressings. Review of the weekly skin report dated 6/6/17 at 5:17 A.M. signed by Licensed Practical Nurse (LPN) A showed: -Excoriation (superficial skin loss) to the left and right lower leg, [MEDICAL CONDITION] to the right foot, left and right lower leg and venous ulcer to the left calf. During a telephone interview on 6/16/17 at 12:45 P.M. LPN A said: -He/she completed the weekly skin report dated 6/6/17; -He/she did not remove the dressings to the left and right lower leg; -He/she did not inspect the resident's feet; -He/she just completed the wound report based on the previous report completed. Review of the medical record for 6/6/17 through 6/12/17 showed no documentation of any whirlpools, showers or further skin assessments. Review of the nurses' notes dated 6/12/17 at 4:03 A.M. signed by LPN B showed: -Resident complained extreme pain in BLE. Resident was given [MEDICATION NAME] 800 mg with no relief. [MEDICATION NAME] 0.5 mg and [MEDICATION NAME] 50 mg was given approximately 30 minutes after the [MEDICATION NAME] with little relief. The resident is non-compliant and combative. This nurse educated the resident on hygiene and removing socks to assess wounds and dressing. The resident allowed this nurse to look at BLE. While right sock was being removed, maggots fell on to the floor. This nurse cleaned the residents RLE and stopped when the resident became combative and started swinging at the nurse. The resident refused to allow the nurse to remove and re-dress the LLE. The LLE dressing was saturated. BLE with redness and swelling. Resident confused and belligerent with staff during wound care. On call physician contacted with orders to send to hospital for evaluation and treatment. During a telephone interview on 6/15/17 at 10:00 A.M. LPN B said: -He/she had not seen the resident's wounds in over a week; -The resident's socks and dressings to BLE were wet; -He/she removed the sock to the right foot and maggots fell off the residents foot; -He/she would estimate approximately 100 maggots were on the resident's foot; -Maggots were coming from under the right great toe, the toe was red and swollen, with the toe nail raised up; -The resident was in a lot of pain; -The resident is confused and did not understand the education on hygiene and wound care. Review of the Medication Administration Record [REDACTED] -[MEDICATION NAME] 0.5 mg given one time on 6/12/17; -[MEDICATION NAME] HCL 50 mg every six hours prn given one time on 6/12/17. Review of the hospital emergency room physician documentation dated 6/12/17 showed: -Resident's BLE are [DIAGNOSES REDACTED]tous (red) and swollen. The resident has small wounds to the tips of several toes on the right foot and obvious maggots coming out between his/her toes and underneath the right great toenail. Review of the history and physical from the hospital dated 6/12/17 signed by Physician A showed: -The resident is unable to give any sort of history. He/she presented with pain in his/her lower extremities, found to have [MEDICAL CONDITION] with maggot infestation. He/she is unable to give any history including who manages him/her in the nursing home. He/she complained of pain in both lower extremities. It is unsure of how long he/she has had wounds present, there is actual live maggot activities seen in several areas of his/her right foot; -BLE are swollen, the right foot is swollen. The great toenail on the right foot is lifted up. There is maggot activity seen at the base of the nail bed at the front, saw two live maggots underneath the nail bed. The third and fourth toe are macerated (softening and break down of the skin resulting from prolonged exposure to moisture) together. There is live maggot activity between the toes as well. It is painful for him/her. He/she is alert, but he/she is not oriented. During an interview on 6/12/17 at 4:00 P.M. Physician A said: -He/she assessed the resident in the hospital; -There were numerous maggots on the resident's right foot, under the right great toe and between the resident's toes; -The maggots ranged in size from the size of a grain of rice to one inch long; -The resident is confused and has not refused any treatments to the wounds. During an interview on 6/12/17 at 10:00 A.M. LPN C said: -He/she worked Monday through Friday on the hall that the resident resides; -The resident was uncooperative with care; -He/she last saw the resident's legs on 6/9/17; -Both legs had dressings on the lower leg; -He/she did not remove the dressings; -The resident had blue slipper socks on; -He/she did not remove the socks. During an interview on 6/12/17 at 12:30 P.M. LPN D said: -He/she reviews the bath sheets for the residents; -The last completed bath sheet for the resident was on 6/6/17; -The resident refused his/her bath on 5/23/17, 5/25/17, and 5/31/17. During an interview on 6/12/17 at 1:50 P.M. Unit Manager (UM) A said: -He/she was responsible for doing the treatment on the resident's legs on 6/9/17; -The resident refused for the treatment to be done; -He/she did not look at the resident's feet; -He/she did not document in the medical record, notify the physician or the responsible party of the resident's refusal; -The resident is confused and does not comprehend what refusing treatment means. During an interview on 6/12/17 at 2:00 P.M. UM B said: -He/she was responsible to monitor the nurses, CNA's and resident care on the hall that the resident resides; -He/she does not remember the last time he/she saw the resident's legs or toes; -He/she has not worked as a nurse on the hall or done any treatments for the resident. During an interview on 6/12/17 at 3:30 P.M. CNA B said: -He/she worked on the hall the resident resides; -He/she has worked the last five days; -The resident wore blue slipper socks; -The resident has not taken off the blue slipper socks; -He/she has not seen the resident's toes. During an interview on 6/12/17 at 4:00 P.M. the resident said: -He/she could recall what day and year it was and that he/she was in the hospital; -He/she does not remember the last time he/she took a whirlpool or a shower; -He/she does not remember when his/her socks were changed; -His/her legs and feet have hurt for a while; -He/she does not remember the last time someone looked at his/her feet. During a telephone interview on 6/13/17 at 10:50 A.M. Family Member A said: -He/she was unaware that the resident was in the hospital; -He/she has never received a telephone call regarding the wounds on the resident's legs or that the resident refused any treatments. -He/she last saw the resident on 6/7/17. During an interview on 6/13/17 at 2:00 P.M. the DON said: -The resident is alert but confused and would refuse care; -She would expect the nurses to notify the physician and the responsible party of the refusal of cares as the resident does not comprehend the consequences of refusing treatments or cares; -She would expect the staff to re-approach the resident when the resident refuses care or treatments; -She would expect the staff to assess the residents BLE and toes with each shower or whirlpool; -She would expect the staff to notify the physician and responsible party of any problems with the resident; -She would expect the staff to change the resident's dressings and socks when they become soiled. MO 4 and MO 1

Based on observations, interviews, and record reviews, the facility failed to ensure one of 13 sampled resident's and one closed resident record prevented the development of a Stage 2 (a partial thickness loss of the skin) pressure ulcer (PU) on the coccyx for Resident #1 and failed to assess, provide treatment, and obtain a consultation with a wound specialist for the worsening of the PU on both feet for Resident #2. The resident had stage 4 (full thickness tissue loss; with yellow or black tissue present) PU's to both feet. The facility census was 129. Review of the facility policy for Weekly Skin Audit dated 11/12 showed: -A skin audit will be documented on residents weekly. Any identified skin conditions will be documented and treatment initiated; -Every resident will have a head to toe skin evaluation performed and documented on a weekly basis; -Any skin abnormalities identified during this review can be documented in the Interdisciplinary notes; -The physician and family will be notified of any abnormalities; -Treatment will be imitated per the physician's order; -The Unit Manager/charge nurse will review and sign all weekly skin audits; documentation and care plan interventions have been implemented; -Weekly skin evaluations are to be kept with the Treatment Record and filed monthly in the Medication/Treatment section of the medical record. Review of the undated facility policy for Pressure Ulcer and Skin Condition Guide for Wound Evaluation Documentation showed: -It is the practice of this facility to ensure residents with PU receive necessary evaluation and treatment to promote healing, prevent infection and prevent new ulcers from developing; -Upon identification of a PU, regardless if developed in-house or upon admission, the area is to be documented on the Wound Evaluation form or in electronic format; -Contact the physician, interdisciplinary team, family members, and significant others as indicated; -Initiate appropriate treatment per treatment protocol and physician orders; -Evaluate further interventions that may be indicated to promote healing and prevent infection; -Documentation of wound status will occur at least once a week; -The physician is to be notified if there is no improvement in the area, signs and symptoms of infection or signs of deterioration; -The unit manager or charge nurse are to be responsible to ensure PU treatment plan is addressed on the resident's plan of care; -The Director of Nursing Services and/or designated licensed nurses will make PU rounds on a weekly basis. Documentation of the area will be addressed. Resident progress or lack of progress will be evaluated. Directives may be given for further interventions and changes in the plan of care. The resident's current care plan will also be reviewed. 