Every finding on record at Ridgewood Specialty Care

Based on observation, clinical record review, policy review, and staff and resident interviews, the facility failed to ensure 2 of 10 residents on a mechanical soft diet received the correct texture (Residents #44 and #64). The facility reported a census of 55 residents.Findings included: Review of the facility policy Therapeutic Diets, revised October 2017, revealed the provider prescribed therapeutic diets in accordance with the resident's goals and preferences. Therapeutic diets were part of a treatment plan and included alterations to texture. Review of the document, Diet Type Report listed Residents #44 and #64 with a diet order for mechanical soft. Review of a document titled, [name of corporation redacted] FW25 Traditional SUN No Alts Diet Spreadsheet for lunch on 12/17/25 indicated the menu item of Buttered Corn mechanical Soft as 1 each corn PU (pureed). During an observation on the noon meal service on 12/17/25 starting at 12:15 PM, Staff A, [NAME] served Resident #44 corn vs the mechanical soft pureed corn. Staff A caught the mistake before Resident #44 consumed the corn. Staff A stated kitchen prepared another tray for the resident. At 1:12 PM, Staff A, [NAME] prepared room trays for staff to deliver.At 1:32 p.m., Resident #64 had a lunch plate in her room. The resident finished with her lunch, with a few kernels of regular corn remaining on the plate. The resident stated she ate the corn without problems.During an interview on 2/17/25 at 2:01 PM, the Dietary Manager stated the meal tickets staff referred to when they served meals directed diet texture orders for residents. During an interview on 12/17/25 at 2:05 PM, Staff A, [NAME] stated she had a feeling she gave Resident #44 the wrong diet so she asked Staff B, an Administrator of a sister facility to check.During an interview on 12/17/25 at 2:10 PM, Staff B stated Staff A, [NAME] asked her to check Resident #44's plate and her plate contained regular corn.

Based on review of facility Quality Assurance and Performance Improvement (QAPI) meeting documentation, Centers for Medicare and Medicaid Services (CMS) Statement of Deficiencies, facility policy review, and staff interview, the facility failed to carry out Quality Assurance (QA) activities to prevent the reoccurrence of a deficient practice related to meal textures serviced to residents. The facility reported a census of 55 residents.Findings include:Review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Pro-gram-Governance and Leadership, revised March 2020, revealed a Policy Interpretation and Implementation section, which directed, in part:a. The governing body is responsible for ensuring the QAPI program is implemented and maintained to address identified priorities. b. The responsibilities of the QSPI Committee are to collect and analyze performance indicator data and other information; and establish benchmarks and goals by which to measure performance improvement.Review of the Centers for Medicare and Medicaid Services(CMS) Statement of Deficiencies, dated 10/31/24, listed, in part, a deficiency for F803 - Menus Meet Resident Needs/Prepared in Advance/Followed. The current survey, conducted 12/15/25-12/22/25 identified concerns related to staff serving incorrect textures to residents (F803).On 12/22/25 at 3:28 PM, the Administrator provided a binder which included documentation of facility QA activities since the last recertification. Review of the binder revealed no documentation of QA activities which focused on staff providing the correct diet textures to residents. The Administrator stated she had no additional QA documentation other than what the binder containedDuring an interview on 12/22/25 at 3:53 p.m., the Administrator stated that most of the QA activities were focused on nursing but stated she asked for test trays of different textures to sample. She acknowledged that this would not evaluate whether or not staff provided the correct diet textures to residents. On 12/22/25 at 4:28 p.m., via email, the Administrator provided the following additional documents: Certificates of Completion for staff related to modified diets; Meal Observation Audits conducted 11/6/24-12/13/24; Diet and Fluid Consistency Audits, conducted 10/29/24-12/8/24. The facility lacked further, more recent, documentation of QAPI/QA program activities related to residents receiving the correct diet texture. The facility lacked evidence of an ongoing QAPI program related to this focus area including a process of addressing how the committee would conduct the activities necessary to identify and correct the deficient practice. The facility lacked documentation of monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revision as needed.

