Every finding on record at Providence Place

The facility identified a census of 35 residents. The facility had one main kitchen and one dining area. The facility failed to ensure that staff members properly tested the dishwashing sanitization chemicals. The facility also failed to ensure food items were labeled and dated when opened. These deficient practices placed residents at risk for contamination and foodborne illness.Findings included:- During the initial tour of the kitchen and dining room area on 08/10/25 at 10:05 AM, an open undated gallon of milk was in the refrigerator. During review of the dishwashing process, Dietary Staff BB stated the facility had not started using the dishwashing machine and washed the dishes by hand in the three-sink system. Dietary Staff BB stated that the facility washed the dishes in hot water and chemicals. Dietary Staff stated the facility did not have test strips at that time to test the water or have a log to review.On 08/12/25 at 10:11 AM, Dietary Staff BB stated that every item that was opened should be labeled and dated. Dietary Staff BB stated the facility had received the dishwasher test strips to test the dishwashing water to prevent foodborne illness.The facility's undated Sanitary Conditions for Food policy documented it was the policy of this facility to procure food from sources approved or considered satisfactory by Federal, State, and/or local authorities.

The facility identified a census of 64 residents. The sample included 16, with three reviewed for accidents. Based on observation, record review, and interview, the facility failed to secure potentially hazardous cleaning chemicals in a safe, locked area and out of reach of eight cognitively impaired, independently mobile residents. The facility additionally failed to safely transfer Resident (R) 37, resulting in a non-injury fall, and ensure R9's fall interventions were followed. This placed the affected residents at risk for preventable accidents.Findings Included:- On 08/10/25 at 10:10 AM, an initial walkthrough of the facility was completed. An inspection of the 300 Hall revealed an unsecured cabinet across from the vending machine that contained disinfectant bleach wipes and a Clorox spray bottle. Both containers contained the warning, Keep out of reach of children, hazardous to humans, can cause eye irritation, harmful if swallowed. On 08/12/25 at 10:00 AM, a Certified Nurse’s Aide (CNA) M stated that cleaning chemicals were to be stored in a locked closet or drawer. On 08/12/25 at 10:30 AM, Licensed Nurse (LN) G stated all cleaning products were to be secured in a locked area away from the residents. On 08/12/25 at 11:30 AM, Administrative Nurse D stated that staff were expected to ensure chemical products were locked up after use. The facility’s “Chemical Storage” policy, revised 02/2023, indicated the facility will ensure an environment free from potentially hazardous materials, chemicals, and equipment. - R37’s Medical Diagnosis section within the Electronic Medical Record (EMR) noted diagnoses of chronic kidney disease, emphysema (long-term, progressive disease of the lungs characterized by shortness of breath), muscle weakness, need for assistance with personal cares, reduced mobility, and seizures (violent involuntary series of contractions of a group of muscles). R37’s “Quarterly Minimum Data Set (MDS) completed 05/24/25 revealed a Brief Interview for Mental Status (BIMS) noted a Brief Interview for Mental Status (BIMS) score of zero, indicating severe cognitive impairment. The MDS noted she required partial to moderate assistance with bathing, transfers, bed mobility, dressing, toileting, and personal hygiene. The MDs noted she had no lower or upper extremity impairments. The MDS noted she used a wheelchair for mobility. The MDS noted she had one non-injury fall since her last assessment. R37’s “Falls Care Area Assessment (CAA)” completed 03/17/25 indicated she was at risk for a decline in her activities of daily living (ADL) related to her decreased mobility, fatigue, and cognitive impairment. The CAA noted she had a history of falls. The CAA noted that a care plan was implemented to minimize the risks related to her fall history. R37’s “Care Plan” initiated 09/19/24 indicated she was at risk of falls and altered activities of daily living related to her medical diagnoses. The plan noted she required staff assistance for toileting, transfers, bed mobility, personal hygiene, dressing, and bathing. The plan instructed staff to keep needed items within reach and encourage her to use her call light. The plan noted she had a fall on 07/09/25. The plan noted that the facility provided staff education to ensure the wheelchair brakes were locked before providing transfers. R37’s EMR under “Progress Notes” revealed a “Nursing Note” completed on 07/09/25. The note revealed that direct care staff attempted to transfer R37 to her wheelchair but failed to lock the brakes. The note indicated the wheelchair moved as R17 was being transferred by staff. The note revealed R17 was assisted to the ground by staff and laid on her left side. The note revealed R17 was assessed with no injury reported or found. On 08/10/25 at 08:00 AM, R17 reported she had fallen during transfer but had no injuries. R17 lay in her bed. Her wheelchair had brake extenders and a Dycem (non-slip mat to prevent falls) mat under the cushion. On 08/12/25 at 10:42 AM, Certified Nurse’s Aide (CNA) M stated that staff always ensure the wheelchairs were positioned properly and in the locked position to prevent falls. On 08/12/25 at 11:20 AM, Administrative Nurse D stated staff were expected to lock the brakes before transferring the resident into and out of the wheelchairs. She stated that all staff were educated on proper transfer techniques. The facility’s “Fall Management System” policy, revised 10/2023, stated the facility would ensure a safe environment for all residents. The policy indicated staff would assess each resident’s potential risks, including functional abilities, potential falls, assistive devices, and environment, to ensure resident safety. The policy noted that interventions were implemented based on each resident’s needs to minimize complications. - R9's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), renal failure (inability of the kidneys to excrete wastes, concentrate urine, and conserve electrolytes), symptoms and signs involving cognitive function and awareness, and atrial fibrillation (rapid, irregular heartbeat). The “admission Minimum Data Set (MDS)” dated 03/10/25 documented a Brief Interview of Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The MDS documented R9 used a wheelchair for mobility during the observation period. The MDS documented R9 required substantial to maximum assistance with transfers and dressing. The Quarterly MDS dated [DATE] documented a BIMS score of 15 which indicated intact cognition. The MDS documented that R9 used a wheelchair for mobility during the observation period. The MDS documented R9 was dependent on staff assistance for bathing. The MDS documented R9 require substantial to maximum assistance with transfers and dressing. R9's Falls Care Area Assessment (CAA)” dated 04/16/25 documented he was at risk for falls related to his decreased mobility and history of falls prior to admission to the facility. R9's “Care Plan” dated 03/05/25 documented staff would ensure his call light was in reach and encourage him to call for assistance as needed. The plan of care documented staff would ensure R9 was wearing appropriate footwear when ambulating or wheeling in the wheelchair. The plan of care documented the staff would keep R9’s needed items, water, and other items of choice in reach. The plan of care dated 03/27/25 documented on 03/27/25 therapy would evaluate for recliner safety. The plan of care dated 07/09/25 documented on 01/17/25 nursing staff educated him to call for staff assistance to retrieve any items which are out of reach. The plan of care documented on 03/29/25 non-skid strips were placed on the floor in front of R9’s recliner. The plan of care documented on 04/11/25 staff placed a “Call Before Fall” sign on the wall behind his recliner. On 8/12/25 at 08:51 AM R9 sat in his recliner as he watched TV. R9’s feet were elevated in the recliner. R9’s call light was pinned to the bed out of reach behind his wheelchair. R9’s bedside table with his water and other items was out of reach by the room door. On 08/12/25 at 10:42 AM, Certified Nurse Aide (CNA) M stated everyone had access to all the resident’s care plan and the Kardex (nursing tool that gives a brief overview of the care needs of each resident) that has all their information. CNA M stated it was everyone’s responsibility to ensure the resident’s fall intervention were in place. CNA M stated the new intervention would be on the Kardex and if there were any new interventions added that information would be passed on during shift change report. On 08/12/25 at 10:50 AM, Licensed Nurse (LN) G stated everyone had access to the resident’s care plan and to the Kardex. LN G stated it was everyone’s responsibility to ensure every resident’s fall intervention were in place as care planned. LN G stated if any new interventions had been added to the resident’s care plan after a fall, that information was passed on during the shift change report. On 08/23/25 at 11:10 AM, Administrative Nurse D stated she would expect the charge nurse to add a new intervention on the resident’s care plan after a fall. Administrative Nurse D stated the interdisciplinary team (IDT) would review the new intervention and determine if that was to root cause of the fall. Administrative Nurse D stated everyone had access to the care plan or the Kardex and it was everyone’s responsibility to ensure the fall interventions were in place as care planned. The facility’s “Quality of Care” policy dated 12/2023 documented it was the policy of the facility to provide an environment that remains as free of accident hazards as possible. It was also the policy of the facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs.

The facility reported a census of 44 residents. The facility identified two medication rooms and four medication carts. Based on observations, record reviews, and interviews, the facility failed to secure one of two medication storage rooms. This deficient practice placed the residents at risk for unnecessary medication and administration errors.Findings Included:- On 08/10/25 at 10:05 AM, an initial walkthrough of the facility was completed. An inspection of the 100 Hall Team Office medication storage room revealed that the door was not secured. An inspection of the medication storage room revealed shelves of stock medication, enteral feeding solutions, and medical supplies. On 08/10/25 at 10:11 AM, Licensed Nurse (LN) G stated the door should be locked at all times due to the medications in the room. She stated that sometimes the doorknob would stick and not close properly. She stated staff were expected to ensure the room remained locked when exiting. LN G secured the room at 10:14 AM. On 08/12/25 at 10:30 AM, Administrative Nurse D stated staff were expected to ensure the medication rooms remained locked. The facility's Medication Storage policy (undated) indicated the facility was to secure all medication in a clean, locked, and organized manner to ensure safe handling and administration.

The facility identified a census of 35 residents. The facility identified seven residents on Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record reviews, observations, and interviews, the facility failed to ensure trash was stored and contained properly. The facility further failed to ensure trash was not left on top of the Personal Protective Equipment (PPE) cart, and the clean linen door was not propped open. The facility further failed to ensure soap and paper towels were available in the same room, and gloves were available in the dirty laundry area, and all staff knew where the hand washing sink was in the laundry room. These deficient practices placed the residents at risk for infectious diseases.Findings included:- An initial walkthrough of the facility was completed on 08/10/25 at 07:05 AM. A clear bag of trash was left on top of a PPE cart in the 300 halls. A clean linen closet was propped open in the 300 halls. On 08/10/25 at 10:05 AM, a walk-through laundry accompanied by Housekeeping Staff V occurred. During the walk-through of the laundry room, no handwashing sink was seen, and no PPE was revealed. On 08/11/25 at 08:07 AM, Laundry Supervisor U showed me the laundry soaking sink in the laundry room, and stated that staff wash their hands here, they get soap from the dirty laundry area, come back to the laundry soaking sink, wash their hands, and then go back to the dirty laundry area to dry their hands. [NAME] Supervisor U stated there were gowns by the washing machines, but she had forgotten to get any gloves. On 08/12/25 at 10:42 AM, Certified Nurse's Aide (CNA) M stated that clean linen rooms should not have the door propped open, and it was the responsibility of all staff to ensure trash was picked up and disposed of properly. On 08/12/25 at 12:37 AM, Licensed Nurse (LN) G stated that trash should never be left on a PPE cart. She stated it was the responsibility of the person who left the trash to dispose of the trash. LN G stated that if any staff member sees trash where it was not supposed to be, that staff member should dispose of the trash. She stated linen closets should never be left open. On 08/12/25 at 11:07 AM, Administrative Nurse D stated that it was all staff's responsibility to ensure trash was disposed of properly. She stated linen closets should never be propped open. The facility's Infection Control Program policy dated 04/25 documented the infection prevention and control program was a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. The elements of the infection prevention and control program consist of coordination/oversight, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. The program would be carried out by the facility infection preventionist. It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene based on accepted standards.