1. Review of Resident #2's hospital discharge summary dated 6/8/16 showed: - admitted : 5/17/16. - discharge date : 6/8/16. - [DIAGNOSES REDACTED]. - On 5/20/16: PU on right heel, foul smelling; osteo[DIAGNOSES REDACTED] (infection of the bone) of heel bone and tissue involvement; wound care and off loading of foot with foam waffle boots; Podiatry (foot physician) consult for debridement (removal of dead tissue) prior to biopsy; biopsy grew Staphylococcus aureus (the leading cause of skin and soft tissue infections such as [MEDICAL CONDITION] (infection of the skin) and bone infection), VRE ([MEDICATION NAME]-resistant [MEDICATION NAME] a type of bacteria which have developed resistance to many antibiotics), and corynebacterium (a difficult to control and treat infection seen in animals), treated with [MEDICATION NAME] (an antibiotic), [MEDICATION NAME] (used to treat fungus infections); and [MEDICATION NAME] (an antibiotic) which is to be continued through 7/23/16. - Right and left foot wounds without pus or redness. Review of the facility's Evaluation of PU Risk sheet dated 6/8/16 showed: - At risk for PU formation due to bed immobility, previous PUs, desensitized (not able to feel pain, pressure) skin to pain or pressure. - Care plan interventions. Review of the undated facility Skin and Wound Evaluation Form showed: - No description of wounds to feet. - Staff wrote In RAI MAX (computer program for charting wound information). - Facility did not have RAI MAX information related to this undated form. Review of the facility's Admission/Readmission Evaluation sheet dated 6/8/16 showed: - No evaluation of PU on the right and left foot. Review of the Instant Care Plan (written initially when the resident is admitted before a full care plan is developed) dated 6/8/16 showed: - At risk for skin issues; weekly skin audit; turn/reposition; complete wound/skin evaluation; treatment as ordered. Review of the care plan (complete detailed plan of care) dated 6/8/16 showed: - Problem: Skin integrity impaired related to deep tissue injury right heel. - Goal: Will show signs of healing through next care plan review on 9/8/16. - Approaches: Treat as ordered; pain medications as ordered; protein and calories through meal intake; between meal supplements as ordered; pressure reduction bed and chair; notify physician of changes; laboratory (lab) tests as ordered. Review of a facility Departmental Note (DN) dated 6/8/16 at 10:55 P.M. showed LPN C recorded: - admitted to facility; - No complaints at this time. - Alert and oriented, mechanical lift, vital signs normal. - Did not record evaluation, assessment, and measurements of the wounds to the resident's right foot or left foot. - Did not record any treatment for [REDACTED]. Review of the physician order sheet (POS) dated June, 2016 showed: - Weekly skin assessments. - No orders for wound treatment to the right and left foot wounds. Review of the physician's telephone orders dated 6/8/16 showed: - No orders for wound treatment to the right and left foot wounds. Review of a physician's progress note (PPN) dated 6/9/16 showed: - New admit. - Ulcers to feet. Record review showed no DN, Wound Care Notes, or RAI MAX notes for 6/9/16 through 6/15/16. Review of the admission MDS dated [DATE] showed: - Facility admitted : 6/8/16. - admitted from hospital. - BIMS score of 15, which indicated the resident made his/her own decisions. - Extensive assist of two or more staff for bed mobility. - Total dependence upon two or more staff for transfers. - Total dependence upon one staff for bathing. - Not steady, only able to stabilize with staff assistance for surface to surface transfers (between bed and chair or wheelchair). - No impairment of the upper extremities. - Impairment of both lower extremities. - Wheelchair. - Pain constantly; pain scale level of 10 with 0 being no pain and 10 being very horrible. - At risk for PUs. - No unhealed PUs. - Pressure devices for bed. - Turning program. - Dressings to feet. - [DIAGNOSES REDACTED]. Review of a DN dated 6/16/16 at 9:49 P.M. showed: - LPN F did not record evaluation, assessment, and measurements of the wounds to the resident's right foot or left foot. - Did not record any treatment for [REDACTED]. Review of PPN dated 6/16/16 showed: - Inadequate pain control, osteo[DIAGNOSES REDACTED], and wounds to both feet. Review of a DN dated 6/17/16 at 7:31 A.M. showed: - LPN F did not record evaluation, assessment, and measurements of the wounds to the resident's right foot or left foot. - Did not record any treatment for [REDACTED]. - To hospital emergency room for suprapubic catheter (a sterile tube inserted through the abdomen into the urinary bladder to drain urine) placement. Record review showed no DN, Wound Care Notes, or RAI MAX notes for 6/18/16 through 6/21/16. Review of the Dietary Data History and Initial Screening sheet dated 6/22/16 showed the Registered Dietician (RD) recorded: - PU other site, osteo[DIAGNOSES REDACTED] of ankle and foot, [MEDICAL CONDITION], and chronic pain. - Power chair. - Right and left foot wounds. - Left foot PU measured 21.5 centimeters (cm) long x 12 cm wide x 0.1 cm deep; covered with eschar (a full thickness tissue loss in which the bed of the PU is covered with black, yellow, tan, green or brown tissue and is known as an Unstageable PU), some beefy red tissue. - Bottom of left foot PU measured 4.5 cm long x 4.0 cm wide x 0.2 cm deep. - Left great toe PU measured 2 cm long x 1 cm wide x 0 cm deep. - Right heel PU measured 10 cm long x 11 cm wide x 0.5 deep and covered with black eschar. - Right great toe PU measured 2.5 cm long x 1.5 cm wide x 0.5 cm deep covered with black eschar. Review of a telephone order dated 6/22/16 showed: - Left foot: Clean with wound cleanser, pat dry, skin prep to eschar, cover with Durafiber/Calcium Alginate (a dressing to absorb drainage and promote healing), ABD pad (dressing material), and wrap with gauze wrap on Monday (M), Wednesday (W), and Friday (F). - Right foot: Clean with wound cleanser, pat dry, skin prep (liquid film forming skin protectant which can be used on intact or damaged skin to help prevent irritation caused by friction or trauma) to eschar, cover with Durafiber/Calcium Alginate, ABD pad, and wrap with gauze wrap on M, W, and F. Review of the Care Plan dated 6/22/16 showed: - Problem: Left heel unstageable wound. - Approaches: Monitor for signs and symptoms of infection; treat as ordered; off load (to raise feet/heels off of a surface to prevent pressure and PUs) heels as tolerated; [MEDICATION NAME] (an antibiotic) as ordered; Vitamin C; Multivitamins; wound clinic consult. Record review showed no DN, Wound Care Notes, or RAI MAX notes for 6/22/16 and 6/23/16. Review of a DN dated 6/24/16 at 4:33 P.M. showed the Social Service Director recorded: - She spoke to the resident about scheduling a physician's appointment for a neurology appointment but did not record she talked about a wound clinic appointment. - The resident said he/she always scheduled his/her own appointments, he/she was capable of making his/her own appointments, he/she preferred to make his/her own appointments, and said this was part of regaining his/her independence and self determination. - The Social Service Director to follow up with the resident on Monday, 6/27/16 to obtain information for transportation arrangements. Review of a DN dated 6/24/16 at 4:36 P.M. showed the Social Service Designee (SSD) recorded: - He/she assisted with scheduling appointments with the resident's neurologist and psychiatrist. -The SSD did not speak to him her about a wound clinic appointment. - The resident said he/she would make his/her own appointments for the neurologist and psychiatrist. Review of a telephone order dated 6/24/16 showed: - Discontinue skin prep to eschar on left and right feet. Review of a telephone order dated 6/24/16 showed: - Right foot and Left foot: Clean with wound cleanser; pat dry, [MEDICATION