Based on observations, clinical record review, facility policy review and staff interviews, the facility failed to utilize infection control practices during the draining of a surgical wound for 1 of 3 (Resident #3) reviewed for infection control. The facility reported a census of 55 residents. Findings include: Review of the Minimum Data Set (MDS), dated [DATE], revealed Resident #63 list of diagnoses included an abscess of a limb, unspecified. The MDS identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. Review of the Care Plan for Resident #63, dated 12/15/25, revealed a Focus area to address I have a JP (Jackson Pratt - a surgical device with a tube and a suction bulb that removes excess blood and fluid from a surgical site to prevent buildup, infection and swelling, promote healing) to my right thigh. Interventions included:a. Monitor drain output every shift. Date Initiated: 12/15/25,b. Monitor JP drain site every shift. Notify physician if dislodged, purulent drainage, bleeding, or pain to site. Date Initiated: 12/15/25.c. Perform treatment and flush as needed. Date Initiated: 12/15/25.Review of a document titled, Medicine Progress Note, dated 11/20/25 for Resident #63 revealed, in part: admit date : [DATE]. Assessment/Plan:.Right thigh abscess. Pseudomonas bacteremic 10/29/25 and cleared on 10/30/25 S/P (status post) IR (interventional radiology) placement of drain in his infected hematoma in the right thigh on 11/13[2025]Review of the December 2025 Treatment Administration Record (TAR) revealed: a. On 12/17/25 day shift, 50 milliliters (ml) output of JP drain, signed by Staff C, Licensed Practical Nurse (LPN).b. On 12/17/25 am shift, flush the drain to the right posterior thigh with 10 ml of normal saline three times a day. The drain had a 3-way center port with a tap. Reposition tab to open towards the abscess, flush 5 ml then reposition and flush 5 ml towards the bulb. Reposition tap to the closed position and compress the bulb for suction. Clean the port with alcohol and apply the disinfecting cap to the port. Signed by Staff C, LPN.c. On 12/13/25 and 12/14/25 Staff C, LPN signed off completion of night time flush of drain to right posterior thigh drain with 10 ml normal saline. During an observation on 12/16/2025 at 3:41 pm, Resident #63 had a sign on his door that read contact isolation precautions and an isolation cart that contained gloves and yellow gowns. Resident #63 with an intact dressing with a drainage tube that came from the back of the right calf that led up his pants, out the back of his pants to a bulb attached to his outside pant leg secured with a safety pin. The drainage bulb contained serosanguinous (bloody drainage).During an interview on 12/16/25 at 3:42 pm, Staff F, Registered Nurse (RN) stated Resident #63 had a bacterial infection inside his leg so the contact precautions to be used when the staff are touching him. During an observation on 12/17/2025 at 10:12 am, Staff C, LPN entered Resident #63's room. Staff C completed hand hygiene, donned gloves and a gown. Staff C placed the 10 ml syringe of normal saline, and a clean cup onto Resident #63's bedside table. Staff C did not wipe down the table or place down a barrier. Staff C applied a gait belt around Resident 63's waist and assisted him to stand from the wheelchair to his walker. Staff C then removed the safety pen, which secured the JP drain bulb from Resident #63's pants. The drain contained bloody drainage. Staff C then opened the spout to the bulb. Staff C emptied the drainage into the clean cup and placed the cup back on to the bedside table. Staff C replaced the cap to the drainage bulb and secured it with a safety pen to the residents' pants. Without a change of gloves or completing hand hygiene, Staff C, LPN removed the cap to the 3-way stop-cock on the drain tubing and swabbed it. Staff C picked up the syringe from the bedside stand and connected it to the 3-way stop-cock, turned the dial to open and injected the 10 ml's of saline into the drain tubing. Staff C turned the stop-cock dial to drain into the bulb, removed the syringe, placed it onto the bedside stand next to the cup with the drainage and picked up the cap to replace it on the stop cock. Staff C assisted Resident #63 to sit into the wheelchair, picked