The facility reported a census of 44 residents. The sample included 12 residents, with one reviewed for activities of daily living (ADL). Based on record review, interviews, and observations, the facility failed to ensure Resident (R) 17 received supportive care and services to promote and maintain his quality of life when the facility failed to provide him with his required adaptive utensils while eating his meals. This deficient practice placed the resident at risk for decreased quality of life, isolation, and impaired dignity. Findings Included:- R17's Medical Diagnosis section within the Electronic Medical Record (EMR) noted diagnoses of left sided hemiplegia (paralysis of one side of the body), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), dysphagia (difficulty swallowing), muscle weakness, cognitive communication disorder (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), reduced mobility, and muscle contractures (abnormal permanent fixation of a joint or muscle). R17's Quarterly Minimum Data Set (MDS) completed 06/20/25 revealed a Brief Interview for Mental Status (BIMS) score of ten, indicating mild cognitive impairments. The MDS noted he had upper-body extremity impairments on both sides that affected his range of motion. The MDS noted he required supervision or touch assistance during meals. R17's Functional Abilities Care Area Assessment (CAA) completed 03/17/25 indicated he was at risk for a decline in his ADLs related to his decreased mobility, fatigue, and medical diagnoses. The CAA noted he was at risk for nutritional impairment, skin breakdown, and falls. R17's Care Plan initiated 09/12/24 indicated he was at risk for an alteration of his ADLs related to his medical diagnoses. The plan indicated he required staff assistance for toileting, transfers, bed mobility, bathing, personal hygiene, and dressing. The plan noted he required meal set-up assistance. The plan indicated he needed to build up silverware and a two-handled cup during meals. R17's EMR under Order indicated an active order dated 08/10/25. The order instructed staff to apply R17's left and right wrist orthosis (hand splints to treat contractures) during the day and remove them during the nighttime. R17's EMR under Order indicated an active order dated 09/17/24. The order indicated occupational therapy ordered built-up utensils during mealtimes to increase R17's independence with self-feeding. On 08/11/25 at 08:30 PM, R17 sat in the dining room for breakfast. R17 wore an orthosis on both wrists. R17 ate his lunch with normal silverware and a regular cup without handles. R17 was not offered the special utensils during his meals. On 08/11/25 at 12:05 PM, R17 sat in the dining room for lunch. R17 wore an orthosis on both wrists. R17 ate his lunch with normal silverware and a regular cup without handles. R17 had difficulty handling his utensils as he ate his lunch. R17 was not offered the special utensils during his meals.On 08/12/25 at 09:11 AM, R17 ate his breakfast in the dining room. R17 was not offered the special utensils during his meals.On 08/12/25 at 10:42 AM, Certified Nurse's Aide (CNA) M stated that staff were expected to check the resident's dietary requirements and needs before serving the meals. She stated all staff had access to the care plans and would know if residents required special utensils for meals. On 08/12/25 at 11:20 AM, Administrative Nurse D stated staff were expected to review the planned interventions to ensure each resident's care needs were addressed. She stated the plans were reviewed by the interdisciplinary team weekly and updated. She stated the dietary needs of the residents would be listed in the care plan if they required special utensils and devices. The facility's Adaptive Equipment policy, revised 01/2025, indicated the facility was to ensure each resident was screened for the need of special adaptive equipment to improve the quality of care and independence for the identified resident.

The facility identified a census of 35 residents. The sample included 12 residents, with three residents reviewed for activities of daily living (ADL) care. Based on observation, record review, and interviews, the facility failed to ensure staff assisted Resident (R) 23 with ensuring his fingernails were kept clean. This deficient practice placed R23 at risk for impaired dignity, comfort, and further decline in ADL. Findings Included: - R23's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), hemiparesis (muscular weakness of one half of the body) following a cerebrovascular accident (CVA- stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affecting the right dominant side, muscle weakness, need for assistance with personal care, hypertension (high blood pressure), Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), and sleep apnea (a disorder of sleep characterized by periods without respirations). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of five, which indicated severely impaired cognition. The MDS documented R23 was dependent on staff for oral hygiene, toileting, dressing, and showers, and needed setup or cleanup for eating. R23's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 01/17/25 for R23 documented the CAA triggered due to a BIMS score of two. The CAA documented R23 was pleasantly confused, and his cognition varied throughout the day; R23 was at risk for not getting his needs met. R23's Care Plan dated 05/27/21 documented R23 had an alteration in self-care related to diagnoses of Parkinson's disease, right hemiplegia, and dementia. The plan of care for R23 documented he was dependent on staff for bathing, toileting, and required setup for oral hygiene.On 08/10/25 at 08:24 AM, R2 sat in his wheelchair in front of the birds. R23's fingernails had a dark brown substance under his thumb nails. On 08/11/25 at 7:22 AM, R23 sat in the dining room while staff were assisting him with his breakfast order. R23's fingernails had a dark substance under them.On 08/12/25 at 10:42 AM, Certified Nurse Aide (CNA) M stated that if the resident was a diabetic, the nurses usually cut the fingernails or the activity director. CNA M stated when baths are given, the CNAs have a brush that CNAs clean residents' nails with. On 08/12/25 at 10:50 AM, Licensed Nurse (LN) G stated that residents got a bed bath twice a week. LN G stated CNAs clean fingernails on shower days. She stated that all staff should be looking at fingernails to ensure they are clean. On 08/12/25 at 11:07 AM, Administrative Nurse D stated it was all staff's responsibility to ensure residents do not have dirty fingernails. She stated the CNAs clean fingernails in the shower, and the activities director encourages all residents to get nail care on fingernail day.The facility's Bath/Shower policy dated 01/25 documented it was the policy of this facility to promote cleanliness, stimulate circulation, and assist in relaxation.

The facility identified a census of 35 residents. The sample included 12 residents, with two residents reviewed for hemodialysis (a procedure using a machine to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, record review, and interviews, the facility failed to consistently communicate Resident (R) 51 medical condition with a pre- and post-dialysis communication prior to and post-hemodialysis. This deficient practice placed R51 at risk of potential adverse outcomes and physical complications related to dialysis. Findings included:- R51's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of end-stage renal disease (ESRD- a terminal disease of the kidneys) with dialysis (procedure where impurities or wastes were removed from the blood), hypertension (high blood pressure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), major depressive disorder (major mood disorder that causes persistent feelings of sadness), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), acquired absence of left leg above knee, , peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), muscle weakness, and need for assistance with personal care. The admission Minimum Data Set (MDS) for R51, dated 06/12/25, recorded a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. The MDS documented R51 required hemodialysis during the observation period. R51's Functional Abilities (Self-Care Mobility) Care Area Assessment (CAA) dated 06/12/25 documented R51 has an alteration in functional abilities related to decreased mobility and pain. The CAA documented R51 had recently fallen and had a fractured cervical spine, and always had a hard neck collar. R51's Care Plan dated 06/23/25 documented R51 had ESRD and required hemodialysis. R51's plan of care documented nursing was to check arteriovenous (AV) fistula (an abnormal connection between an artery and a vein) every day for bruit (blowing or swishing sound heard when blood flows through a shunt) and thrill (a fine vibration felt that reflects the blood flow by a dialysis resident's shunt). The plan of care documented R51's AV fistula was located in the left upper extremity, and staff were to encourage R51 to go to scheduled dialysis appointments on Monday, Wednesday, and Friday.R51's EMR under the Orders tab dated 08/04/23 revealed the following physician's order: Dialysis communication form completed and filed after dialysis every day shift, every Monday, Wednesday, and Friday, dated 06/06/25.Assess and document assessment of AV shunt/fistula for Brit and Thrill every shift and as needed, dated 06/06/25. Assess dialysis site to ensure proper dressing was in place upon return from dialysis every shift, every Monday, Wednesday, and Friday, dated 06/06/25. Review of R51's EMR under Misc tab, documented the facility dialysis communication forms lacked evidence of pre- and post-hemodialysis assessment for the following dates: 06/18/25, 06/2025, 06/23/25, 07/11/25, 07/14/25, 07/18/25, and 07/21/25. On 08/12/25 at 10:50 AM, Licensed Nurse (LN) G stated that the process for dialysis communications sheets was when the resident returned from dialysis, the sheet was filled out, and placed in his binder. If the communication sheet was not in the binder, nursing was to call the dialysis center and get report. LN G said staff placed the completed sheet in the folder to be scanned into the resident's chart. On 08/12/25 at 11:09 AM, Administrative Nurse D stated that the facility was to ensure the communication reports were filled out before the resident left for dialysis. The nurse on duty would ensure the forms were returned or call the dialysis center and have the dialysis center return the sheet. Administrative Nurse D stated the facility had been having problems getting the communication sheets back from the dialysis center. She stated the facility started sending the sheets in a binder in hopes the sheets were returned. The facility's Dialysis Pre and Post Care policy dated 12/23 documented it was the policy of this facility to: assist residents in maintaining homeostasis pre- and post-renal dialysis; assess and maintain patency of renal dialysis access; assess resident daily for function related to renal dialysis; and participate in ongoing communication; and collaboration with the dialysis facility regarding dialysis care and services.

The facility identified a census of 35 residents. The sample included 12 residents, with four residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to ensure that Resident (R) 4 had a documented risk assessment that included alternatives that had been tried and failed. This placed the R4 at risk for uninformed decisions and impaired safety related to the risks associated with the use of siderails.Findings included:- R4's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of major depressive disorder (major mood disorder that causes persistent feelings of sadness), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and cerebrovascular accident (CVA- stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The admission Minimum Data Set (MDS) dated 05/08/25 documented a Brief Interview of Mental Status (BIMS) score of four, which indicated severely impaired cognition. The MDS documented R4 required substantial to maximum staff assistance with bed mobility, dressing, transfers, and bathing. R4's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 05/30/25 documented she had decreased mobility, was blind, and had a diagnosis of dementia. R4's Care Plan dated 05/04/25 documented she had bilateral upper quarter bedrails to assist with bed mobility. The facility provided a Bed Rail Safety Assessment dated 05/05/'25 that documented R4's representative had given verbal consent for the side rails. The assessment documented the interdisciplinary team (IDT) justification was all the beds at the facility had the functions on the rails to operate the bed. The bed rails were used for positioning and promoting independence with bed mobility. The assessment lacked the alternatives that had been tried and failed prior to bed rails. The assessment lacked the drug classification that would place a resident at risk for entrapment. On 08/12/25 at 7:19 AM, R4 laid in bed asleep on her right side. R4's bilateral upper bed rails were pulled up and locked into place. On 08/12/25 at 10:45 AM, Certified Nurse Aide (CNA) M stated she had not seen any siderails up on any of the residents. CNA M stated the lower siderails on the beds are secured down. On 08/12/25 at 10:50 AM, Licensed Nurse (LN) G stated side rail assessment was completed at the time of admission, quarterly, annually, and when there was a significant change. LN G stated that the factors that would make siderails unsafe would be their cognitive status, mobility, and history of falls, which would place the resident at risk of entrapment. On 08/23/25 at 11:10 AM, Administrative Nurse D stated a siderail assessment was completed at the time of admission, quarterly, annually, and when there was a significant change. Administrative Nurse D stated the IDT made the final decision if a resident was safe to use siderails. Administrative Nurse D stated R4 held the siderail when staff would provide assistance with bed mobility. Administrative Nurse D stated the IDT would review the resident's medication, mobility, mental status, safety awareness, and history of falls. The facility's Quality of Care policy dated 12/2023 documented it is the policy of this facility to attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails.