NAME] (iodine, a drying solution) to eschar, cover with Durafiber/Calcium Alginate and ABD pad, wrap with gauze wrap, change M, W, F, and PRN. - Discontinue skin prep to eschar on left and right feet. Review of a telephone order dated 6/24/16 showed: - Stop date for [MEDICATION NAME] to left and right feet in 14 days (7/8/16). Review of a DN dated 6/24/16 at 7:46 P.M. showed Registered Nurse (RN) C recorded: - Asses resident's wound status. - Left foot: Unstageable; 21.5 cm long x 12 cm wide x 0.1 deep; eschar; some areas red and beefy, large amount of dried dead skin; large area of eschar measured 4.5 cm long x 4 cm wide x 0.2; bottom of left great toe 2 cm long x 1 cm wide x 0 cm deep, red black in color. - Right heel: Black eschar measured 10 cm long x 11 cm wide x 0.5 cm deep; bottom of right great toe measured 2.5 cm long x 1.5 cm wide x 0 cm deep, red black in color. - Dressing changed from skin prep to [MEDICATION NAME] solution. - Talked with resident about making appointment with wound clinic and resident agreed; resident will call on Monday, 6/27/16. Record review showed no DN for wound clinic appointment, Wound Care Notes, and RAI MAX notes for 6/25/16 through 6/27/16. Review of a DN dated 6/28/16 at 9:16 A.M. showed the RD recorded: - Treatment ongoing for wounds to both right and left feet. - Left foot: PU measured 21 cm long x 12 cm wide x 0.1 cm deep, mostly eschar with some beefy red areas; left great toe wound measured 2.0 cm long x 1.0 cm wide x 0 cm deep. - Right heel: PU measured 10.0 cm long x 11.0 cm wide x 0.5 cm deep with black eschar; right great toe measured 2.5 cm long x 1.5 cm wide x 0.5 cm deep with black eschar; multivitamins and Vitamin C BID (twice daily). Record review for 6/28/16 through 6/30/16 showed no DN for wound clinic appointment, Wound Care Notes, and RAI MAX notes. Review of the Treatment Administration Record (TAR) dated June, 2016 showed: - All dressing change orders were discontinued from 6/22/16 through 6/30/16. Review of the TAR dated July, 2016 showed: - No weekly skin assessments were recorded from 7/1/16 through 7/19/16. - A staff circled the treatment for [REDACTED]. - Wound treatment to the right and left foot were charted as done one time on 7/6/16 and the TAR showed the treatments were discontinued but no discontinued date. - 7/6/16: Cleanse wounds to bilateral feet with wound cleanser, pat dry, apply Durafiber/Calcium Alginate until healed each shift. - No staff recorded they administered treatment to the wounds on 7/13/16 and 7/14/16. - Out of 42 opportunities for administration of Durafiber/Calcium Alginate, staff did not record they treated the wounds to the feet 18 times and did not record on the back of the TAR why the wounds were not treated as ordered. Review of the July, 2016 POS showed: - 6/8/16: Weekly skin assessment. - 6/8/16: Right foot and Left foot- Clean with wound cleanser, pat dry, apply [MEDICATION NAME] to eschar, cover with Durafiber/Calcium Alginate and ABD, wrap with gauze wrap, change M, W, F, and PRN if missing or soiled. Stop Date: 7/8/16. Review of an x-ray report dated 7/1/16 showed: - No fracture or dislocation of the left foot or the right foot. Record review for 7/1/16 showed no DN for wound clinic appointment, Wound Care Notes, and RAI MAX notes. Review of the care plan dated 7/1/16 showed: - Problem: Abrasion to the lateral aspect of the left great toe. - Approaches: Culture the left lower extremity (LLE) and right lower extremity (RLE) wounds as ordered; treat LLE as ordered; ensure dressing covers the left great toe abrasion; assess for signs and symptoms of infection with each dressing change; document; notify physician as needed. Record review for 7/2/16 showed no DN for wound clinic appointment, Wound Care Notes, and RAI MAX notes. Review of a DN dated 7/2/16 at 3:52 P.M. showed RN D recorded: - Late entry for 7/1/16 at 9:00 P.M. - A laboratory technician notified RN D a resident was outside the facility smoking and was injured. - It appeared the resident's foot had fallen off the electric wheelchair platform, that the resident was unaware and continued to allow his/her foot to drag on the pavement as he/she self propelled in his/her wheelchair and he/she appeared to be sliding out of his/her chair. - RN D found the resident with left side of body slid down in the electric wheelchair and the left lower extremity (LLE) hung off the wheelchair platform. - The LLE appeared to be caught between the wheelchair wheel and the side of the platform. - The dressing to the LLE was black and saturated on the lateral (outer) aspect and worn off the bottom of the foot. - He/she had a 1.5 cm long x 3 cm wide denuded (removal of skin), abraded (removal of skin) area to the left great toe with a moderate amount of sero-sanguinous (watery pink to red drainage) drainage. - The resident said he/she may have run over foot. - X-rays ordered. Review of the care plan dated 7/2/16 showed: - Problem: At risk for increased skin breakdown to bilateral thighs secondary to using gait belt to keep BLE on the foot platform of the electric wheelchair per resident's choice. - Approaches: Encourage resident to remove gait belt every two hours; assess bilateral thighs for skin breakdown. - Did not address treatment to the Stage II wounds to the bilateral thighs. Record review for 7/2/16 through 7/5/16 showed no DN for wound clinic appointment, Wound Care Notes, and RAI MAX notes. Review of a telephone order dated 7/6/16 showed: - Discontinue all previous treatment orders to heels. - Clean wound with wound cleanser, pat dry, apply Durafiber/Calcium Alginate and wrap with gauze wrap. - Treatment to heels TID (three times a day). Review of the DN note dated 7/6/16 at 6:09 P.M. showed the Social Service Director recorded: - The resident requested a change in his/her physician. Record review for 7/6/16 through 7/7/16 showed no DN for wound clinic appointment, Wound Care Notes, and RAI MAX notes. Review of the DN note dated 7/8/16 at 4:13 A.M. showed LPN B recorded: - Staff put resident to bed at 1:30 A.M. - A CNA told LPN B the resident's catheter leaked. - LPN B did not check the catheter right away because he/she felt it was most likely positional and would verify if the resident was wet at the next bed check (residents checked every two hours for incontinence). - At bed check the resident was upset and wanted to go to the ER. - He/she would not talk to LPN B and the resident called 911 to take him/her to the hospital. - The ambulance personnel arrived and transported the resident to the hospital. Review of the hospital ER notes dated 7/8/16 showed: - Final [DIAGNOSES REDACTED]. - Presented with concerns over indwelling catheter problem and wounds to feet. - The resident felt the wounds were not cared for adequately by the facility where he/she lived. -Bilateral PU on both heels with eschar formation. No surrounding redness or purulent drainage. - Superficial ulcerations to the posterior left thigh and leg where the indwelling catheter was placed under the resident's thigh. No surrounding redness or drainage. - The resident's wounds were redressed and a new dressing was placed over the apparent PU which involved the urinary catheter and the posterior left thigh and leg. - The resident needed wound care and hospital staff gave him/her a follow-up number to call to make an appointment. Review of the DN note dated 7/8/16/ at 12:40 P.M. showed: - LPN F did not record assessment of the resident after returning from the hospital or that the resident returned from the hospital. - Did not record the wound assessment of heel wounds or wound on back of left thigh. - Did not record the need for the resident to call for follow up wound care for wounds. - Physician A saw resident and wrote new orders for medications but did not address wounds to feet or wound clinic referral. Review of a DN note dated 7/8/16 at 1:20 P.M. showed the Social Service Designee recorded: - The resident requested to change physicians. - The new physician met with the resident this morning and was pleased with the visit. Record review for 7/10/16 showed no DN for wound clinic appointment, Wound Care Notes, and RAI MAX notes. Review of the DN note dated 7/11/16 at 9:37 P.M. showed LPN H recorded: - Bilateral foot dressing changed today. - Measurements charted in skin assessment. - Continue same orders. - Did not show appointment made for the wound clinic. Review of the Weekly Wound Sheet dated 7/11/16 at 11:14 A.M. showed LPN H recorded: - Right heel: Deep tissue injury; measured 7.0 cm long x 6.0 width x 0.1 cm deep; present on admission; moderate exudates (drainage); eschar; pain with treatment, scored at four to five; periwound (skin around wound)- intact and [MEDICAL CONDITION] (swollen); wound edges visible; multivitamins; ABD pad (large dressing), Calcium Alginate/Durafiber, skin prep, and wrap with gauze dressing. - Left foot: Deep tissue injury; measured 7.0 cm long x 7.0 cm wide x 0.1 cm deep; present on admission; moderate exudate; mild