the syringe and cup off the bedside stand and failed to clean the bedside stand. Staff C placed the cup with contaminated bloody drainage on to the sink counter and stated the drainage was less than 50 ml's. Staff C emptied the drainage into the toilet. Staff C dropped the contaminated cup, gloves and gown into the trash with a clear bag. A red contamination bag not utilized for disposal. Without completing hand hygiene, Staff C propelled the resident out of the room to the main living room. Staff C did not sanitize the bedside table, or the sink counter prior to exiting the room. During an interview on 12/17/2025 at 10:35 am, Staff D, Housekeeper stated she had been employed for 4 months but was aware the red bags were for contaminated items. She stated they are placed in the large red bag container in the dirty utility room then transferred into the garage for a company to pick them up. Staff D stated the clear trash bags are placed into the main trash and transferred into the outside trash. Staff D stated there are 2 residents in contact isolation. She stated Resident #63 had the isolation sign and isolation cart outside his room but did not have red bags nor isolation barrels in the room so the clear trash bags were discarded into the main trash. During an interview on 12/17/2025 at 10:44 am, Staff E, Housekeeping Supervisor stated there were two residents in the facility on contact isolation. Staff E stated Resident #63 arrived on 12/12/25 and was placed onto contact isolation but was unaware of why. Staff E stated when she became aware Resident #63 was in isolation precautions on 12/15/25, she asked the Assistant Director of Nursing (ADON) about the contact isolation, the ADON responded that she will ask the corporate nurse. Staff E stated the ADON had not responded to her nor asked for isolation barrels for that room. During an interview on 12/17/25 at 10:58 am, the ADON/Infection Preventionist (IP) stated Resident #63 arrived on 12/12/25 and was to be on contact isolation precautions so she had placed the sign on the door with an isolation cart for the staff. The ADON stated she was aware of why Resident #63 needed the Enhanced Barrier Precautions (EBP) due to the wounds and treatment but was not aware of the reason for the contact isolation, the diagnosis of Pseudomonas. The ADON stated she felt badly as she was the infection control nurse. The ADON stated the isolation barrels and red bags were being placed in the room immediately. During an interview on 12/22/25 at 1 pm, Staff C, LPN stated the observation on 12/17/25 was the first time he had provided care for Resident #63 and he did not think about having a red biobag for the discarded items that would have been contaminated with bodily fluids from the drain device when emptied. Staff C stated he was aware of placing contaminated items on the bedside stand and sink counter and that the house keeping clean his room daily so he was not concerned. During an interview on 12/22/2025 at 11:46 am, the Director of Nursing (DON) stated she was the infection preventionist for three years at this facility before accepting the position of DON and the expectation of nursing staff would be for them to utilize a barrier, hand hygiene before, after and during care, utilize red biobags for the bodily fluids and items contaminated with bodily fluids. The DON stated she accepted the referral for Resident #63, was aware of the Pseudomonas and directed the ADON/IP to place him on contact isolation which included the sign, a Personal Protective Equipment (PPE) cart outside of the room and isolation barrels. The DON stated she informed the ADON/IP of the diagnosis and the contact isolation for Resident #63. The DON stated she had asked Staff C, LPN why he did not take a red bag with him if he was dealing with bodily fluids and he replied that he didn't think about doing that. The DON stated her expectation was that the nurses understand isolation precautions and how to handle bodily fluids properly. The policy titled Infection Control Regulations Governing Implementation revealed written standards, policies and procedures which must include standard and transmission-based precautions to be followed to prevent spread of infections and when isolation should be used for a resident.