The facility identified a census of 35 residents. The sample included 12 residents, with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to act upon the Consultant Pharmacist (CP) recommendations for Resident (R) 4. This deficient practice placed R4 at risk for unnecessary medication use, side effects, and physical complications.Findings included:- R4's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of major depressive disorder (major mood disorder that causes persistent feelings of sadness), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and cerebrovascular accident (CVA- stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The admission Minimum Data Set (MDS) dated 05/08/25 documented a Brief Interview of Mental Status (BIMS) score of four, which indicated severely impaired cognition. The MDS documented R4 required substantial to maximum staff assistance with activities of daily living (ADL). The MDS lacked indication a drug regimen review was completed during the observation period. R4's Psychotropic Drug Use Care Area Assessment (CAA) dated 05/30/25 documented she was at risk of adverse side effects related to the medication she received. R4's Care Plan dated 06/25/25 documented nursing staff would administer medication as ordered by the physician.R4‘s EMR under the Orders tab revealed the following physician orders: Dulcolax (laxative) oral tablet delayed release (DR) five milligram (mg) (bisacodyl), give one tablet by mouth every 24 hours as needed for constipation, dated 05/02/25. The order lacked do not crush instructions. Review of the Monthly Medication Review (MMR) from August 2024 to July 2025 documented recommendations from 07/01/25 to add do not crush to Dulcolax DR order. Review of R4's August 2025 Medication Administration Record (MAR) lacked do not crush instructions for Dulcolax medication.On 08/11/2025 at 12:24 PM, R4 sat upright in a Broda chair (specialized wheelchair with the ability to tilt and recline) as the nursing staff assisted her with lunch. On 08/23/25 at 11:10 AM, Administrative Nurse D stated she expected the pharmacy reviews would be reviewed and acted upon within seven days of receiving the MRR's. The facility's Pharmacy Services policy dated 12/2023 documented it was the policy of the facility that the drug regimen of each resident would be reviewed at least once a month by a licensed pharmacist. A medication regimen review (MRR) includes a review of the resident's medical chart. Identified irregularities would be documented on a separate written report that included the resident's name, the relevant drug, and the irregularity identified. The report would be sent to the attending physician, the facility's Medical Director, and the Director of Nursing Services (DNS) to be acted upon.

The facility reported a census of 36 residents. The sample included 12 residents. Based on record review and interviews, the facility failed to submit accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ - Staffing Data Report) when the facility failed to submit accurate weekend staffing coverage hours. This placed the residents at risk for unidentified and ongoing inadequate staffing. Findings included: - A review of the facility's submitted PBJ data from 04/01/24 through 03/31/25 indicated the facility triggered for excessively low weekend staffing for Fiscal Year (FY) Quarter One 2024 (10/01/24 to 12/31/24) A review of the facility's working schedule, time sheets/punches, and posted staffing hours indicated no gaps or loss of hours. On 08/12/25 at 11:20 AM, Administrative Nurse D stated the facility used agency staff during the triggered period, and the time may not have been documented appropriately on the reporting. The facility's Payroll-Based Journaling policy, revised 10/2023, indicated staffing and census information will be reported electronically to the Centers for Medicare and Medicaid Services (CMS). The policy indicated that staffing information during the recorded time period shall be made available to residents, family members, and the public within 24 hours of a written or verbal request.

The facility had a census of 29 residents. Based on observation, interview, and record review, the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal year (FY) 2023 Quarter 2 and Quarter 3 indicated the facility did not have licensed nurse coverage 24 hours a day, seven days a week on multiple (10) dates. Review of the facility licensed nurse timeclock data for the dates listed on the PBJ revealed a licensed nurse was on duty for 24 hours a day seven days a week. On 11/01/23 at 02:24 PM, an observation revealed a licensed nurse on duty in the facility. On 11/01/23 at 12:05 PM Administrative Staff A stated staff reporting to CMS was done through the hospital/previous owners and would be until the end of November 2023. He stated the facility would take over staff reporting in December 2023. Administrative Staff A stated that he was not aware of any staffing issue reported on the PBJ and that the facility did not have any days where there were no nurses on duty to cover every shift. The undated facility provided Payroll-Based Journal policy documented It is the policy of this facility to submit information on a quarterly basis to CMS as required that details the hours facility staff works in specific job titles. Data reported includes, for every direct care worker, the dates they worked, and the number of hours worked on that day. The facility failed to submit complete and accurate staffing information through PBJ as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing.

The facility identified a census of 29 residents. The sample included 13 residents. Based on record review, interviews, and observations, the facility failed to provide wheelchair foot pedals for Residents (R)15, R178, R21, and R175. This deficient practice placed the residents at risk for impaired safety and comfort. Findings Included: - On 10/30/23 at 07:34AM staff transported R15 from the main hallway to the dining room in a wheelchair. R15's wheelchair lacked foot pedals. R15 wore socks and his feet slid on the floor as he was pushed to the dining room. A review of R15's Care Plan revealed no documented interventions related to his foot pedals. On 10/30/23 at 11:33PM housekeeping staff pushed R178 down the main hallway in his wheelchair. R178's wheelchair did not have foot pedals in place and his feet made contact with the ground on several occasions. A review of R178's Care Plan revealed no documented interventions related to his foot pedals. On 11/01/23 at 01:16PM staff transported R21 from the dining room to his room in a wheelchair without foot pedals. R21 had non-slip socks on as his feet, and his feet slid along the floor during the transport. A review of R21's Care Plan revealed no documented interventions related to his foot pedals. On 11/01/23 at 01:32PM staff pushed R175 around the central hallway nurse' station with no foot pedals. His feet slid on the floor during transport. A review of R175's Care Plan revealed no documented interventions related to his foot pedals. On 11/01/23 at 01:30PM Certified Nurse's Aide (CNA) M stated some of the resident refused to allow foot pedals to be put on their wheelchair. She stated all the residents have foot pedals for their wheelchairs. On 11/01/2023 at 01:40PM Licensed Nurse (LN) G stated some resident wheeled themselves around the facility and the foot pedals were removed for their convenience. She stated staff would never allow a resident's feet to drag on the ground while staff propelled the resident in a wheelchair. On 11/01/2023 at 02:05PM Administrative D reported staff were expected to utilize foot pedals while transporting residents around the facility in wheelchairs. She stated foot pedals were available for use for all residents with wheelchairs. She stated staff should never allow the residents feet to touch the ground while being transported in a wheelchair. A review of the facility's Adaptive Equipment revised 10/2023 indicated the facility will evaluate and ensure the usage of adaptive equipment as provided. The facility failed to utilize wheelchair foot pedals for R15, R178, R21, and R175. This deficient practice placed the residents at risk for impaired safety and comfort.

The facility reported a census of 29 residents. Based of observations, record review, and interviews, the facility failed to ensure safe storage of medications for one of three medication rooms. This deficient practice placed the residents at risk for unnecessary medication and administration errors and/or diversion. Findings Included: - On 10/20/23 at 07:05AM a walkthrough of the facility's Prairie View hallway revealed the medication storage room door was propped fully open and unattended by nursing staff. The medication storage cart within the room was left unlocked and contained medications for all five residents on the Prairie View hallway, Resident (R)8, R11, R13, R19 and R125. At 07:21AM Licensed Nurse (LN) G entered the hallway and reported the medication room should not have been left open. She stated she was not sure why the room was propped open, or the cart left unlocked. She stated staff were to ensure they secured the door as the left the room. On 11/02/23 at 02:05PM Administrative Nurse D stated staff were expected to securely close the medication room doors when not in use. She stated the medication carts within the rooms should be locked for added security of the medications. The facility's Medication Access and Storage policy revised 10/2023 indicated that all drugs and biologicals were to be stored in locked compartments accessible only by licensed personnel. The policy indicated all medication rooms, carts, and supplies remain locked when not attended. The facility failed to ensure safe storage of medications for one of three medication rooms. This deficient practice placed the residents at risk for unnecessary medication and administration errors or diversion.

The facility identified a census of 29 residents. The sample included 13 residents with one reviewed for notification of changes. Based on observation, record review, and interviews, the facility failed to notify Resident (R)127's medical provider of her weight loss or changes in meal intake. This deficient practice placed R127 at risk for complication related to weight loss and malnutrition (condition that develops when the body is deprived of vitamins, minerals and other nutrients) due to delayed physician involvement. Findings Included: - The Medical Diagnosis section within R127s Electronic Medical Records (EMR) included diagnoses of chronic kidney disease, osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), muscle weakness, history of fractures (broken bones), and history of falls. R127's Admission Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Metal Status (BIMS) score of nine indicating moderate cognitive impairment. The MDS indicated she required set-up assistance with meals. The MDS indicated she weighed 117.2 pounds (lbs.). The MDS documented the resident was not on a physician-prescribed weight loss regimen. R127's Functional Abilities Care Area Assessment (CAA) completed 10/31/23 was at risk for altered functional abilities related to her medical diagnoses. The CAA indicated she required assistance with her activities of daily living (ADL). R127's Cognitive Impairment CAA completed 10/31/23 indicated she had impaired cognition and instructed staff to cue and reorient her as needed. R127's Care Plan initiated 10/18/23 she had a self-care deficit related to her ADL. The plan noted she was on a regular diet with regular texture. The plan instructed staff to monitor her intake and record every meal. The plan instructed staff to monitor and report symptoms of dysphagia, malnutrition, decreased appetite, and weight loss to the medical provider. An Admission Nutrition Evaluation completed 10/18/23 indicated R127 weight was 117.2 lbs. The evaluation indicated she was at risk due to due to acute disease in the past three months. A Mini-Nutritional assessment dated [DATE] indicated R127 was at risk of malnutrition. A Nutrition/Hydration Risk Evaluation completed 10/20/23 noted R127 was at moderate risk for malnutrition. The evaluation noted she took no medications contributing to weight loss risks. R127's EMR revealed her admission weight on 10/17/23 was 117.2 lbs. The EMR recorded her weight decreased to 99.1 lbs. on 10/25/23 and 97.2 lbs. on 10/27/23. R127's EMR, between 10/25/23 through 11/01/23, lacked evidence of physician notifications related her weight loss or change in her oral intake. A review of R127's EMR under Documentation Survey Report from 10/17/23 to 11/01/23 indicated no meal intake monitoring occurred from 10/21/23 to 10/29/23 for breakfast, lunch, and dinner meals. On 10/30/23 at 08:11AM R127 reported she recently had issues with weigh loss but ate her meals. R127 consumed her entire breakfast without concerns in the dining room. On 11/01/2023 at 01:30PM Certified Nurses Aide (CNA) M stated direct care staff would complete scheduled weights of the resident per the physician's orders. She stated if a resident's weight was off by three pounds the resident would immediately be reweighed and the nurse notified of the change. She stated meal intake monitoring would be documented in the EMR system and the physician would be notified of changes in oral intake by the nurse. She stated R127 just recently admitted to the facility and had no complaints related to her meals or eating. On 11/01/2023 at 01:40PM Licensed Nurse (LN) G stated residents with noticeable weight changes would be placed on weekly weights and monitored closely for diet, medications, and intake. She stated the resident's weight loss would be reported to the physician and dietician for review. She stated a progress note would be completed to document the notification and well as changes in care. She stated residents at risk for weight loss and malnutrition were closely monitored for oral intake. On 11/01/2023 at 02:05PM Administrative Nurse D stated staff were expected to ensure the medical provider and registered dietician were notified of suspected weight loss. She stated the facility would increase weight monitoring occurrences and provide dietary supplementation for residents at risk for malnutrition. She stated staff were expected follow each resident's care planned interventions and orders. A review of the facility's Weight Monitoring policy revised 10/2023 indicated the facility ensured acceptable parameters of body weight. The policy noted each resident will be provided ongoing evaluation and interventions to prevent significant weight loss. The policy indicated the physician will be notified in changes related to each resident's preferences, diet, allergies, meal consumption, and weight. The facility failed to notify R127's medical provider of her weight loss or changes in meal intake. This deficient practice placed R127 at risk for complication related to weight loss and malnutrition due to delayed physician involvement.