odor; slough; periwound-intact and [MEDICAL CONDITION]; wound edges visible; pain with treatment, scored at four to five; repositioning, powered air mattress; ABD pad, Calcium Alginate/Durafiber, and skin prep. Record review for 7/12/16 showed no DN for wound clinic appointment, Wound Care Notes, and RAI MAX notes. Review of the DN note dated 7/13/16 at 12:37 P.M. the RD recorded: - The resident now had two new Stage II (serous filled blister or partial thickness skin loss presented as a shallow open ulcer with red pink wound bed without slough or dead tissue) wounds to inner thighs. - Followed by wound care nurse for other wounds. Review of the DN note dated 7/13/16 at 1:49 P.M. the Social Service Director recorded: - Offered to make appointments for neurological and psychiatric appointments but the resident declined. - Did not record she offered to make a wound clinic appointment for the resident. Record review for 7/13/16 showed no DN for wound clinic appointment, Wound Care Notes, and RAI MAX notes. Review of the Weekly Skin Sheet dated 7/14/16 at 8:31 P.M. showed LPN F recorded: - Deep tissue injury to the left bottom foot. - Deep tissue injury to the right heel. Record review for 7/14/16 through 7/19/16 showed no DN for wound clinic appointment, Wound Care Notes, and RAI MAX notes. Review of the hospital History and Physical dated 7/18/16 showed: - Chief complaint: Wounds to bilateral feet; resident requested wound consult and reported the nursing facility was not meeting his/her needs. - Presented for evaluation of bilateral heel wounds. - The resident reported persistent worsening of bilateral PU on his/her heels over the last two and a half months. - The PU was a small spot upon admission to the nursing facility. - He/she worried his/her foot would need to be amputated (surgically removed). - He/she tried to make an appointment with a Podiatrist (foot specialist) but was told he/she needed wound care to the foot. - He/she tried to make an appointment for wound care but was told to see a surgeon. - Significant PU to right heel; the resident stated the right heel was the worst wound. - The physician did not look at the left heel wound. - The resident wore compression booties to protect the heels. - Bilateral heels with open wounds, right heel wound deep, measured 5 cm in diameter, draining and deep. - Wound care consulted; [MEDICATION NAME] (an antibiotic) started; wound cultures (lab test that determines bacteria causing an infection) pending. - Podiatry consult for debridement of foot wound. - All wounds are unstageable PU covered with eschar, odorous, and wound edges are not attached. - The ER physician made photographs of the resident's foot wounds. Review of a hospital physician consult dated 7/19/16 showed: - Reason: Bilateral foot wounds. - History: Bilateral PU to heels and left lateral foot; did not receive appropriate care for his/her wounds and he/she was admitted through the ER yesterday; able to feel pain in the affected heel; did not have much sensation in his/her lower extremities per report from resident; not clear why he/she did not have care for his/her feet in the past. - Past medical history: [MEDICATION NAME] [DIAGNOSES REDACTED], [MEDICAL CONDITION], and [MEDICAL CONDITION] disorder (mental disorder marked by alternating periods of elation and depression). - Unable to move lower extremities; right foot demonstrates a large PU involving the majority of the heel with eschar unattached at the edges; surrounding skin somewhat dusky (lack of circulation); the left foot had a smaller wound that involved the middle of the foot and a second PU on the outside of the foot covered with eschar with unattached edges and dusky surrounding skin. - Plan: Continued maintenance of feet to properly heal wounds. Wound consult for management of wounds and podiatry consult for debridement with further testing; may need skin flap coverage at a later date; possible [MEDICAL CONDITION] if necessary. Review of the DN note dated 7/19/16 at 5:24 P.M. showed LPN C recorded: - Late entry for 7/18/16: Sent to the hospital ER for treatment and evaluation of foot wounds. - Resident requested to be sent to ER after wound care completed because he/she felt he/she needed surgery on his/her feet. - The resident said he/she tried to contact physicians outside the facility to evaluate for surgery but physicians did not give him/her the response he/she was looking for. - When he/she went to theER on [DATE], the ER physician wanted to admit him/her because of the wounds and he/she refused. - He/she wanted the wounds to be cared for at the facility. - He/she decided he/she wanted a second opinion, a surgery appointment and chose to go to the ER. During an interview on 7/19/16 at 3:15 P.M., LPN B said: - The resident made his/her own decisions. - The resident called 911 to take him/her to the hospital on [DATE] because he/she said LPN B did not care about him/her and did nothing about his/her leaking catheter. - At bed check he/she was not wet. - The facility had a wound nurse who treated the resident's wounds but he/she no longer worked at the facility. - There had been no wound nurse since he/she left until recently, but the new wound nurse was on vacation. - All nurses provided wound care after the wound nurse left. - Wound information was written in the RAI MAX but LPN B did not find any reports in the computer. During an interview on 7/20/16 at 7:35 A.M., LPN G said: - The previous shift nurse told him/her the resident's heels were mushy. - The previous shift nurse provided treatment to the heels but the resident was concerned about the condition of his/her heels and the resident wanted to go to the hospital to be evaluated and to have surgery on his/her heels. - Previous shift called for transportation to take the resident to the hospital. - LPN G did not know of any wounds to the resident's thighs. During an interview on 7/20/16 at 8:30 A.M., the DON and Administrator said: - The DON was new to the facility and said she did not know much about the resident. - LPN H was the new wound nurse and started on 6/27/16. - He/she was on vacation for the last week and was back today. - He/she worked the floor at times. - All nurses performed wound care on the resident. - The resident changed physicians around 7/8/16. - The new physician was not a wound physician and did not assess the resident's wounds. - The resident became anxious about his/her wounds and wanted to go to the hospital. - It was hard to find wound notes in the facility's computer system. - It was not unusual for the resident to make his/her own decision about many things. - The resident called for an ambulance to transfer him/her to the hospital on [DATE] and 7/18/16. - The resident signed him/herself out of the facility as he/she pleased. During an interview on 7/20/16 at 9:00 A.M., RN B said: - He/she cared for the resident's wounds on 7/13/16 or 7/14/16 and charted the information on the TAR. - The resident had wounds on his/her heels bilaterally and on the side of the left foot. - He/she was not aware of wounds to the resident's thighs. - He/she did not know if the resident refused wound care and seemed eager to have a consult with the wound clinic. During an interview on 7/20/16 at 12:40 P.M., LPN H said: - He/she was the wound nurse for two weeks and then went on vacation for the past week. - He/she had no outside training in wound care. - He/she worked at the facility for three months and did treatments as a floor nurse prior to accepting the position as wound nurse. - As the new wound nurse, one day a week he/she worked four to five hours as the wound nurse and the rest of the day as a floor nurse. - He/she thought that schedule would change soon. - The previous wound nurse followed Resident #2 and provided care. - LPN H only saw the dressing changes but did not provide care to the wounds. - Floor nurses provided care to wounds routinely; the wound nurse saw residents one time a week usually. - The last order by the physician was to change the bilateral feet dressing TID. - One foot was black from toes to heel. - The wound treatment changed several times. - On 7/1/16, the [MEDICATION NAME] to the eschar areas was discontinued. - On 7/17/16, Durafiber/Calcium Alginate was used. - Wounds to the resident's toes were healing as of the last time he/she saw the wounds on 7/14/16. - There were pinpoint scabs on the two great toes. - The wounds to the toes were caused by the resident dragging his/her feet on the ground when in his/her old wheelchair. - The facility obtained a new electric wheelchair for the resident and he/she now used the new wheelchair for locomotion. - Both heels were covered with black eschar. - There were dry areas that lifted up around the wounds on both feet. - He/she did not know of wounds to the resident's thighs. - During a meeting on 7/13/16, a staff reported the resident had wounds to his/her thighs but gave no measurements. - RN D reported the wounds were from the gait belt used by the resident