Based on observation, interview, and clinical record review, the facility failed to provide Resident #23 the correct diet ordered liquid consistency during medication administration causing excessive coughing and production of copious amounts of phlegm. Resident #23 has diagnoses of dysphagia (difficulty swallowing) and a history of pneumonitis due to inhalation of food and vomiting. This deficient practice resulted in an Immediate Jeopardy (IJ) to the health and safety of residents who resident in the facility. The facility reported a census of 56 residents. The State Agency (SA) informed the facility of IJ that began on October 23, 2024 at 8:02 AM, on October 23, 2024 at 1:00 PM. The Facility Staff removed the Immediate Jeopardy on October 24, 2024 through the following actions: a. The facility provided education with staff, including agency staff, to follow physician orders for fluid consistency. b. The facility provided education with nursing staff, including agency staff, on adequately assessing residents with changes in condition, to include vital signs and appropriate assessments. Physician is to be notified immediately and staff to remain with resident if change in condition. c. Resident #23 was assessed at bedside. The physician was notified. Physician orders were obtained for the following: Chest x-ray, referral to speech therapy, suction as needed (suction machine placed at bedside), crush medications as indicated, monitor lung sounds and pulse oximetry (blood oxygen) every shift for three days. d. Completed an audit of all residents on an altered liquid consistency to ensure that it is reflected on their Medication Administration Record (MAR), resident care plan, and Kardex. e. Director of Nursing (DON) or designee will monitor and audit 4 medication passes per week for 6 weeks to ensure appropriate fluid consistency given as physician ordered. DON or designee will monitor and audit 3 changes in condition per week for 6 weeks to ensure appropriate assessments are completed and physician notifications are completed. Concerns are to be addressed with Quality Assurance Performance Improvement (QAPI). The Scope and Severity was lowered from an J to a D at the time of the survey after ensuring the plan of removal was put in place and implemented. Findings Include: The Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #23 scored a 4 out of 15 on a Brief Interview for Mental Status (BIMS) test, indicating severely impaired cognition. The MDS listed diagnoses included: aphasia (inability to swallow), cerebrovascular accident (CVA-interruption of blood flow to the brain leading to neurological issues), transient ischemic attack (TIA-a brief blockage of blood flow to brain), or stroke, and dysphagia (swallowing difficulties). The MDS identified Resident #23's with a Mechanically altered diet - requires change in texture of food or liquids (e.g., pureed food, thickened liquids). The Oral/Dental Status of the resident indicated No natural teeth or tooth fragment(s). A review of Physician Orders revealed an order, dated 4/27/23, for Regular/NAS (no salt added) diet. Level 4 Pureed texture, Level 2 Mildly Thick (Nectar) consistency. The Speech Therapy SLP Evaluation and Plan of Treatment, dated 10/4/23, revealed that Resident #23 was at risk for aspiration and needed to remain nectar thickened liquids. The Care Plan, updated on 10/22/2024, included a Focus area to address I am at increased nutritional risk d/t (due to) med dx (diagnosis) of severe protein-calorie malnutrition, dysphagia, underweight, HTN (high blood pressure), HLD (high cholesterol), GERD (gastroesophageal reflux disease, cause of heartburn). An Intervention included, in part: Regular diet, Puree texture, level 2 mildly thick Nectar thick liquids. Date Initiated: 10/27/23. Revision on: 7/8/24. The resident's Medical Diagnosis report listed a primary medical diagnosis upon admission as pneumonitis(inflammation of the lungs) due to inhalation of food and vomit. A SPN Focused Evaluation on 7/12/24 noted the resident had a mild cough, with most of his coughing occurring during meals. During an observation on 10/23/24 at 8:02 AM, Staff A Certified Medication Assistant (CMA) administered the Resident #23's medications with regular (thin) consistency water. After the administration, the resident began coughing significantly. Staff A retrieved nectar thickened water to assist Resident #23 with his coughing spell while Staff D Licensed Practical Nurse (LPN) commented that Resident #23 was thickened liquids to which staff A replied I know. Staff D then commented she normally administered Resident #23's medications in pudding to prevent him from choking to which Staff A replied that she was not aware of that. During an interview on 10/23/24 at 8:13 AM, Staff A, CMA stated that during the morning medication administration, she provided Resident #23 with