The facility identified a census of 29 residents. The sample included 13 residents. Based on observation, record review, and interviews, the facility failed to secure protected health information (PHI) for Resident (R)125. This deficient practice placed R125 at risk for decreased psychosocial wellbeing due to lack of privacy. Findings Included: - The Medical Diagnosis section within R125's Electronic Medical Records (EMR) included diagnoses of fracture of right femur (broken bone), aphasia (difficulty speaking), dementia (progressive mental disorder characterized by failing memory, confusion), and a cerebral infarction (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). R125's Admission Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Metal Status (BIMS) score of three indicating severe cognitive impairment. The MDS indicated he was independent with ambulation and utilized a manual wheelchair and dependent for staff assistance for mobility over 50 feet. R125's Communication CAA completed 10/21/23 indicated he was at risk for altered communication related to his aphasia. The CAA instructed staff to give him extra time to form words and assist him with functional abilities. The CAA noted care planning would address his risks. R125's Care Plan initiated 10/13/23 indicated he was at risk for impaired cognitive function or impaired thought process. The plan instructed social services to provide psycho-social support as needed. The plan noted he took medication with black box warnings (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration) On 10/20/23 at 07:05AM a walkthrough of the facility's Prairie View hallway revealed the medication storage room door was propped fully open and unattended by nursing staff. A laptop on top of the medication cart was left unlocked with R125's Medication Administration Report (MAR) displayed facing towards the door and visible from doorway. At 07:21AM Licensed Nurse (LN) G entered the hallway and reported the medication room should not have been left open. She stated patient information should not be left displayed in view. She stated the monitor should be shut off when not in use. On 11/02/23 at 02:05PM Administrative Nurse D stated staff were expected to securely close the medication room doors when not in use. She stated PHI should be kept out of view from other residents or those who did not need the PHI. She stated staff were expected to ensure PHI was protected for the resident's privacy. A review of the facility's Resident Rights revised 10/2023 indicated the facility will ensure each resident's privacy and ensure all residents were educated and informed of their rights. The facility failed to secure PHI out of view for R125. This deficient practice placed the R125 at risk for decreased psychosocial wellbeing due to impaired privacy.

The facility identified a census of 29 residents. The sample included 13 residents. Based on observations, record review, and interviews, the facility failed to provide the necessary care and services for activities of daily living (ADL) for Resident (R)5 when staff pulled on R5 under her arms instead of using available equipment to assist in repositioning her. This deficient practice placed R5 at risk for injury. Findings included: - R5's Electronic Medical Record (EMR) documented diagnoses age related osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), unsteadiness on feet, and hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebral infarction (stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affecting left side. The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R5 was dependent and required staff for all effort for transition from laying to seated position, seated to standing, and chair/bed/toilet transfers. The ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 04/25/23, documented R5's ADL functional rehabilitation potential would be addressed in R5's Care Plan. R5's Care Plan with an initiated date of 10/30/23, documented R5 was at risk for falls/injury related to left hemiplegia and osteoporosis. R5's Care Plan with an initiated date of 10/30/23, documented R5 had an alteration in functional abilities related to left-side hemiplegia. An intervention initiated 10/30/23 documented R5 was dependent on staff for rolling left and right, transferring from sitting to lying, and lying to sitting. An intervention with an initiated date of 10/30/23, documented R5 was dependent for chair, bed and shower transfers and required use of a Hoyer Lift (total body mechanical lift). An observation on 10/30/23 at 11:18 AM revealed R5's representative propelled R5 in her wheelchair in a common area. R5 had a Hoyer lift sling under her in the wheelchair. R5's representative asked staff for assistance in repositioning R5 in the wheelchair. Administrative Nurse D came over and attempted to reposition R5. Administrative Nurse D stood behind R5 and placed her arms under R5's arms and attempted to lift R5 up and back into the chair, two times, causing R5's shoulders and arms to raise upward before being assisted by another staff member. Once the other staff member arrived to assist, Administrative Nurse D and the staff member moved to each side of R5 and repositioned R5 in her wheelchair manually without the aid of the lift. On 11/01/23 at 02:10 PM Certified Nurse Aide (CNA) M stated if a resident required repositioning in a wheelchair, and required a Hoyer lift for transfers, that she would use the Hoyer lift to reposition them in the wheelchair. She stated that she would refrain from pulling on the resident under their arms as she was afraid it may hurt them. On 11/01/23 at 02:24 PM Licensed Nurse (LN) H stated if a resident required repositioning in a wheelchair and the resident was unable to do it on their own, she would have them lock the chair and have another staff assist her in reposition them. She stated they would reposition the resident with two people going under the resident's arms, she further stated if the resident already had a Hoyer sling under them then she would use the sling to reposition them and not pull on the resident. On 11/01/23 at 02:39 PM Administrative Nurse D stated she expected staff to safely reposition a resident in a wheelchair, so the resident did not fall on the floor. She stated that she repositioned R5 in the common area due to R5 was tilted in the wheelchair and she was concerned R5 may fall out of the chair onto the floor. She stated if a resident had a Hoyer sling in their chair, then staff could use that to help reposition the resident and not pull on the residents extremities. The undated Quality of Care policy documented It is the policy of this facility that residents are given the appropriate treatment and services to maintain or improve his/her abilities. The facility failed to provide the necessary care and services needed to reposition R5 in her wheelchair when staff pulled on R5 under her arms instead of using available equipment to assist in repositioning her. This placed R5 at risk for injury.

The facility identified a census of 29 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 1 had the physician-ordered ankle foot orthotics (AFO-brace that supports the ankle and foot)and services to prevent reduction of range of motion [ROM] and/or mobility. This deficient practice left R1 at risk for further decline and decreased ROM or mobility. Findings included: - R1's Electronic Medical Record (EMR) documented a diagnosis of generalized muscle weakness, contracture (abnormal permanent fixation of a joint or muscle) of the left and right elbow, wrist, and shoulders, hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebral infarction (stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affecting left side. The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R1 was dependent on staff for activities of daily living (ADL) and transfers. The ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 09/02/23, documented R1's ADL functional rehabilitation potential would be addressed in R1's Care Plan. R1's Care Plan with an initiated date of 05/20/16, documented R1 had a self care deficit related to decreased mobility secondary to hemiplegia and contracture of her hands. Intervention with an initiated date of 11/29/21 documented a foot board was added to R1's wheelchair pedals to help keep her feet from sliding off. A Written Order dated 11/29/21 documented therapy to evaluate and treat for positioning foot drop (inability or difficulty in moving the ankle and toes upward). A Physician's Order dated 10/18/23 documented bilateral AFO for contracture management. An observation on 10/31/23 at 03:50 PM revealed R1 sat in a recliner in her room with her feet elevated on the footrest and her feet/toes were pointed down, toward the wall across from her. R1's representative was in the room with her. R1 stated that she did not have a brace for her feet/ankles and that she had never received one. R1's representative stated that R1 was supposed to have a brace to help keep her feet straight; however, the facility never got the braces for her. He further stated that he had asked about getting something to help with her feet before the facility changed ownership and was told staff would check into it. He stated that he was recently told that the facility was checking into getting the AFO braces for R1, but she had still not received them yet. On 11/01/23 08:02 at AM Consultant HH stated her therapy team started therapy services for the facility in October of 2023. She stated that she was not aware if R1 admitted to the facility with the foot drop issue; however, she stated that her team identified the issue and were in the process of having the AFOs ordered for R1. She stated that documentation had to be sent to an outside facility to be reviewed and that the braces would be ordered through this outside facility and sent to R1. She stated that R1 was not receiving therapy services at the facility previously as there was no in house therapy under the previous ownership. On 11/01/23 at 02:24 PM Licensed Nurse (LN) H stated she believed R1 had braces for her feet/ankle a long time ago and that R1 thought they were uncomfortable. She stated that R1's representative bought a new wheelchair for R1, and staff used the footboard on her new wheelchair instead. She stated that she was unsure if anything further had been done to address R1's foot/ankle issues. On 11/01/23 at 02:39 PM Administrative Nurse D stated R1's representative had come to staff with concerns about R1's foot drop and was worried it had gotten worse. Administrative Nurse D stated that staff had spoken with the previous provider about having her sent to an outside clinic to see if something could be done to address the issues with her feet before the facility had therapy services. Administrative Nurse D further stated the facility has inhouse therapy services that were looking into finding something that will work for R1. She stated that the believed R1's representative mentioned his concerns about R1's foot drop at the beginning of September 2023 and that staff had told him they were looking into finding something for R1 to help with the issue. Administrative Nurse D stated they had tried to use different things in the past to help with R1's foot drop and nothing had worked. The undated facility provided Range of Motion policy documented It is the policy of this facility to prevent a resident's loss of range of motion and appropriate treatment and services will be administered to increase range of motion and/or prevent further decrease in range of motion. The facility failed to ensure R1 had the physician-ordered AFO and services to prevent reduction of ROM and/or mobility. This deficient practice left R1 at risk for further decline and decreased ROM or mobility.

The facility identified a census of 29 residents. The sample included 13 residents with three reviewed for bowel and bladder management. Based on observation, record review, and interviews, the facility failed to implement individualized interventions to improve/maintain Resident (R)15's bowel and bladder incontinence. This deficient practice placed R15 at risk for complications related to incontinence. Findings Included: - The Medical Diagnosis section within R15s Electronic Medical Records (EMR) included diagnoses of chronic kidney disease, acute kidney failure, history of falls, weakness, and a need for assistance with personal care. R15's Admission Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 11 indicating mild cognitive impairment. The MDS indicated he required partial to moderate assistance with toileting care and transferring. The MDS noted he was frequently incontinent of bowel and bladder with no toileting program. R15's Urinary Incontinence Care area Assessment (CAA) completed 10/21/23 indicated he had an alteration in continence related to his recent fall and hospitalization . The CAA noted he had bowel and bladder incontinence and was toileted upon request. The CAA noted his care plan would address his care needs. R15's Care Plan initiated 10/11/23 indicated he had an alteration in self-care related to his hospitalization prior to his admission. The plan indicated his fall resulted from syncope (fainting) during toileting. The plan indicated he required assistance of one staff for bathing, bed mobility, dressing, and personal hygiene. The plan lacked individualized interventions to maintain and promote R15's highest level of functioning related to incontinence. R15's Admission Bowel and Bladder assessment completed 10/11/23 indicated he was incontinent of bowel and bladder. The assessment indicated he was alert and oriented. The assessment indicated he had initiative and willingness to participate in the toileting program. The assessment noted he was a likely candidate for bowel and bladder re-training. On 11/01/23 at 01:30PM Certified Nurse's Aide (CNA) M stated R15 was checked on ever two hours and provided incontinence products. She stated he had both bowel and bladder incontinence. She stated some residents were toileted more frequently due to their heavy incontinence patterns. She stated most resident were check and change every few hours. On 11/01/2023 at 01:40PM Licensed Nurse (LN) G stated direct care staff would encourage bathroom use before laying him down for bed. She was not sure if individualized interventions were implemented but most residents were checked on at least every two hours. On 11/01/2023 at 02:05PM Administrative D stated each resident was screened upon admission for incontinence and a care plan implemented to maintain or improve the resident's incontinence status. She stated each resident's incontinence status was monitored and documented. She stated the interdisciplinary team would meet to discuss interventions to improve incontinence and prevent infections. The facility's Incontinence Management policy revised 10/2023 stated that resident will be evaluated for bowel and bladder incontinence management. The policy noted that pattern evaluations will be provided to residents for individualized continence management programs. The assessment The facility failed to implement individualized toileting interventions related to bowel and bladder incontinence for R15, who was a candidate for bowel and bladder retraining. This deficient practice placed R15 at risk for complications related to incontinence.