to keep his/her legs from slipping off the foot platform of his/her old wheelchair and the gait belt rubbed on the resident's thighs. - LPN H was not aware of a treatment to the wounds on the resident's thighs. - Staff notified him/her of new wounds or a report would trigger in the RAI MAX. During an interview on 7/20/16 at 1:00 P.M., LPN C said: - He/she worked the evening of 7/18/16. - He/she administered treatment to the resident's wounds and the heels were mushy (soft, semi-liquid) to touch. - The heels and left foot were black and had odorous drainage. - The resident wanted to go to the ER because his/her new physician did not look at the wounds and he/she felt the wounds were worse because they felt mushy. - LPN C called for private transportation and sent the resident to the ER for evaluation. During an interview on 7/20/16 at 2:30 P.M., RN C said: - When the resident returned from the hospital on [DATE], he/she attempted to make a wound clinic appointment for him/her but the resident wanted to make the appointment him/herself on Monday, 7/11/16. - RN C gave the resident the wound clinic number to call for an appointment. - RN C checked back with the resident on 7/11/16 to see if he/she made the appointment and he/she did not. - RN C checked back on other days to see if the resident made the appointment but he/she did not. - He/she changed the dressing on the resident's feet on 7/11/16 and the wounds looked much better than on 6/24/16; they were not mushy. - The resident wanted treatments performed on his/her own time; he/she would be out and about all day and staff would have to catch him/her to get treatments done. During an interview on 7/20/16 at 2:40 P.M., the Social Service Director said: - Nursing staff asked her to assist the resident in setting up appointments for a neurology and psychiatric physicians, but the resident wanted to keep his/her independence and make the appointments him/herself. - She checked back with the resident weekly to see if the resident made the appointments and the resident kept saying he/she would do it next week. - She did not know if the resident ever made an appointment for the wound clinic. - RN C talked with the resident about the wound clinic appointment. During an interview

Based on observation, interview and record review, the facility failed to ensure staff provided adequate supervision and care to prevent accidents for one of 16 sampled residents when Resident #2 experienced a fall and sustained a fracture to his/her nose and bilateral frontal lobe hemorrhage (bleeding in the brain). The resident's plan of care directed staff to assure he/she wore nonskid or gripper socks when up. The resident did not have nonskid or gripper socks on, got up by his/herself and fell as he/she walked to the bathroom in his/her room unassisted. The facility census was 135. The facility did not provide a policy for Accident/Incident Prevention. Review of the undated facility policy for Accident and Incident Documentation and Investigation showed: -An incident is defined as an occurrence which is not consistent with the routine operation of the facility or the routine care of a particular resident. -Accidents and incidents will be analyzed for trends or patterns to enable the facility to enhance preventive measure to reduce the occurrence of incidents. -The licensed nurse may complete a nurse's note and update the resident care plan as needed. -The nurse's note could contain the following documentation: clear, objective facts of what occurred; an evaluation of the resident's condition at the time of the accident/incident could include a description of the resident, vital signs, and any other physical characteristics apparent as a result of the accident/incident; any treatment provided; the resident's outcome and any information concerning the incident. 1. Review of Resident #2's care plan for falls, dated 4/19/11, with a goal date of 8/6/16, showed: -At risk for falls and injuries related to falls due to unsteady gait and use of antidepressants and narcotics. Ambulates with walker, needs reminders to use the walker. Non injury fall on 11/17/15; fall from bed on 9/23/15; fall in room on 6/11/16 and instant care plan on 6/15/16; -Goal: will have no injuries related to falls during the next review; -Approaches include: monitor for acute changes in mentation or functional ability, refer to physical and occupational therapy; fall mat next to bed at all times; contour mattress to bed; encourage to ask for assistance; bed alarm; supervision with transfers; discontinue fall mat; bed alarms and nonskid socks; green tape of walker to remind resident to use the walker; gripper socks; maintain environment free from clutter; place items within reach; transfer to hospital for treatment. - The care plan did not indicate dates staff added or discontinued approaches. Review of nurses notes showed: -11/17/15: non injury fall; -9/27/15: fell from bed; -3/30/16: resident found on floor face down trying to get up; laceration to forehead. Review of the annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 5/2/16, showed: -Unable to make decisions; -Depression; -Favorite activities included going outside and participate in religious activities; -Supervision of bed mobility, transfers, walking in the room and corridor, dressing, eating, toilet use and personal hygiene; -Used a walker for ambulation; -Occasionally incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. -Received scheduled and as needed pain medication; -No history or recent falls; -Received anti-anxiety medication daily; -No therapy or restorative programs. Review of the Care Area Assessment (CAAs, a tool used for care planning decisions), dated 5/2/16, the MDS information provided by staff indicated staff needed to address the following areas in the resident's plan of care showed delirium, cognitive loss, activities of daily living (ADLs), urinary incontinence, falls, nutritional status, pressure ulcers and psychotropic drug use. Review of the physicians' order sheet (POS), dated June 2016, showed: -Namenda (a medication used to treat Alzheimer's type dementia) 28 milligrams (mg) daily; -Aricept (a medication used to treat Alzheimer's type dementia) 10 mg daily; -Buspirone HCL (a medication used to treat anxiety) 5 mg two times a day; -Ultram (a medication used for pain) 50 mg every four hours as needed; -Ativan (a medication used to treat anxiety) .05 mg, one half tablet every eight hours as needed; -Fentanyl patch (a narcotic used to treat pain) 25 mcg/hour applied to the skin every 72 hours. Review of nurses' notes, dated 6/11/16, at 11:59 A.M., showed: -The resident had a witnessed fall in room. -Per certified nurse aide (CNA), the bed alarm was sounding from the resident's room. -As the CNA entered the room, the resident was seen walking to the bathroom, using his/her walker. -Before the CNA could get to him/her, the resident stopped suddenly, then fell forward, almost like he/she passed out. -The CNA immediately called for help. -CNA called out the resident's name, the resident did not respond. -The CNA tapped the resident's arm, called his/her name a second time, the resident did not respond. -Nurse ran into the room, the resident was on the floor of the bathroom with his/her head leaning against the wall, blood flowing steadily from the top of the resident's nose. -Nurse asked the certified medication technician (CMT) to call 911 while he/she stayed with the resident. -Resident was non-responsive for approximately one minute, with labored breaths. -The resident then opened his/her eyes, making a grunting sound. -After approximately three minutes, the resident was responding, able to state his/her name. During an interview on 6/24/16, at 10:10 A.M., CNA C said: -He/she took care of the resident on 6/11/16. -He/she heard the resident's alarm and when he/she entered the room, the resident was standing in the bathroom door, which was approximately 10 feet away from the bed. -The resident had regular socks on but did not have any shoes on. -The resident fell forward, hitting his/her face on the concrete floor. During an interview on 6/22/16, at 2:15 P.M. CMT A said: -He/she was at the nurses' station and heard a noise on 6/11/16. -He/she heard an alarm, but was not for sure which resident's alarm was sounding. -He/she heard CNA C yell for the nurse. -He/she saw the resident laying on the floor face down in a pool of blood. -He/she left the room and began making copies of the medical record for the ambulance. Review of nurses' notes showed on 6/15/16, the resident returned from hospital with [DIAGNOSES REDACTED]. Review of the instant care plan, dated 6/15/16, showed: -Fall, therapy screen, interdisciplinary team to meet; -Fall precautions, bed alarm, therapy and offer fluids. -No one added any new interventions in an attempt to keep the resident from getting up without assistance or to make sure he/she wore non-skid/gripper socks at all times. - The instant care plan did not describe to