non-thickened liquids. Staff A was aware that Resident #23 was ordered a thicken liquid diet but she was not aware that he normally received his pills with pudding. Staff A normally mixed his Miralax (stool softener) with water to dissolve the Miralax and then added a thickened supplement to it afterwards but was running low on the supplement so she forgot to thicken the liquid. On 10/23/24 at 8:30 AM, Staff D, LPN stated that the pudding was just a personal preference for the resident and that she believed that the resident had Speech Therapy change his liquid consistency several times. Staff D noted that there was an area on the electronic MAR that documented the resident preferences. On 10/23/24 at 9:26 AM, via phone, Staff R Registered Dietician (RD) stated Resident #23 had an order for nectar thick liquid which was in place since April of 2023. She stated she would absolutely not be ok with him receiving thin liquids since he had dysphagia(difficulty swallowing) and could aspirate(inhale food or liquids into the lungs). On 10/23/24 at 9:56 AM, the Certified Dietary Manager (CDM) stated Resident #23 had always received thickened liquids. On 10/23/24 at 10:39 AM, the Director of Nursing (DON) stated residents should receive the ordered liquid consistency and Resident #23's order was nectar thick. She stated (after a coughing episode) she expected the nurse to complete a full respiratory assessment to include vitals, an oxygen level, and a check for cyanosis (blue color to the skin). She stated she expected the nurse to notify the provider and check on them every 15-30 minutes. She stated she expected staff to stay with him if they thought something was stuck (in the throat). On 10/30/24 at 12:35 PM, Staff N, Speech Therapist stated that she believed that Resident #23 was a high risk for aspiration as that was why he was ordered for a mechanically altered diet. He did not have any teeth and she recommended that he be provided with nectar thickened liquids at all times. 35434 The facility policy, revised September 2017, tiled Dysphagia-Clinical Protocol declared the staff and physician would identify residents with a history of swallowing difficulties or related diagnoses such as dysphagia (difficulty swallowing). The policy stated if a modified consistency was indicated, nursing would obtain an order for such restrictions from the physician. The facility policy, revised April 2019, titled Administering Medications directed staff to administer medications in accordance with prescriber orders

Based on observation, menu review, policy review, and staff interview, the facility failed to provide the correct texture for 5 of 5 residents with a mechanical soft diet order. The facility reported a census of 56 residents. Findings: The Therapeutic Spread Report-Spring/Summer Menu '24 for Week 2 Tuesday Lunch directed staff to provide residents on a mechanical soft diet ground chicken and noodles. During an observation on 10/22/24 at 11:51 AM, Staff V [NAME] prepared the lunch meal and stated the residents who received a mechanical soft diet would receive the regular chicken and noodles. Staff R Registered Dietician(RD) was present and stated the residents with a mechanical soft diet order would be fine with the regular chicken and noodles but stated she needed to look at the spreadsheet [Therapeutic Spread Report]. She looked in the kitchen and could not locate a spreadsheet so she left the kitchen to retrieve one. When she returned she told Staff V to break it into pieces and the dice it. The State Agency requested Staff R look in the pan of chicken and noodles to verify that this did not need to be ground. Staff R looked in the pan and told Staff V to grind the portions used for the residents with mechanical soft. The pieces of shredded chicken were up to approximately 1.5 inches in length. During an interview on 10/23/24 at 9:26 AM, via phone, Staff R RD, stated the expectation was for dietary staff to follow the therapeutic diet spreadsheets. She stated residents on a mechanical soft diet should receive ground food. During an interview on 10/23/24 at 2:37 PM, the Certified Dietary Manager( CDM) stated she found out yesterday that the sheets they had in the kitchen did not have the right information (for therapeutic diets) but stated they now had the spread sheets in the kitchen. The facility policy Dysphagia-Clinical Protocol revised 9/2017, Assessment and Recognition section indicated the staff and physician would identify residents with a history of swallowing difficulties or related diagnoses such as dysphagia (difficulty swallowing). The policy stated if a modified consistency was indicated, nursing would obtain an order for such restrictions from the physician. During email correspondence on 10/30/24 at 11:48 PM, the Administrator stated the facility did not have a separate policy regarding mechanically altered diets.