The facility identified a census of 29 residents. The sample included 13 residents with one reviewed for nutrition. Based on observation, record review, and interviews, the facility failed to monitor Resident (R)127's weight loss or changes in dietary intake. This deficient practice placed R127 at risk for complication related to weight loss and malnutrition (condition that develops when the body is deprived of vitamins, minerals and other nutrients). Findings Included: - The Medical Diagnosis section within R127s Electronic Medical Records (EMR) included diagnoses of chronic kidney disease, osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), muscle weakness, history of fractures (broken bones), and history of falls. R127's Admission Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Metal Status (BIMS) score of nine indicating moderate cognitive impairment. The MDS indicated she required set-up assistance with meals. The MDS indicated she weighed 117.2 pounds (lbs.). The MDS documented the resident was not on a physician-prescribed weight loss regimen. R127's Functional Abilities Care Area Assessment (CAA) completed 10/31/23 was at risk for altered functional abilities related to her medical diagnoses. The CAA indicated she required assistance with her activities of daily living (ADL). R127's Cognitive Impairment CAA completed 10/31/23 indicated she had impaired cognition and instructed staff to cue and reorient her as needed. R127's Care Plan initiated 10/18/23 she had a self-care deficit related to her ADL. The plan noted she was on a regular diet with regular texture. The plan instructed staff to monitor her intake and record every meal. The plan instructed staff to monitor and report symptoms of dysphagia, malnutrition, decreased appetite, and weight loss to the medical provider. An Admission Nutrition Evaluation completed 10/18/23 indicated R127 weight was 117.2 lbs. The evaluation indicated she was at risk due to due to acute disease in the past three months. A Mini-Nutritional assessment dated [DATE] indicated R127 was at risk of malnutrition. A Nutrition/Hydration Risk Evaluation completed 10/20/23 noted R127 was at moderate risk for malnutrition. The evaluation noted she took no medications contributing to weight loss risks. R127's EMR revealed her admission weight on 10/17/23 was 117.2 lbs. The EMR recorded her weight decreased to 99.1 lbs. on 10/25/23 and 97.2 lbs. on 10/27/23. R127's EMR, between 10/25/23 through 11/01/23, lacked evidence of physician notifications related her weight loss or change in her oral intake. A review of R127's EMR under Documentation Survey Report from 10/17/23 to 11/01/23 indicated no meal intake monitoring occurred from 10/21/23 to 10/29/23 for breakfast, lunch, and dinner meals. On 10/30/23 at 08:11AM R127 reported she recently had issues with weigh loss but ate her meals. R127 consumed her entire breakfast without concerns in the dining room. On 11/01/2023 at 01:30PM Certified Nurse's Aide (CNA) M stated direct care staff would complete scheduled weights of the resident per the physician's orders. She stated if a resident's weight was off by three pounds the resident would immediately be reweighed and the nurse notified of the change. She stated meal intake monitoring would be documented in the EMR system and the physician would be notified of changes in oral intake by the nurse. She stated R127 just recently admitted to the facility and had no complaints related to her meals or eating. On 11/01/2023 at 01:40PM Licensed Nurse (LN) G stated residents with noticeable weight changes would be placed on weekly weights and monitored closely for diet, medications, and intake. She stated the resident's weight loss would be reported to the physician and dietician for review. She stated a progress note would be completed to document the notification and well as changes in care. She stated residents at risk for weight loss and malnutrition were closely monitored for oral intake. On 11/01/2023 at 02:05PM Administrative Nurse D stated staff were expected to ensure the medical provider and registered dietician were notified of suspected weight loss. She stated the facility would increase weight monitoring occurrences and provide dietary supplementation for residents at risk for malnutrition. She stated staff were expected follow each resident's care planned interventions and orders to prevent or avoid unnecessary weight loss for the residents. A review of the facility's Weight Monitoring policy revised 10/2023 indicated the facility ensured acceptable parameters of body weight. The policy noted each resident will be provided ongoing evaluation and interventions to prevent significant weight loss. The policy indicated the physician will be notified in changes related to each resident's preferences, diet, allergies, meal consumption, and weight. The facility failed to monitor R127's weight loss or changes in dietary intake. This deficient practice placed R127 at risk for complication related to weight loss and malnutrition.

The facility identified a census of 29 residents. The sample included 13 residents with five residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to provide adequate pulse monitoring for Resident (R)125's anti-hypertensive beta-blocker (class of medication used to treat high blood pressure). This deficient practice placed R125 at risk for unnecessary medications and adverse medication effects. Findings Included: - The Medical Diagnosis section within R125's Electronic Medical Records (EMR) included diagnoses of fracture of right femur (broken bone), aphasia (difficulty speaking), dementia (progressive mental disorder characterized by failing memory, confusion), cerebral infarction (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), and congestive heart failure (a condition with low heart output and the body becomes congested with fluid). R125's Admission Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Metal Status (BIMS) score of three indicating severe cognitive impairment. The MDS indicated he admitted on [DATE]. The MDS noted he had hypertension (high blood pressure) and heart failure. R125's Communication Care Area Assessment (CAA) completed 10/21/23 indicated he was at risk for altered communication related to his aphasia. The CAA instructed staff to give him extra time to form words and assist him with functional abilities. The CAA noted care planning would address his risks. R125's Psychotropic Medication CAA completed 10/21/23 indicated he was at risk for adverse medication affects. The CAA noted care planning would address his risks. R125's Care Plan initiated 10/13/23 indicated he had congestive heart failure. The plan instructed staff to administer his antihypertensive medication as ordered and observe him for adverse effects. The plan indicated he took metoprolol (antihypertensive beta-blocker medication) related to his heart failure. R125's EMR under Physician's Orders dated 10/06/23 revealed an order to administer 25 milligrams (mg) of metoprolol tartrate by mouth once daily for hypertension. The Medication Administration Record (MAR) indicated the medication was scheduled to be given at 07:00AM. The orders lacked instruction to monitor R125's pulse before administration. A review of R125's EMR revealed no consistent pulse monitoring to correspond with the administration of R125's daily metoprolol. On 10/30/23 at 08:00AM, R125 sat in his wheelchair in his room. He was clean and well groomed. On 11/01/2023 at 01:40PM, Licensed Nurse (LN) G reported the facility currently had no standing orders to monitor antihypertensive medications due to the recent ownership change. She stated the nurses were expected to use their nursing judgement when administering medications. On 11/01/2023 at 02:05PM Administrative Nurse D stated that many of the orders have not been updated in the new system since the ownership change. She stated staff were expected to administer medications based on the physician's order and call if they had questions. A review of the Medication Administration policy 10/2023 indicated medications will be prepared, monitored, and administered per the physician's order. The facility failed to provide adequate pulse monitoring for R125's anti-hypertensive beta-blocker medication. This deficient practice placed R125 at risk for complications related to unnecessary medications and adverse medication effects.

The facility reported a census of 54 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure 1 of 8 residents sampled for medication administration (#242) was free from a significant medication error. Findings included: - Review of resident #242's electronic record documented the resident admitted to the facility on [DATE] at 4:30 P.M. with [DIAGNOSES REDACTED]. Review of the hospital discharge summary documented resident #242 had a four day hospitalization and diagnosed with [REDACTED]. The admission nurse's data assessment dated [DATE] documented the resident arrived to the facility, in a wheelchair, alert and oriented to his/herself and place, with facial droop and left sided arm and leg weakness. The hospital transfer orders dated 1/6/15 recorded the resident received the following anti-hypertensive medications (medications used to control elevated blood pressure): [MEDICATION NAME] 10 milligrams (mg) by mouth daily, [MEDICATION NAME] 50 mg by mouth daily, and isosobide [MEDICATION NAME] 30 mg by mouth daily. The transfer order directed staff to hold the resident's blood pressure medications if the resident's blood pressure (SBP) was less than (<) than 160 millimeters of mercury (ml/Hg). The resident's initial care plan dated 1/7/15 lacked documentation related to the resident's anti-hypertensive use and/or any medications. Review of the nurse's progress notes dated 1/7/15 at 3:49 P.M. recorded the resident arrived to the medication room this morning at 8:30 A.M., was alert and oriented, had mild left sided facial droop and had full range of motion to both his/her arms. Direct care staff V gave the resident his/her A.M. medication (BP 146/86). At 9:40 A.M. staff found the resident in his/her wheelchair, slumped to the left and forward with his/her left arm flaccid (limp-like), behind him/her, and the right arm grasping the bed comforter. Direct care staff V summoned help and nurse practioner JJ assessed the resident. The resident's BP was 88/50, heart rate (HR) of 60 beats per minute (BPM), and had weakness in his/her left arm. Nurse practioner JJ ordered the resident transferred to the hospital to rule out a stroke. Review of the resident's BP record revealed: 1/6/15 at 4:42 P.M. BP =161/76 1/7/15 at 12:05 A.M. BP= 145/68 1/7/15 at 8:05 A.M. BP=146/86 Observation on 1/7/15 at 10:10 A.M. revealed the resident with his/her eyes open, pale skin color, on a cot, accompanied by emergency medical personnel, and transferred to the hospital by ambulance. Interview on 1/8/15 at 12:00 P.M. administrative licensed nurse D reported resident #242 received all three of his/her BP medications on 1/7/15 at 9:00 A.M. when his/her BP was 146 SBP over 86 DBP. Staff should have held the medications per the physician's orders [REDACTED].M. and nurse practioner JJ and transferred the resident to the hospital for altered mental status/possible stroke. His/her BP was 88 SBP /50 DBP and HR of 60 BPM. Administrative licensed nurse D stated he/she asked the medical director if the decrease in BP could have caused a stroke and he/she answered "unfortunately, yes." Interview on 1/8/15 at 12:20 P.M. medical director doctor LL stated this resident was a special case. The normal parameters for withholding BP medication were lower than that, so you would have to ask the physician who wrote the order why the parameters were higher. Sometimes, however, the BP parameter's were set higher in stroke patients to aide with increased perfusion (blood flow). Physician LL stated giving the resident his/her BP medications could cause a stroke but there was no way to definitively know. Interview on 1/8/15 at 2:16 PM with licensed nurse K stated nursing took every resident's blood pressure (BP) every morning when they come up to get their medications. If a resident's blood pressure was elevated, he/she rechecked the blood pressure, gave the resident their BP medications and called their doctor, then re- check it in 15 minutes to see if it went down. For a BP of 90/40, he/she said he/she would hold the resident's BP medication and check their BP again. If their BP remained low, then monitor and make sure there were no signs of [MEDICAL CONDITION] (low BP) and call the physician. He/she said signs of [MEDICAL CONDITION] were weakness, confusion, or dizziness. Interview on 01/08/2015 at 2:17 PM licensed nurse J stated the nurse or medication aide should take the resident's BP before giving medication, chart it in the computer and the computer He/she said by looking at resident's medications, he/she said he/she used nursing judgment on when it was safe to give BP medications, there was not a standing order or policy of parameters for when to hold BP medications, unless it was specifically written by the resident's physician. Interview on 1/8/15 at 2:41 PM with direct care staff Q stated if he/she took a resident's blood pressure (BP) or saw a BP of 90/40, he/she said he/she would re-take the BP and if it was still low, hold the BP medication and notify the nurse in charge. Direct care staff Q said common parameters for low BP was a systolic of less than 100 and a high BP, one 160/115 would concern him/her and he/she would report it to the charge nurse. Interview on I/8/15 at 3:20 P.M. administrative licensed nurse D stated licensed nurse W worked the evening on 1/7/15 discovered the error at 5:00 P.M. when the hospital asked for a list of the resident's medications and when he/she received them. Nurse W reported that was when he/she noticed staff gave the medications and the BP was out of the physician ordered parameters when given. Administrative licensed nurse stated there was an immediate inservice on BP monitoring with staff. Interview on 1/12/15 at 1:40 P.M. licensed practioner JJ stated he/she was concerned of a stroke and that was why the facility sent the resident to the hospital. He/she said it was unlikely that lowering the resident's BP led to a stroke. Licensed practioner JJ said staff should follow the physician's orders [REDACTED]. Interview on 1/12/15 at 1:30 P.M. administrative licensed nurse D stated there were no contributing factors to the medication error such as a transcription error and stated the direct care staff V had to look at the BP parameters in the computer before he/she gave the medications. The facility's Blood Pressure Parameters policy revised 4/24/13 documented: When a person moved into the community with an order for [REDACTED].< 60 was used. The policy lacked documentation to follow physician ordered blood pressure parameters. The facility failed to follow physician's orders [REDACTED].