staff what fall precautions meant. Review of the daily care guide (a care plan used by the CNAs to give care), printed on 6/22/16, showed: -Risks included falls; -Interventions: bed alarm on at all times while in bed, contour mattress, encourage the resident to participate in activities, gripper socks on when out of bed, remind the resident to use assistive devices, toilet every two hours, up with assistance on one staff and gait belt with walker; -The daily care guide did not address any new interventions to prevent falls. -Did not include the intervention for a fall matt; -The care plan did not have interventions for the side effects of drowsiness and dizziness with the use of the pain medication, anti-anxiety medication or the medication to treat Alzheimer's type dementia. Observation on 6/22/16, at 12:15 P.M., showed: - The resident sat in a wheelchair in the dining room with regular socks on. - Dark purple, yellowish colored bruising covered the resident's entire face. - An alarm on the back of the wheelchair turned off. Observation of the resident's room on 6/22/16, at 12:30 P.M., showed: - The resident lying in bed; - A small refrigerator sitting on an bedside cabinet next to the resident's bed with a bath blanket under the door of the refrigerator. - Water leaked out of the refrigerator onto the blanket. - The resident's bed positioned 2 feet off the floor with a fall mat placed next to the right side of the bed and the left side of the bed placed against the wall. - No gripper socks were visible in the room. - The resident wore a pair of regular socks. - The bed alarm lay on the floor and the call light placed on the over the bed table 3 feet from the bed and the resident. Observation on 6/24/16, at 10:05 A.M., showed: - CNA A and CNA B transferred the resident with a gait belt from a shower chair to the bed; - The resident wore regular socks. - The bed positioned 2 feet off the floor, the bed alarm sat on the floor turned off; - The fall mat propped against the bedside table; - The resident's call light on the over the bed table three feet from the bed and away from the resident. During an interview on 6/24/16, at 10:10 A.M., CNA B said: - The resident should have gripper socks on at all times. - A fall mat should be by the bed. - No one told them to do anything different with the resident after his/her most recent fall. During an interview on 6/24/16, at 10:10 A.M., CNA C said: -CNAs used the daily care guides to know how to provide care for the residents. -These were the CNAs care plans. -He/she did not know of any other care plans. During an interview on 6/24/16 at 4:40 P.M. the DON said: -Interventions for falls should be placed in the care plan and Daily Care Guides after each fall. -The interventions on the care plan and the Daily Care Guides should match. -Staff should follow the interventions on the care plans and the Daily Care Guides. -Alarms should be functional at all times. -The nurse should check the alarms on every shift. -Fall mats should be placed beside the bed if they were an intervention. -The refrigerator should have been removed from Resident #2's room when it started leaking. MO 5

Based on observation, interview, and record review, the facility failed to assure staff used transfer techniques to prevent accidents for two additional residents (Resident #25 and #26); failed to assure staff implemented measures to prevent accidents for one of 21 sampled residents (Resident #12) when staff did not return the bed crank levers under the bed out of the resident's path; and did not assure one additional resident (Resident #27) was clear of a closing fire door during a fire drill which resulted in injury to the resident. The facility census was 123. 1. Review of Resident #25's MDS, dated [DATE], showed: - Short- and long-term memory problem; - Severely-impaired cognitive skills for daily decision making; - Required extensive assistance of one person for transfers; - Did not walk; - [DIAGNOSES REDACTED]. Review of the care plan problem dated 4/5/10, showed the problem "Impaired mobility due to CVA (cerebrovascular accident/stroke) and generalized weakness." Approaches did not include directions related to transfer. Review of the resident's current Daily Care Guide showed the resident required the assistance of two + staff for transfers. Observation on 10/3/11 at 7:10 P.M., showed CNA U transferred the resident from the wheelchair to bed as follows: - Put a gait belt (special belt applied around a resident's waist and used as a handle when assisting the resident to transfer and walk) around the resident's waist. - Lifted the resident with both hands on the gait belt. The resident's toes barely touched the floor and the resident did not bear any weight on his/her feet during the transfer. During an interview on 10/3/11 at 7:32 P.M., CNA U said when he/she transferred the resident he supported most of the resident's weight, but said the resident could bear a little weight. 2. Review of Resident #26's care plan, showed the problem dated 8/15/11, "At risk for injury due to falls related to [DIAGNOSES REDACTED]. Approaches listed for staff to take related to that problem included, "Use two assist with gait belt for transfers." Review of the resident's MDS dated [DATE] showed: - BIMS score of 7 indicating severe impairment of cognitive skills. - [DIAGNOSES REDACTED]. - Required extensive assistance of one person for transfers. Observation on 10/5/11 at 6:45 A.M., showed CNAs M and S transferred the resident as follows: - Applied a gait belt around the resident's waist. - Both lifted the resident with the gait belt. The resident's feet did not touch the floor. During an interview on 10/6/11 at 1:45 P.M., CNA S said staff always lifted the resident entirely with the gait belt. The resident did not bear weight or put his/her feet on the floor. He/she did not remember ever learning that staff should not lift a resident with a gait belt if the resident is not able to bear any weight. During an interview on 10/7/11 at 12:00 P.M., the DON said staff should not lift a resident entirely with a gait belt. If a resident is not able to bear any weight on his/her feet, staff should re-evaluate the resident for a safer transfer method. Staff had not reported that Resident #25 and #26 were not able to bear weight. During an interview on 10/7/11 at 11:05 A.M., Physical Therapy Assistant (PTA) C said if a resident is not able to bear weight on his/her feet, staff should re-evaluate him/her for a transfer method other than a gait belt transfer. Staff should not lift a resident completely by the gait belt. 3. Review of Resident #12's Minimum Data Set (MDS), a federally-mandated assessment instrument completed by facility staff, dated 07/04/11, showed: -A BIMS score of 15, indicating the resident was able to make decisions. -Resident self-propels in wheelchair in room and corridor. Observation on 10/05/11 at 5:25 A.M., showed the resident: did and said the following : -Was receiving assistance with A.M. care from CNA L. -Self-propelled to bathroom. -Called the surveyor to the end of the bed as he/she approached the end of bed to attempt to enter the bathroom. -Pointed out the two bed crank levers that staff had left out at the end of his/her bed. -The resident said these are in my way and I have a hard time getting around them. I have told staff to put them up out of my way. In an interview on 10/01/11 at 8:45 A.M., Resident #12 said: -He/she had mentioned putting in the bed crank levers to at least four staff members, but could not remember their names. -He/she felt like it doesn't do any good, no one listens. In an interview on 10/07/11 at 10:40 A.M., the Director of Nursing said staff should maintain a safe path for the residents by returning the bed crank levers back under the bed after using them. This would prevent injury and skin tears as well as provide a path of safety by the end of the bed. 4. Observation on 10/4/11, at 3:11 P.M., showed the maintenance director announced over the public address system the facility would conduct a fire alarm test and staff needed to ensure they cleared (made sure no residents would be hit when the fire doors closed) all the smoke doors (doors that automatically close during a fire alarm to prevent smoke from passing from one section of the building to another.) Review of Resident #27's MDS dated [DATE], showed the resident scored a 12 on his/her BIMS (cognition moderately impaired). During an interview on 10/4/11, at 3:25 P.M., Resident #27 said he/she tried to pass through the smoke doors during the fire alarm. The smoke door hit him/her arm. He/she said his/her arm hurt as he/she held an ice pack over a bruised area on his/her right arm. During an interview on 10/7/11, at 3:45 P.M., the administrator said staff needed to watch the smoke doors during a fire alarm test and ensure no one passed though them. During the days all department heads should watch the fire doors during a test and at night, the nursing staff watched the doors.