Based on observation, policy review, and staff interview, the facility failed to ensure safe food handling and kitchen sanitation for 1 of 2 kitchen observations. The facility reported a census of 56 residents. Findings: A kitchen observation on 10/21/24 starting at 9:26 AM, revealed: a. A metal bowl of fruit sat in the sink on the left hand side of the kitchen. b. [NAME] crumbs were present on the top of the dish washer. c. Staff M, Dietary Aide (DA), ran a dishwashing cycle. The Certified Dietary Manager (CDM) then dipped a test strip into the dish machine water and it remained white. According to the test strip container, a white color indicated 0 parts per million sanitizer concentration. Staff M stated he tested it this morning but forgot to write it down but it turned green to indicate 100 ppm. A follow-up observation on 10/21/24 at 9:43 a.m., revealed the test strip was 100 ppm. The CDM stated she adjusted the sanitizer tubing. d. The October 2024 Dish Machine Temperature Log for the period of 10/1/24-10/21/24 was blank and lacked documentation staff checked the dish machine strip: 1/1/24, 1/2/24, 1/6/24, 1/7/24, 1/8/24, 1/9/24, 1/10/24, 1/11/24, 1/12/24, 1/14/24, 1/15/24, 1/16/24, 1/17/24, 1/18/24, 1/19/24, 1/20/24, 1/21/24. e. Staff M had a mustache approximately 3/4 inches in lengths and did not wear a hair restraint to cover this area. Observations in the kitchen on 10/22/24 revealed: a. At 9:15 AM, the facility's ice machine had a red substance accumulating alongside the inner top part of the dispenser. b. At 10:45 AM, during lunch preparation, and again at 11:15 a.m., Staff L, DA observed with significant hair hanging out from the back of her hair net. c. At 11:15 AM, Staff M, DA while making coffee, picked up a wrapper off the floor. Without completing hand hygiene, Staff M continued to make and dispense the coffee, and began to assemble room trays. d. At 12:55 PM, a plate of half eaten food was found in the microwave, cold to touch and a sticky substance on the outside of the microwave. A trash can, next to the microwave, overflowing to the point the lid could not be closed. The trash receptacle near the handwashing sink overflowing on to the floor. During an interview on 10/23/24 at 2:37 PM, the CDM stated hair nets should cover all hair and staff should wash their hands after picking up garbage. She stated the maintenance department was responsible for cleaning the ice machine. Staff should test the dishwasher three times per day but were not doing this. She stated she completed training related to this. She stated the kitchen should be clean and in good order. The facility policy Sanitization, revised October 2008, Policy Statement declared The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation, in part, directed staff to: #8. Dishwashing machines must be operated using the follow specifications: Low-Temperature Dishwasher (Chemical Sanitization) a. Wash Temperature (120 degrees F (Fahrenheit). b. Final rinse with 50 parts per million (ppm) hypochlorite (chlorine) for at least 10 seconds. #12. Ice machines and ice storage containers shell be drained, cleaned, and sanitized per manufacturer's instructions and facility policy. The facility policy Food Preparation and Service, revised April 2019, Policy Statement declared Food and nutrition services employees prepared and served food in a manner that complied with safe food handling practices. Policy Interpretation and Implementation, Food Preparation Area section, in part, directed staff to: #5. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of food-borne illness. Policy Interpretation and Implementation, Food Service/Distribution section, in part, directed staff to: #4. Food and nutrition services staff, including nurses services personnel, wash their hands before serving food to residents. Employees also wash their hands after collecting soiled plates and food waste prior to handing food trays. #7. Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc) so that hair does not contact food.