The facility's census totaled 50 residents with 4 residents sampled for falls. Based on observation, interview and record review, the facility failed to provide timely and effective interventions to prevent falls for 1 of 4 sampled (#1) residents. Findings included: - Resident #1's physician's orders [REDACTED]. The quarterly Minimum Data Set 3.0 assessment ((MDS) dated [DATE] documented the Brief Interview for Mental Status (BIMS) score of 6 which indicated the resident's cognitive status was severely impaired. The MDS further documented the resident required limited assistance of 1 staff with bed mobility, transfers, dressing, toilet use and personal hygiene. The MDS also documented the resident had 2 or more falls with no injuries. The admission MDS dated [DATE] documented the resident had no falls prior to admission. The Fall Care Area Assessment (CAA) dated [DATE] documented to see the activities of daily living (ADL) CAA which revealed the resident had increasing weakness and tiredness at home, a decline in mobility and now needed the assistance of one staff person with ADLs. The resident received therapy for strengthening and increased mobility. The resident used a wheelchair as the primary mode of locomotion. The resident was mostly Spanish speaking. The revised fall care plan dated [DATE] related to decreased mobility and confusion included the following interventions: keep the walkways and the room free of clutter, keep the floors clean and dry, non-skid sole shoes with all transfers and/or ambulation, pharmacy consult to review medications every month and make recommendations as indicated, physical therapy and occupational therapy as prescribed, and restorative nursing as recommended for safety, increase ambulation, transfers, endurance, and activities of daily living (ADLs). The resident was admitted [DATE] and 18 falls were documented in the nurse ' s notes as follows: On [DATE] at 16:33 P.M. the resident stated he/she fell sometime this morning and yesterday with no injuries. The investigation report documented the resident fell from bed, and moved to a low-rider bed and to continue with therapy for safety. The care plan was not updated due to this fall. On [DATE] at 2:39 P.M. staff found the resident lying on his/her left side on the floor with his/her head near the foot of the bed with no injuries. The resident's room was changed. The investigation report documented the resident fell during a self transfer, and to provide slipper socks. The care plan was not updated due to this fall. On [DATE] at 7:51 P.M. the resident staff found the resident sitting on the floor between the bed and the wheelchair. The resident complained of pain in his/her head, right shoulder, and the left side of his/her back. The investigation report documented the resident transferred him/her self from his/her wheelchair to his/her bed, and did not lock his/her wheelchair,and fell to the floor hitting his/her head and shoulder. The resident was sent to the emergency room . The care plan was not updated due to this fall. On [DATE] at approximately 1:50 A.M. staff found the resident sitting on the floor next to his/her bed. The resident stated he/she was transferring from the wheelchair back to his/her bed after going to the bathroom when the wheelchair rolled back because the brakes were not locked. The resident was not injured. The investigation report documented the resident fell while ambulating with regular socks worn. The resident refused to wear non-skid socks and had a fall mat and a low bed. The care plan was not updated due to this fall. On [DATE] a 5:15 P.M. staff found the resident sitting on the floor in front of the right side of his/her bed on the fall mat with his/her back against the side of the bed with his/her head resting on the mattress. The resident was not injured. The investigation report documented the resident slid to the floor when transferred him/herself while wearing regular socks. The facility gave the resident another pair of non-skid (gripper) socks. The care plan documented the resident had a non-injury fall with no additional interventions. On [DATE] at 9:00 P.M. staff found the resident lying on floor next to his/her bed on the left side. The resident had no visible injuries except a bump above the left forehead. The resident was transferred to the hospital. The investigation report documented the resident fell from his/her bed and complained of head pain. The care plan documented the resident with a hematoma - collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma, to the resident ' s left forehead. The facility placed the left side of the bed against the wall with a fall mat on the right side of his/her bed. On [DATE] at 5:15 A.M. staff found the resident lying on the floor in his/her room on his/her right side, his/her upper-body was between the nightstand and the bed, his/her lower body was curved around the night stand. He/she complained of left knee/leg pain and a bruise on the back of his/her skull, he/she expressed some discomfort at that site. The facility sent the resident to the hospital. The investigation report documented the resident was out very late the night before with family and needed to use the bathroom. The resident was sick with a cough and his/her spouse recently died . Staff were to offer toileting early morning around 4:00 A.M. and to make sure the resident used the toilet before going to bed. The care plan instructed the staff to take the resident to the bathroom before bed and to awaken around 4:00 A.M. and offer the bathroom. On [DATE] at 4:45 A.M. staff heard the noise of a resident falling and he/she called for help. Staff found the resident lying on the floor in front of his/her wheelchair, just inside the door to his/her room. The resident had no injuries. The investigation report documented staff should take the resident to the bathroom before going to bed and then at 4:00 A.M., and bring the resident to the nurses ' station after the 4:00 A.M. toileting. The care plan instructed the staff to bring the resident to the nurses ' station after the 4:00 A.M. toileting for closer monitoring. On [DATE] at 3:20 A.M. staff found the resident lying on his/her back behind his/her bedroom door. The resident did state he/she hit his/her head, and complained of lower back pain and right rib pain, with pain rated 8 of 10 (0 to 10 pain scale with 10 being the worst pain felt) with no redness or bruising noted. The investigation report documented the resident laid down on the floor to sleep. The resident fell four times this week in his/her room. The resident complained of back and thigh pain. The doctor ordered blood work, urinalysis, and x-ray of the lumbar (lower back) and pelvis. The care plan documented the doctor ordered x-rays, blood work, and would follow up on the next visit. On [DATE] at 11:01 P.M. staff found the resident lying on his/her right side on the floor of his/her room in front of his/her nightstand. The resident complained of discomfort to his/her bilateral lower extremities and back. The investigation report documented the resident could not sleep, staff to assist to the bathroom around 4:00 A.M. each night, and if he/she stays up to bring out of his/her room and keep near the nurses ' station for closer monitoring. The care plan documented the doctor would evaluate the need for medication to help with anxiousness and sleep. On [DATE] at 11:24 A.M. staff found the resident sitting on the floor between his/her wheelchair and his/her bed with no injuries. The investigation report documented the resident had a urinary tract infection and pneumonia (inflammation of the lungs), was out of sorts, frequently fell in his/her room, and spoke no English. The facility would treat the infections and protect him/her from sustaining major injury from any fall. The care plan documented to continue to treat the current infections while protecting him/her from injuries as much as possible. The investigation report documented staff found the resident on his/her bottom on the bathroom floor with his/her wheelchair behind him/her and the toilet in front of him/her. The staff would provide 30 minute visual checks to protect him/her as much as possible from sustaining any major injury from fall, and to treat infections. The care plan documented to continue to protect him/her from injury as well as able and treat infections. The clinical record lacked documentation related to this fall. On [DATE] at 6:15 A.M. staff found the resident lying on the floor between his/her bed and his/her wheelchair with his/her head underneath the bed and no injuries. The investigation report documented the resident rolled out of his/her bed, had an infection, and to continue to protect from major injury from a fall and treat infections. The care plan documented to continue to protect him/her from injuries as able and to treat the current infections. On [DATE] at 12:15 P.M.staff found the resident lying on his/her right side on the floor outside of his/her bathroom. The resident had a skin tear to his/her left arm, red marks on his/her left shoulder, the middle of his/her forehead and the left upper side of his/her head. The investigation report documented the resident fell going to the bathroom after lunch, continue to protect from sustaining major injury from falls, treat infections, and the medication Ativan (anti-anxiety) was ordered as needed. The care plan documented Ativan as ordered, continue to protect as able from injury, and treat the current infections. On [DATE] at 11:05 A.M. staff found the resident on the floor on his/her back with his/her head toward the foot of the bed with no injuries. The investigation report documented the resident fell trying to get out of bed on own and no injuries. The resident was in a low bed and lying on the mat. Family member spoke to the resident in his/her language and reinforced to call for assistance. Physical therapy will screen. The care plan lacked interventions related to this fall. On [DATE] at 11:10 P.M. staff found the resident on the floor lying on his/her back on a fall mat with no injuries. The investigation report documented the resident rolled out of bed onto the bedside mat with no injuries. The facility will get a body pillow for him/her to sleep with and create comfort and safe boundaries. The care plan documented the resident was in a room closest to the nurses ' station and to provide a body pillow on the outside of the bed to provide comfort and identify boundaries. On [DATE] at approximately 3:00 P.M. staff observed the resident roll out of his/her bed with his/her head on the floor and his/her feet in the bed with no injuries. The investigation report documented staff found the resident on the floor. A lipped mattress was placed on the bed to provide boundaries and the family requested a quarter rail placed on the bed. The care plan documented the resident had a lipped mattress placed on his/her bed to provide boundaries. On [DATE] at 11:20 P.M. staff found the resident in a semi-sitting position in the middle of his/her fall mat with his/her head on the mattress and his/her legs were extended out from his/her body with no injuries. The investigation report documented the resident rolled off his/her bed. A paddle type call light was placed on the bed, so when the resident rolls the call light will turn on and alert the staff. The care plan documented the call light was switched to a paddle type so the call light can lie flat on the outside of the bed beside the resident and hopefully the resident would roll onto the call light and alert the staff that the resident was possibly rolling out of his/her bed. On [DATE] at 10:30 A.M. staff found the resident on the floor between his/her wheelchair and his/her bed with no injuries. The investigation report documented the resident had inappropriate behaviors such as hitting others. A urinalysis (UA) was ordered and if the UA was negative then will send the resident for psychological treatment. The care plan documented the resident was acting out and became combative. The resident would be admitted for psychiatric treatment if the UA was clear. The UA revealed many bacteria and the doctor ordered an antibiotic for the resident. The revised [DATE] nurse aides ' care guide revealed the resident was occasionally incontinent,staff were to wake the resident up around 4:00 A.M. and offer the toileting, after the 4:00 A.M. toileting, bring the resident to the nurses ' station. When the resident goes to bed place a body pillow on the outside of the bed to provide a boundary, and place a paddle call light beside the resident on the outer side of the bed so he/she will roll on the call light if he/she would roll out of the bed. Review of the medical record revealed the resident was sent to the emergency roiagnom on [DATE](returned after assessment of his/her head and shoulder), [DATE] (returned after assessment of the hematoma on his/her head), and [DATE] (returned after assessment of the bruise to the back of the skull). The resident was observed on [DATE] at 9:30 A.M. in bed sleeping with a body pillow placed next to the wall, a fall mat on the floor next to the bed, and the call light placed across the resident's chest. On [DATE] at 1:44 P.M. direct care staff O spoke to the resident in Spanish then repositioned the resident. The resident fell back to sleep. Direct care staff O revealed the resident did not awaken today. Direct care staff O revealed the resident did this occasionally, slept through the day. On [DATE] at 10:00 A.M. the resident was awake and sitting in a wheelchair in his/her room going through the dresser drawers, no staff were observed on the hall at this time. On [DATE] at 11:30 A.M. observed the resident ambulating per wheelchair to the dining room for lunch. The resident stopped and talked in Spanish to a staff member and then proceeded to the dining room. Direct care staff O revealed on [DATE] at 1:47 P.M. the resident required help with all of his activities of daily living. Direct care staff O revealed the resident did not wake up today. Direct care staff P revealed on [DATE] at 4:10 P.M. staff turned the resident every 2 hours and was his/her condition was deteriorating. Licensed nursing staff H revealed on [DATE] the resident required frequent monitoring related to falls. The facility had fall mats at the bedside, a low bed, and nonskid socks to prevent falls. The staff would sometimes just find the resident walking around. The resident spoke Spanish and was hard to communicate with. The [DATE] revised facility policy " Fall Prevention and Management Protocol " documented after a fall the licensed nurse would attempt to identify the cause of the fall and document findings in the nurses ' notes. The interdisciplinary team would review the fall and make appropriate recommendations to the plan of care to help prevent falls. The facility staff would review the plan of care and would add a new intervention to help prevent future falls. The facility failed to develop and implement interventions to prevent further falls for this high fall risk, cognitively impaired resident who had 18 falls in 6 months with 3 emergency room visits.