This deficiency is uncorrected. For previous examples, refer to SOD dated 10/7/11. Based on observation, interviews, and record review, the facility failed to assure staff implemented measures to prevent accidents for one of two sampled residents (Resident #39) which resulted in an unobserved fall with injury. Staff failed to provide adequate supervision in the secure unit when staff did not monitor residents in the dining room after the evening meal. Staff transferred residents to their rooms as two of the four staff left the secured unit leaving residents unattended in the dining room. The facility census was 124. 1. Review of Resident #39's care area assessment summary (CAAS, used to develop the care plan) dated 2/14/11, showed: - The resident triggered (information from the assessment that needs further assessment or action) for the care area of falls. - Staff addressed falls in the resident's care plan. Review of the Restraint Evaluation and Restraint Reduction policy dated 8/11 showed: - Seat belts, wheelchair lap belts that are front fastened and can be easily unfastened by the alert and somewhat oriented resident are not considered a physical restraint if the resident can demonstrate self-release upon request. - The policy did not address when the seat belts should be released. Review of the care plan updated 9/8/11, showed: - At risk for injuries related to falls; - Alarmed Velcro belt when up in the wheelchair; - Staff educated to ensure all safety belts were reapplied before the resident left the dining room. - Physical therapy (PT) and occupational therapy (OT) as ordered. Review of the facility educational in-service record dated 9/16/11 showed administrative staff inserviced nursing staff on falls and ensuring safety equipment was in place. This inservice did not address ensuring staff provided adequate supervision during meal service. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/28/11 showed: - The facility admitted the resident on 2/7/11. - Long- and short-term memory problems; - Severely cognitively impaired; - Disorganized thinking; - Extensive assist of one staff for transfers; - Limited assist of one staff for locomotion on the unit he/she lived; - Manual wheelchair for mobility; - Two non-injury falls since admission to the facility; - Restorative nursing (RA) program for range of motion (ROM) exercises of extremities; - [DIAGNOSES REDACTED]. Review of the fall risk evaluation form staff completed dated 10/29/11, showed: - Intermittent confusion; - Three or more falls in the past three months; - Chair bound, required restraints and assist with toileting; - Balance problems with standing or walking; - Decreased muscular coordination; - Required assistive devices (wheelchair); - Currently on medications that could cause falls (blood pressure medication, anti-depressant medication, and anti-seizure medication); - diagnosed with [REDACTED]. - A score of 10 or above represented the resident was a high risk for falls. The resident's total score was 18. Review of the physician's orders [REDACTED]. - Aspirin (a medication to thin the blood which can cause bruising, and used for pain and fever) 81 milligrams (mg) daily. - Zoloft 100 mg daily for depression. - Lisinopril 5 mg for high blood pressure. - Depakote Sprinkles (used to treat mood or seizures) 125 mg every evening. - [DIAGNOSES REDACTED]. Review of the physical therapy plan of treatment dated 11/10/11 showed: - Goals: The resident will safely transfer from a wheelchair with assist of one staff. - Cognition: Dementia, poor memory and safety awareness, and alarm belt on the wheelchair. Review of the Daily Unit Management staff assignment sheet dated 11/29/11 showed: - Do not leave the unit until you tell the nurse. - RN B did not assign CNA C, CNA Y, and CNA Z any particular residents on the unit. - Everything and everyone should look and smell good. - Spot check and clean room and fingernails. - Details: Barrier cream and oral cares. - When new admit arrives, get weight immediately and vital signs. Review of nursing notes dated 11/30/11 for 11/29/11 showed Registered Nurse (RN) B documented: - The resident was alert and confused the evening of 11/29/11. - Visited by family member (FM) B prior to the evening meal; - At 7:00 P.M., staff found the resident on the floor of the TV room, he/she lay on his/her back in front of the wheelchair. - There was a large hematoma (swollen,bruised area) on the left side of the forehead. - The resident moved all extremities without difficulty . - The left and right pupils were not equal in size but did react to light (could be indicative of a head injury). - Complained of right hip (the resident fell on his/her left side) and neck pain; staff applied ice to the left forehead. - RN B notified the physician and the resident's durable power of attorney (DPOA, a person who made decisions for the resident) of the fall. - Emergency crew members arrived to transport the resident to the hospital emergency room for evaluation and applied a cervical (neck) collar (a soft collar that is used to prevent further possible injury to the neck and spinal cord) on the resident. - At 10:30 P.M., the resident returned to the facility from the hospital emergency room . - All x-rays were negative, no fractures were found, but bruising to the forehead, ear, chin, and elbow were noted. - The staff started neurological checks (frequent checking of vital signs, mental status, and movement of extremities). Review of a nursing note dated 12/6/11 for 11/29/11 the director of nurses (DON) wrote showed: - Late entry for 11/29/11, safety note: The resident was in the dining room of the secured unit (a locked unit for dementia residents for safety purposes and to better meet the resident's needs) for the supper meal. - The resident left the dining room before staff reapplied the Velcro alarm belt. - The resident "made it" to the TV room. - The resident bent over and fell forward from the wheelchair. - RN B assessed the resident and sent the resident to the emergency room for evaluation. - A CT scan (x-ray) was performed to rule out a possible subdural hematoma (brain injury, swelling, and/or bleeding). - The CT scan was negative for brain injury. - Administrative staff educated unit staff on resident safety and use of the Velcro alarm belt after the resident's fall, and PT supplied a new wheelchair and a semi-pommel (a seat cushion which provides support and helps prevent sliding or falling out of the wheelchair) cushion. Review of x-ray reports dated 11/29/11 showed: - CT of the head: Left forehead hematoma, no fracture of the skull, and no brain hemorrhage or other brain injury. - Pelvic x-ray: No fractures. Review of a Quality Improvement Tool implemented after the resident's fall dated 12/1/11 showed: - The facility did not identify how staff would effectively monitor residents at risk for falls when staff transported residents to their rooms and/or left the secured unit, leaving the dining room and TV room unattended. During an interview on 12/6/11 at 10:15 A.M. and 4:00 P.M., the DON said: - The facility added staff to the secured unit after the survey (exit 10/7/11). - One licensed nurse, two CNAs are scheduled to work the regular shift hours and the facility added another CNA to work from 11:00 A.M. until 7:00 P.M. to assist with feeding the residents on the secured unit. - The evening of 11/29/11, there were three CNAs and a nurse working. - Staff served the evening meal around 5:40 P.M. every evening and staff always removed the resident's Velcro alarm belt during meals. - She did not know who took the resident to the dining room and released the Velcro alarm belt for supper. - During the investigation of the fall, all staff who worked that evening said they did not see the resident leave the dining room after supper, did not know what time he/she left the dining room, did not see the resident fall, and did not know how long the resident lay on the floor. - CNA Y found the resident on the floor and called the nurse for help. - The resident told staff he/she bent forward to pick something off the floor and fell forward out of the wheelchair. - CNA C reported today that family member (FM) B visited the resident before supper and tried to remove the Velcro alarm belt from the resident. - CNA C said he/she told FM B the resident needed the belt in place to keep him/her from falling and getting up by him/herself, and to please not remove the belt. During an interview on 12/6/11 at 2:30 P.M., CNA Y said: - Three CNAs and a nurse worked the night the resident fell . - Staff were busy with a new admit, serving meals, and assisting residents with the supper meal. - He/she did not know who wheeled the resident to the dining room and removed the Velcro alarmed belt. - Staff always released the belt from the resident and turned the alarm off during meals. - CNA Y saw the Velcro alarmed belt strapped to the resident before supper, but did not know if the alarm worked or not, he/she did not remove the belt to see if it alarmed. - He/she did not see the resident leave the dining room, did not know what time the resident left the dining room and went into the TV room; the resident could wheel him/herself