Based on clinical record review, policy review, and staff and resident interviews, the facility failed to ensure staff spoke to residents with respect and dignity for 1 of 2 residents reviewed for dignity (Resident #20). The facility reported a census of 56 residents. Findings: The Minimum Data Set(MDS) assessment tool, dated 8/27/24, listed diagnoses for Resident #20 included bipolar disorder (a disorder characterized by alternating periods of depression and mania), schizophrenia (a mental health illness that affected a person's thoughts, feelings, and behaviors), and obsessive-compulsive disorder. The MDS listed a Brief Interview for Mental Status(BIMS) score of 3 out of 15, indicating severely impaired cognition. The Care Plan, Revision On: 9/9/24, included a Focus area to address I have impaired cognitive function/dementia or impaired thought processes. An Intervention included, in part: COMMUNICATION: Face me when speaking and make eye contact, and Stop and return if I am agitated. Date Initiated: 4/15/24. During a phone interview on 10/28/24 at 12:46 PM, Staff O Registered Nurse (RN) stated Staff P Licensed Practical Nurse (LPN) told him he needed to go to Resident #20's room. He stated Staff Q Certified Nursing Assistant(CNA) was very angry and stated she could not tolerate this disrespect anymore while she pointed her finger at him. Staff O stated the resident could have had hallucinations and she should have been receptive to his behavior. Staff O stated the resident was not in all senses and she shouldn't be that angry. He stated after the interaction, Staff Q immediately went home. During a phone interview on 10/28/24 at 2:00 PM, Staff P stated Staff Q stood beside Resident #20's roommate and stated that he didn't get to talk to her that way, it was rude and disrespectful, and she wouldn't put up with that. Staff P stated Staff Q was disrespectful, demeaning, and spoke to him like he was a child. During an interview on 10/29/24 at 10:25 PM, Staff Q stated Resident #20 swore at her and called her a b----. She told him he didn't need to disrespect her that way and she would not be disrespected. She stated after this interaction, Staff O sent her [Staff Q] home. An Incident, Accident, Unusual Occurrence Note, dated 10/16/24 at 10:00 PM, revealed a CNA yelled at a resident in Room [number redacted] and stated he was not going to be rude and disrespectful to her and told the resident his behavior was unacceptable. The CNA explained that the resident was rude and threw his remote. The nurse asked the CNA to leave the room. On 10/30/24 at 10:02 PM, the Assistant Director of Nursing (ADON) stated staff should speak to residents in a kind and respectful manner and stated if the resident had behaviors, she expected staff to remain calm and continue to be kind and respectful. On 10/30/24 at 10:16 PM, the Administrator stated staff should speak to residents kindly and with an attitude of customer service. He stated Staff Q could have chosen her words better. The facility policy Dignity revised February 2021, directed staff to care for residents in a manner that promoted and enhanced his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.

Based on observation, clinical record review, policy review, and staff interview, the facility failed to ensure call lights were accessible for 2 of 24 residents reviewed for call lights (Residents #18 and #28). The facility reported a census of 56 residents. Findings: 1. The Minimum Data Set(MDS) assessment tool, dated 8/13/24, listed diagnoses for Resident #18 which included dementia, diabetes, and cognitive communication deficit. The MDS stated the resident was dependent of staff for toileting and toileting hygiene and listed her Brief Interview for Mental Status(BIMS) score as 13 out of 15, indicating intact cognition. A Care Plan entry, dated 2/16/24, stated the resident required the assistance of 1 staff for toileting. On 10/22/24 at 8:35 AM, the resident sat in her recliner. The call light hung down from the wall on the other side of the bed, not in reach of the resident. On 10/22/24 at 9:02 AM, the resident's call light remained out of reach and a staff member retrieved it for her. 2. The MDS assessment tool, dated 10/5/24, listed diagnoses for Resident #28 which included diabetes, fracture of the tibia(frontal leg bone), and weakness. The MDS stated the resident was dependent on staff for toileting hygiene and listed the resident's BIMS score as 14 out of 15, indicating intact cognition. A 10/3/24 Care Plan entry stated the resident required substantial to maximal assistance with the bed pan. On 10/21/24 at 1:49 PM, the resident sat in a chair in her room. The resident's call light hung down from the wall on the other side of the bed, not within reach of the resident. The facility policy Answering the Call Light, revised March 2021, directed staff to ensure the call light was within easy reach of the resident. On 10/30/24 at 10:02 AM, the Assistant Director of Nursing (ADON) stated call lights should be accessible to residents and stated if she noticed a call light not in reach, she would educate the responsible staff member.