The facility identified a census of 52 residents. The sample included 24 residents. Based on observation, interview and record review, the facility failed to assess and provide effective pain relief and failed to prevent skin breakdown for one resident who admitted to the facility without skin breakdown for one of one residents (#209). Findings included: - Resident #209's physician's orders [REDACTED]. The POS ordered staff to give the resident Tylenol as needed for pain, [MEDICATION NAME] 5 milligrams (mg) 4 tablets by mouth every 3 hours as needed for pain and [MEDICATION NAME] 300mg, 3 tablets by mouth three times a day for pain. The Admission Minimum Data Set (MDS) 3.0, dated 02/23/11, recorded a Brief Interview for Mental Status (a tool for assessing cognition) score of 14, indicating the resident was cognitively intact. The MDS recorded the resident required total assistance of staff for bed mobility, toileting, personal hygiene and bathing with assistance of 2 staff. The MDS recorded that resident received pain medications and had occasional pain. The MDS further recorded that at times, the pain made sleeping at night hard and the pain limited the resident's day-to-day activities. The resident rated his/her score on a pain scale from 0-10 as a 10, highest pain on the scale. The Care Area Assessment for pain dated 02/23/11 recorded the resident admitted to the facility with a right above the knee amputation and surgical wound dehiscence (separation of a wound closure). The resident had pain when getting up. The resident reported the [MEDICATION NAME] worked when he/she asked for it. He/she rated their pain as a 10 out of 10 at it's worst. The resident reported the pain woke him/her up at night. Review of the pain assessment dated [DATE] revealed the resident was alert and able to verbally communicate. The resident had intermittent pain and a condition associated with a potential for pain. The resident reported moderate pain. The care plan dated 02/28/11 for pain directed nursing staff to assess the resident for pain, location of pain and intensity of pain. The care plan further directed nursing staff to monitor for pain and assess the resident's degree of pain and record the degree of pain relief after administering the prescribed pain medications. The care plan directed nursing staff to administer pain medications prior to therapy or exercise. The physician's orders [REDACTED]. Review of the March 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s pain for medication effectiveness after administering this medication. The physician's orders [REDACTED]. The Wound Skin Notes dated 04/04/11 at 12:19 P.M. recorded the resident complained of scrotum enlargement and that it was swollen and painful. The resident was going to the emergency room to have it checked. The resident requested on 04/01/11 for staff to hold the [DEVICE] for a few days due to pain so the last 4 days, staff dressed the right amputation site wound with [MEDICATION NAME]. Because of the scrotum was so close to the area of the stump wound, dressing the wound with anything was painful. Review of the April 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M., the day the skin notes recorded the resident requested the [DEVICE] be held due to scrotum pain. Staff failed to re-evaluate the resident for his/her pain and failed to follow up on the efficacy of the pain medication administered. Review of the April 2011 MAR indicated [REDACTED].M. Review of the April 2011 MAR indicated [REDACTED]. Review of the April 2011 MAR indicated [REDACTED].M. and at 9:30 P.M. on 04/04/11 the day the resident went to the emergency room for pain. During observation on 04/05/11 at 10:30 A.M. licensed nursing staff E and licensed nursing staff D entered the resident's room and informed the resident that they were going to perform the dressing change to the right stump wound. The resident lay in bed during the wound care. Licensed nursing staff D placed a pillowcase under the resident's large, swollen scrotum lifting it and pulling it toward the left leg away from the right stump wound. The resident held his/her forehead with the left hand while her/his eyes were closed shut and yelled, " Ouch, that hurts, oh,oh no that hurts, ah, it hurts " . Licensed staff E instructed the resident to take deep breaths and told the resident he/she was doing ok. Licensed staff D began asking the resident questions about other activities, but the resident stated, "I'm in so much pain I can't even think straight." Licensed staff D said, "I think I might call and try to get something more for pain as the [MEDICATION NAME] isn't covering it today." Licensed staff E performed the dressing change to the right stump area as the resident continued to moan and complain of pain. At 10:40 A.M., licensed staff A entered the resident's room and requested to talk to the resident. The resident told licensed staff A that he/she was in so much pain right now and couldn't talk. Licensed staff A stated he/she would return later and exited the room. The resident continued to hold his/her head with the left hand and then held his/her right abdomen with the right hand and said, "It hurts all the way up into my stomach." The resident continued to complain of pain and moaned throughout the wound care. Staff failed to offer to stop the treatment and failed to offer any more pain medication. After licensed staff E completed the wound, he/she told the resident, "Let ' s let you rest from this ordeal and then later we will come and clean you up." The resident requested staff look at a sore area on his/her left abdomen area. Staff performed wound care to this area. The resident did not complain of pain during the wound care to the left abdominal wound. During interview on 04/05/11 at 11:15 A.M. the resident reported staff gave him/her some pain medication that morning, but the medication did not take effect in time for the staff to do the dressing change on the wound. The resident rated his/her scrotum and abdominal pain during the wound care at a 10 on a pain scale of 0-10 with 10 being pain at it's worst. Review of the April 2011 MAR indicated [REDACTED].M. and staff failed to document the effectiveness of the pain medication. During interview on 04/05/11 at 11:25 A.M. licensed staff D reported he/she assessed this resident in the morning during vitals and then again before therapy and after therapy for any pain and documented the assessment on the MAR, then he/she returned in about an hour and reassessed the resident for the effectiveness of the medication. During observation on 04/05/11 at 2:05 P.M. licensed staff E and direct care staff D entered the room and informed the resident that they would clean him/her and perform Foley catheter care. Licensed staff E performed wound care to a new skin sore on the resident's left upper leg that was under the resident's stomach. Direct care staff D performed the Foley catheter care. The resident did not complain of pain during catheter care. Licensed staff E held a cloth bag, which he/she reported, was made by himself/herself for this resident and that was the first time they were going to use the bag in an attempt to support the resident ' s large scrotum. Licensed staff E held the cloth bag while direct care staff D lifted up the resident's large scrotum and pushed it into the bag. The resident yelled out moaning and held his/her right abdominal area. Staff E told the resident, "Take deep breaths buddy." Staff attached the bag holding the resident's scrotum to a belt that staff placed around the resident's abdomen. At 2:15 P.M. the resident stated, "I ' m hurting." Licensed staff E said, "I know you are hurting, but they are elevated." Then licensed staff E asked the resident if he/she was still hurting. The resident reported he/she still had pain. Licensed staff E stated he/she would go and get a small "peanut pillow" to help hold up the scrotum. Licensed staff E left the room and then returned with a small pillow, which he/she placed under the resident ' s scrotum. The resident continued to complain of pain in his/her back, right abdomen and scrotum. At 2:25 P.M. licensed nursing staff D entered the room and asked the resident if he/she could give the resident something for pain. Licensed nursing staff D asked the resident to rate his/her pain on the pain scale from 0-10. The resident reported his/her pain rated at a 20. Staff D gave the resident [MEDICATION NAME]. During interview on 02/05/11 at 2:45 P.M. licensed nursing staff E reported staff assessed this resident for pain every shift and as they were care planned. Licensed staff E stated, "We should have medicated the resident prior to doing that care this afternoon, it was a bad call." Review of the April 2011 MAR indicated [REDACTED].M. and at 2:15 P.M. During interview on 04/05/11 at 3:00 P.M., the resident reported he/she asked the staff for pain medication when his/her back hurt and it helped for 2-3 hours. The resident continued that he/she took the medication for the scrotal pain, but it did not work very well for the scrotal pain. He/she reported staff did not offer any pain medication prior to the perineal/scrotal care, but he/she thought if staff had given him/her some pain medication then he/she would not have hurt so much. He/she reported, "staff work backwards, they don't think about how I hurt until after they have touched me and the pain is so bad." The resident reported that on Monday 04/04/11 early in the morning on the night shift he/she asked a nursing assistant to tell the nurse he/she needed some pain medication because his/her swollen scrotum was hurting. He/she reported the nurse did not come into his/her room for a long time. By the time he/she saw the nurse the pain was really bad. The nurse told him/her that they were not informed by the aide that he/she was having pain. The resident reported this incident to the social services staff. During interview on 04/06/11 at 10:04 A.M. administrative staff E reported this resident complained to her/him on Monday 04/04/11 that he/she needed to see a doctor for the scrotum swelling and discomfort. Administrative staff E reported the resident complained that he/she told the nurse aide he/she needed something for pain, but the nurse did not come to his/her room until much later because the aide failed to inform the nurse about the resident's pain. Staff E reported this resident was tearful and she/he felt the resident was overwhelmed and suffering from grief over the loss of his/her leg and required a lot of encouragement from staff. During interview on 04/06/11 at 10:15 A.M. the resident reported his/her pain rated a 6 on the 0-10 Numeric Pain Intensity Scale. He/she reported staff gave him/her some pain medication earlier, but the medication did not work very well for the scrotum pain. He/she reported the staff nurse did not return to ask if the medication was effective. He/she reported the nursing staff usually did not return after giving pain medication to ask if it helped the pain. He/she said, "They are so busy, I don't think they think about it." During interview on 04/06/11 at 10:17 A.M., licensed nursing staff D acknowledged she/he gave this resident pain medication at 8:00 A.M. but did not reassess him/her for pain after that. Licensed nursing staff D reported the resident did not say he/she needed anything else for pain. During interview on 04/06/11 at 10:55 A.M., administrative staff B reported this resident received physical and occupational therapy. He/she reported this resident had complained of pain during therapy and had refused to get up out of bed and reported to staff B that he/she was afraid to get out of bed due to pain. Administrative staff B reported the resident said, "Can't do it cause it hurts" both in the evenings and in the mornings during therapy. Review of the daily therapy treatment times and the resident's MAR indicated [REDACTED].M. and 12:21 P.M., 03/28/11 at 7:56 A.M., 12:35 P.M., 1:28 P.M. and at 2:40 P.M., 03/29/11 at 10:25 A.M. and 11:31 A.M., 03/30/11 at 9:57 A.M. and on 03/31/11 at 7:31 A.M. and at 10:38 A.M. The facility nursing staff failed to give the resident any as needed pain medication prior to these treatments as directed on the care plan. The facility provided a policy entitled Policy and Procedure: Pain Assessment with a revised date 11/22/2006. This policy directed nursing staff to perform a comprehensive pain assessment for a pain score of 5 or higher, have the resident rate pain using the 0-10 Numeric Pain Intensity Scale, document the administration of pain medication and reassess to ensure effectiveness of the intervention on the MAR, routine use of as needed medications (PRN) medications would be changed to scheduled with the PRN of the same medication used for breakthrough pain, adjust interventions until a resident defined pain relief level had been achieved, nursing and therapy departments would work together to meet the pain needs of the residents and any staff member should report to the charge nurse or Director of Nursing of when a patient complains of pain. The facility failed to assess and monitor this resident for pain. The facility failed to address this resident's complaints of pain. The facility failed to administer as needed pain medications prior to therapy treatments as planned, resulting in the resident's refusal to get out of bed due to the pain. The facility failed to reassess the resident for pain medication effectiveness after administering as needed pain medication. -The facility also failed to prevent the development of skin sores for this resident who admitted to the facility without skin sores. The Admission Minimum Data Set (MDS) 3.0 dated 02/23/11 recorded a Brief Interview for Mental Status (a tool for assessing cognition) score of 14, indicating the resident was cognitively intact. The MDS recorded the resident required total assistance of staff for bed mobility, toileting, personal hygiene and bathing with assistance of 2 staff. The resident was at risk for pressure ulcers and had no unhealed pressure ulcers. The resident had a surgical wound and received surgical wound care and dressings. The Care Area Assessment for skin dated 02/23/11 recorded the resident admitted to the facility with a right leg amputation with a stump incision that dehisced (separation of a wound closure). The staff wound care nurse saw the resident for the incision wound. The resident had [MEDICAL CONDITION] and weighed over 500 pounds. The resident required 2-4 staff to assist with activities of daily living. The Braden assessment (a tool to assess the potential for pressure ulcers) dated 03/02/11 recorded the resident with a score of 15, which indicated mild risk for the development of pressure ulcers. Review of the Admission assessment dated [DATE] revealed the facility admitted the resident with a surgical wound and no other skin sores. physician's orders [REDACTED]. Review of the March and April 2011 MARs revealed staff provided the [MEDICATION NAME] and aloe vista antifungal treatments to this resident. Review of the bath sheets for March and April 2011 documented the following: 03/13/11 The resident had a bath and was very red under the abdominal skin folds. 03/17/11 The resident had a swollen scrotum, but no documentation of skin fold redness. 03/20/11 at 3:00 P.M. The resident had a bath earlier he/she gave him/herself on day shift. 03/27/11 The resident had a bed bath, but no documentation of skin sores or redness. 03/28/11 No documentation of any skin redness. 03/31/11 No documentation of any skin sores or redness. 04/03/11 The resident had a bed bath and no documentation of any redness. During observation on 04/05/11 at 11:00 A.M., after staff completed the resident's wound care on the right stump, licensed nursing staff E then cleaned a skin wound on the resident's right abdomen. Licensed nursing staff E cleansed the small wound and then applied aquagel AG to the right pannus wound and covered with a dressing and secured hypoflex to the abdomen. Staff E then told the resident, " Let's let you rest from this ordeal and then later we will come and clean you up." The resident requested for staff to look at a sore area on his/her left abdomen area. Staff E pushed the resident's skin fold on the left side of the abdomen up while licensed nursing staff D held the abdomen fold as well. A strong smelling foul odor was noticeable when staff held the skin fold up and revealed an open superficial skin sore between the two skin folds, which licensed staff E cleaned using soap and water, and licensed staff E applied revina medication to the wound. The skin sore did bleed a small amount after cleaning. This sore measured 6.8 centimeters (cm) in length, 0.1 cm in width and had 0 depth. During observation on 04/05/11 at 2:05 P.M., licensed staff E and direct care staff D entered the room and informed the resident that they would clean him/her and perform Foley catheter care. Licensed staff E performed wound care to a new skin sore on the resident's left upper leg that was under the resident's stomach. Licensed staff E reported this area as a blister with the top skin intact that measured 2.6 cm long x 0.8 cm wide. Licensed staff E used skin prep around the blister and reported this was a new skin sore area. Licensed staff E placed a [MEDICATION NAME] dressing to cover the area and placed a towel under the resident's abdomen. During an interview on 04/05/11 at 2:30 P.M., licensed nursing staff E acknowledged the resident's chart lacked documentation that staff notified the physician of the skin wounds on the right side of the resident's abdomen. Staff started the [MEDICATION NAME] AG medicated treatment to the right abdomen on 03/14/11, but nursing staff failed to notify the physician or obtain a treatment order. Licensed nursing staff E also acknowledged she/he did not have a physician's orders [REDACTED]. Licensed nursing staff E stated she/he would obtain an order from the physician for those treatments at that time. During interview on 04/05/11 at 3:00 P.M., the resident reported he/she received bed baths. Staff would let him/her wash what he/she could reach. The resident reported for the past 2 weeks or so staff did the bathing for him/her. The resident reported that staff did not always clean under all of the abdominal folds. The resident reported when he/she was at home he/she cleaned up good every day and never smelled. The resident reported staff had not cleaned him/her under all the skin folds since last week. The resident continued that he/she needed cleaned up daily. The facility failed to prevent the development of skin sores for this dependent resident who admitted to the facility without skin sores.