around the unit. - The resident removed the belt if asked and sometimes removed the belt his/herself. - CNA Y left the unit shortly before 7:00 P.M. to take the meal tray cart back to the kitchen and did not see the resident in the TV room until he/she returned to the unit. - The other two CNAs on the unit transferred residents from the dining room to the residents' rooms as he/she left the unit. - He/she looked in the TV room about 7:00 P.M. to see how many residents were there and saw the resident lying on the floor. - The resident lay on his/her back, the wheelchair was in front of the resident, and there was a big bump, bruised area on his/her left forehead. - The resident did not yell out for help, but was alert and talking. - The resident complained of neck pain and said he/she tried to pick something off the floor and fell out of the wheelchair. - The Velcro alarm belt was not attached to the resident and it did not sound an alarm to let staff know the resident fell . - CNA Y summoned the charge nurse to come to assess the resident. During an interview on 12/6/11 at 3:00 P.M., CNA Z said: - He/she was new to the facility and worked with the resident for a short while. - Staff served the evening meal between 5:30 P.M. and 5:45 P.M. on 11/29/11. - Staff always released the Velcro alarm belt and turned the alarm off during meals. - He/she did not know who wheeled the resident to the dining room for supper or who released the belt. - The resident could release the belt him/herself. - Normally staff would reapply the belt after the meal, before the resident left the dining room. - He/she did not know when the resident left the dining room, did not know how he/she left the dining room, or when he/she fell . - The resident could wheel him/herself around the unit and may have left the dining room him/herself. - He/she took another resident to his/her room, walked back up the hallway, and CNA Y called for help in the TV room. - When he/she entered the room, he/she saw the resident lying on his/her back in front of the wheelchair and there was a big bump and bruise on the resident's left forehead. - The resident was alert and complained of neck pain. During an interview on 12/6/11 at 3:15 P.M., CNA C said: - He/she did not see the resident fall. - He/she saw FM B visiting with the resident around 3:00 P.M. - 4:00 P.M., FM B was "messing with the belt," and he/she told FM B not to remove the belt, it was for the resident's safety to have it in place. - CNA C did not know who took the resident to the dining room or who removed the Velcro alarm belt at supper because he/she transferred another resident to his/her room. - He/she did not know when the resident left the dining room or who removed him/her from the dining room. - The next time he/she saw the resident, the resident lay on the floor of the TV room with a towel under his/her head and a towel on his/her forehead. - The resident was awake but did not say anything while CNA C was in the TV room. - He/she did not know what time the accident happened except it was "after supper." During an interview on 12/6/11 at 3:45 P.M., RN B said: - Staff normally served supper between 5:30 P.M. and 5:45 P.M. - He/she served trays and helped assist residents to eat. - The resident was in the dining room during the supper meal. - He/she did not know when or what time the resident left the dining room to go to the TV room. - He/she left the secured unit a little before 7:00 P.M., between 6:45 P.M. and 6:50 P.M., to get spoons to use with the medication pass. - When he/she returned around 7:00 P.M., CNA Y called for him/her to come see the resident in the TV room. - The resident lay on his/her back with the wheel chair in front of him/her. He/she was alert and talking, moved all his/her extremities well, pupils were not equal in size but they reacted light, and his/her hand grip was good. There was a large hematoma to the left side of the forehead. - The resident first said he/she did not have any pain, but a little later complained of neck pain. - He/she called the nursing supervisor, 911, the physician, and the DPOA to inform them of the fall. - The Velcro alarm belt was not attached to the resident and the alarm did not sound. Staff remove the belt and turn off the alarm during meals. - He/she checked the alarm to see if it worked properly and the alarm worked fine. It was turned off. - He/she knew the belt alarmed earlier in the shift because the resident "popped" the belt and it alarmed. - FM B visited the resident around 3:00 P.M. - 4:00 P.M. but he/she did not know if FM B touched the belt. - He/she did not know when or how the resident left the dining room, and did not know who removed the belt from the resident; staff always removed the belt and turned it off during meals. - The resident could take the belt off and would remove the belt at times but he/she would not be able to turn off the alarm. - The resident did wheel him/herself around the unit; it was very possible the resident wheeled him/herself out of the dining room and into the TV room. - All staff were busy removing trays and taking residents to their rooms. - He/she did not know why staff did not know when the resident left the dining room or why staff did not reapply the Velcro belt. - He/she believed the resident lay on the floor for five to seven minutes but did not know the exact time of the fall. - He/she reentered the unit around 7:00 P.M. and CNA Y summoned him/her to look at the resident who fell in the TV room. Review of four Documentation of Employee Discussion for Corrective Counseling forms the DON wrote dated 11/30/11, showed: - RN B, Certified Nurses' Aides (CNA) C, CNA Y, and CNA Z: Did not ensure the alarmed Velcro belt alarm was in place and activated when the resident left the dining room. -The documentation did not include staff leaving residents on the secured unit unattended which resulted in a fall with injury. Observation and interview on 12/6/11 at 3:45 P.M. showed the following: - The resident sat in the PT room and performed exercises with PT staff. - The resident leaned to the left as he/she sat and was not able to sit up straight without assistance. - A large black, purple, and green colored bruise covered the left side of the forehead, the entire eye, cheek, and face down to the lower part of the left jaw. There was a small blue/green fading bruise to the resident's chin. - When the surveyor asked the resident what happened to his/her face, the resident responded, "I fell off a bus, isn't it awful?" Review of written statements by RN B, CNA C, CNA Y, and CNA Z showed: - RN B's statement, dated 11/29/11: The resident sat in the dining room on the evening of 11/29/11 and visited with other residents before the supper meal. RN B left the unit at approximately 6:45 P.M. - 6:50 P.M. to get spoons for the medication pass; he/she returned about 7:00 P.M. and upon his/her return, staff told him/her "to look at this." - CNA C's statement, dated 12/6/11: He/she worked the secured unit on 11/29/11 and was not in the dining room or TV room at the time staff found the resident on the floor. He/she helped another resident after supper. He/she told the DON he/she remembered FM B took the resident's Velcro alarm belt off the resident and he/she told FM B the resident could not get up or walk alone. - CNA Y's statement, dated 11/6/11: He/she came in at 2:00 P.M. on 11/29/11 and the resident was already in the dining room. He/she did not know if the resident's alarm worked; the belt was on the resident while he/she assisted the residents to eat. He/she did not know when the resident left the dining room. He/she found the resident on the floor of the TV room after he/she returned from taking the supper trays to the kitchen. The resident lay on his/her back and had a bruise and bump on the left side of his/her face. CNA Y called a nurse to see the resident. - CNA Z's statement, undated but the surveyor observed written on 12/6/11, showed : The resident was in the dining room before staff passed supper trays. During a telephone interview on 12/8/11 at 10:40 A.M., the Assistant Director of Nursing said she expected staff to be accountable and monitor the location of residents and monitor their actions. Alarm belts should be the last resort. He/she expected the charge nurse to ensure the residents' safety during his/her shift. During a telephone interview on 12/9/11 at 11:45 A.M., the DON said: - 30 residents resided on the secured unit on 11/29/11. - 28 of the 30 residents ate in the dining room that evening. - Resident #39 ate the evening meal in the dining room. - Protocol instructed charge nurses to remain in the dining room during every meal. - When staff removed the Velcro alarm belts, they have to manually turn off the alarms or reattach the belt to stop it from sounding. - Staff removed the restraint belts for all residents, including Resident #39, during all meals. This is a protocol used, not a policy. - All staff work together to care for the residents, she did not know who was assigned to care for Resident #39 the evening of 11/29/11. - The resident wheels him/herself all over the unit, so anyone could have removed the belt and turned the alarm off.