The facility identified a census of 52 residents. The sample included 24 residents. Based on observation, interview and record review, the facility failed to prevent the development of avoidable pressure ulcers for 2 of 2 residents sampled for pressure ulcers. (#247, #116) Findings included: - Resident #247's [DIAGNOSES REDACTED]. The Admission Minimum Data Set 3.0 Assessment (MDS) with an Assessment Reference Date (ARD) of 3-21-11 documented the resident with a swallowing disorder, unclear speech, rarely or never understood, impaired short and long-term memory and severely impaired decision-making skills. The MDS also documented the resident required extensive to total assistance with activities of daily living (ADLs), had an indwelling foley catheter, incontinent of bowel, had 1 unhealed pressure ulcer at stage I or higher and 2 unstageable deep tissue pressure ulcers. The Care Area Assessment (CAA) dated 3-21-11 documented the resident admitted with a status [REDACTED]. The CAA further documented the resident with a low [MEDICATION NAME] level and received Prostat supplement. The CAA also documented the resident with red heels and a pink coccyx, and documented that staff repositioned the resident every 2 hours and floated his/her heels. The Admission Nursing assessment dated [DATE] documented the resident with a pink coccyx and addressed a mass on the right forearm and a cluster type mass below the buttocks. The assessment lacked any documentation of a problem or skin concerns with the resident's heels. The initial care plan, dated 3-14-11, documented the resident with a pink coccyx and directed staff to reposition the resident every 2 hours and provide perineal care. Review of the bath sheet dated 3-25-11, documented the resident with pressure sores on both heels with blisters. The nurse's notes dated 3-26-11 at 3:40 P.M., documented the resident with a pink, spongy left heel with a blister like appearance with heel protectors in place and floated on pillows. Staff documneted on 3-28-11, the care plan an intervention to apply skin prep to his/her heels. The nurse's notes dated 3-30-11 at 1:30 A.M., documented the resident with a fluid filled blister on the left heel and staff would notify the wound care nurse and physician of the blister. The comprehensive care plan dated 4-2-11 documented the resident at risk for developing a pressure ulcer related to decreased mobility with a goal to maintain intact skin, remain free of redness or blisters. Among the interventions, the care plan also directed staff to float the resident ' s heels and provide heel protectors. Observation on 4-4-11 at 11:52 A.M. revealed the resident's left heel with a purple black unstageable pressure ulcer measuring approximately 3 centimeters (cm) on the inner aspect of the heel and with a smaller purple black unstageable pressure ulcer adjacent to it. Observation of the right heel revealed a dark brown unstageable pressure ulcer approximately 1.0 cm circumference. During record review, the wound note dated 4-4-11, no time documented, recorded the resident with 2 areas of suspected deep tissue injury and staff applied skin prep twice daily. The note further documented the resident with a dark area on the right heal that measured 1.0 x 1.0 cm. During staff interview on 4-6-11 at 7:28 A.M., direct care staff A stated that the resident required total assistance with ADLs and his/her heels did not have any redness at admission. He/she also stated that the resident's heels " got red " and the wound nurse gave them heel protectors and told them to float his/her heels on a pillow. During staff interview on 4-6-11 at 10:45 A.M., licensed nurse E confirmed the resident required total assistance with ADLs and did not have any skin breakdown upon admission. He/she also stated staff notified him/her of the resident's heels and he/she placed heel protectors on the resident and floated his/her heels. During staff interview on 4-6-11 at 2:00 P.M., licensed nurse C acknowledged the initial care plan lacked interventions for preventing pressure ulcers and the admission assessment lacked documentation concerning any skin breakdown of the heels. During staff interview on 4-6-11 at 4:40 P.M., licensed nurse B acknowledged the CAA recorded the resident with red heels upon admission and stated there was miscommunication and was not correct because the resident did not have red heels upon admission. The facility failed to provide interventions to prevent the development of 3 avoidable, unstageable pressure ulcers on this dependent resident's heels. - Resident #116 ' s [DIAGNOSES REDACTED]. The Admission Minimum Data Set 3.0 Assessment, (MDS) with an Assessment Reference Date (ARD) of 3-4-11, documented the resident's Brief Interview for Mental Status (BIMS) score of 15 indicating the resident as alert, oriented, and independent with decision-making skills. The MDS further recorded the resident required extensive assistance with activities of daily living (ADLs), had an indwelling foley catheter and on scheduled pain medications. The MDS further documented the resident with a stage I pressure ulcer. The Care Area Assessment , (CAA) dated 3-7-11 documented the resident admitted to the facility after a hospitalization for a pelvic fracture after a fall. The resident required assistance of 1-2 staff with transfers related to weakness and decreased range of motion of his/her left leg, had forgetfulness, a foley catheter, required oxygen use and had pain. The CAA also documented the resident had a stage I pressure ulcer on his/her coccyx. The admission assessment dated [DATE] documented the resident with a red coccyx, a skin tear to the left elbow and bruising to the left hip and thigh. The 2-25-11 Braden Scale (a scale used to determine the risk of developing a pressure ulcer) documented a score of 16, which indicated the resident at low risk for development of a pressure ulcer. The Braden Scale on 3-11 and 3-17 also documented a score of 16. The initial care plan dated 2-25-11 documented the resident with impaired skin integrity related to a skin tear and surgical wound, and interventions directed staff to assess the wound daily, provide treatment to the wound as ordered and document the wound assessment weekly. The 3-10-11 care plan documented the resident at risk for developing a pressure ulcer related to decreased mobility and had a stage I ulcer on his/her coccyx upon admission. Interventions directed staff to assess, record, and report skin conditions, prevent sheering with transfers, provide diet and supplements, apply moisture barrier cream to the coccyx, therapeutic mattress to bed and a cushion in his/her wheelchair. On 3-21-11 the care plan documented a suspected deep tissue injury to the resident's left heel and right lateral ankle and directed staff to apply skin prep to the ankle and heel daily and as needed. The care plan lacked interventions to apply heel protectors or float the resident's heels. The nutritional assessment, dated 2-28-11, documented the resident with inadequate oral intake related to a decreased appetite. He/she recommended offering the resident snacks and nutritional supplements. The assessment documented the resident with a low [MEDICATION NAME] level of 2.9. Normal range for [MEDICATION NAME] was 3.5-5. The 3-23-11 dietary progress note documented the resident with a poor appetite, did not like the food and declined any substitutions. Record review of the wound notes, dated 3-28-11, documented the resident with a purplish suspected deep tissue injury on the back of the left heel and skin prep applied and covered with foam daily. The wound measured 1.5 centimeters (cm) length x 1.0 cm width x 0 cm depth. Observation on 4-4-11 at 3:32 P.M., revealed the resident in bed lying on his/her back with his/her shoes on and directly on the mattress without the heels floated. Observation on 4-5-11 at 2:41 P.M., revealed the resident lying on bed on his/her back with his/her shoes on and without the heels floated. Observation on 4-6-11 at 7:15 A.M., revealed the resident lying in bed without his/her heels floated. The resident stated he/she needed to go to the bathroom but staff shut his/her light off and told him/her they would be back, but did not come back. Observation on 4-6-11 at 7:25 A.M., revealed a dressing on the resident's left heel and a pinkish/red area on the resident's right ankle approximately 0.5 cm circumference with skin intact. At that time, the resident stated he/she had the area on the right ankle over a year and it looked a little red at this time, but did not have any pain with it. When asked about the dressing on his/her heel, he/she said, " They told me I was in bed too much and it got sore." He/she also said that it was better but was painful at times. During staff interview on 4-6-11 at 7:30 A.M., direct care staff A reported the resident could not care for him/herself at admission and had a lot of pain, so staff had to reposition him/her. During staff interview on 4-6-11 at 10:09 A.M. licensed nurse E confirmed the resident did not have any skin breakdown of his/her heels upon admission and would expect staff to float the resident's heels while in bed because of the resident's fractured pelvis and inability to reposition his/herself. The facility failed to provide interventions to prevent an avoidable unstageable pressure ulcer for this dependent resident.