Based on observations, facility record review, and staff interview, the facility failed to ensure resident equipment is cleaned and in good repair for 1 of 1 residents (Resident #14) reviewed. The wheelchair belonging to Resident #14 was observed for 3 days to have food debris on the wheelchair frame, seat cushion and lap belt. The facility reported a census of 56 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], for Resident #14 revealed a diagnosis of Huntington's disease, muscle wasting and dependent on a wheelchair for mobility. The Care Plan for Resident #14 revealed an inability to ambulate, required the assistance of 1 staff member with the reclining wheelchair and required substantial assistance to eat. During an observation on 10/21/24 at 1:30 PM, Resident #14 while in his wheelchair, had what appeared to be dried food substances on the lap belt. During an observation on 10/22/24 at 9:06 AM, Resident #14 while resting in bed, had his wheelchair positioned next to the bed. The seat of the wheelchair contained food debris, that went down the sides of the wheelchair and onto the lap belt. During an observation on 10/23/24 at 9:25 AM, Resident #14's wheelchair noted to have the same dried food substance on the seat cushion and on the seatbelt. During an interview on 10/23/24 at 12:58 PM, Staff B, Certified Medication Aid, (CMA) stated staff would change their clothes after a meal, if it was dirty. Staff B stated the HS shift (overnight) cleaned wheelchairs according to a schedule. During an interview on 10/23/24 at 2:53 PM, Staff F, Certified Nursing Assistant (CNA) stated if the resident needed their wheelchair cleaned right away, it was everyone's responsibility to keep them clean. Staff F stated each hall has a scheduled time for night shift to scrub down the wheelchairs. A document titled night shift cleaning schedule by the nursing staff (10-6a shift) revealed wheelchair cleaning every night, all wheel chairs must be cleaned at least once a week. During an interview on 10/23/24 at 1:15 PM, The Director of Nursing (DON) stated the cleaning schedule document was a guide line during the down time on the night shift. She stated all wheel chairs should be cleaned and Resident #14's wheelchair got dirty so quick because of the way he ate.

Based on observation, clinical record review, family and staff interviews, the facility failed to develop a culturally competent care plan for 1 of 3 residents reviewed (Resident #36). The facility reported a census of 56 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], revealed diagnoses for Resident #36 included diabetes mellitus, chronic obstructive pulmonary disease and heart disease. The MDS identified Resident #36's preferred language as Spanish. The Brief Interview of Mental Status (BIMS) score of 4 out of 15 indicated a severe cognitive impairment. The Care Plan, Date Initiated: 2/19/24, included a Focus area to address The resident has an interpretation need. I am unable to read or write. Interventions included, in part: Interpreter needed Spanish Ph: [phone number redacted] ID# [ ID # redacted] Date Initiated: 4/11/24. Resident's preferred language is: Spanish (Mexico). Date Initiated: 2/19/24. The Care Plan Special Instructions notation documented Spanish speaking .Interpreter needed Spanish Ph. [phone number redacted] ID# [ID number redacted]. During an observation on 10/21/24 at 10:25 AM, Resident #36 was sitting in the dining room by self, frowning, with her head drooped. The resident did not participate in the activity occurring in the attached living room. During an observation on 10/21/24 at 1:16 PM, Resident #36 exited the shared bathroom, used walker to forcefully strike the floor and shouted in Spanish to her roommate, then walked to her bed to lay down. The roommate, Resident #55 stated that behavior happened daily and she felt awful as she was unable to speak Spanish. During an interview on 10/21/24 at 2:04 PM, a family member stated a couple of staff members speak Spanish and her mother liked Spanish music. The daughter expressed concern for mother not having needs met due to language barrier. During an interview on 10/24/24 at 11:00 AM, Staff T, Certified Nursing Assistant (CNA) stated she believed Resident #36 verbal aggressiveness had to do with the language barrier and people not understanding her. Staff T stated Resident #36 would ask for something in Spanish that staff could not understand. Staff T stated she would have some conversation, Enough to find out what she needs. Staff T stated Resident #36 would benefit from something directed toward her culture as she displayed signs of isolation, always in room, did not participate in activities. During an interview on 10/24/24 at 1:30 PM, the Director of Nursing (DON) stated Staff G, MDS Coordinator completed the Care Plans. During an interview 10/24/24 at 1:50 PM, Staff G stated she visited the facility 3 days a week to complete the Care Plans and the DON or Assistant Director of Nursing (ADON) would complete the changes to the Care Plans. Staff G stated the Social Services Director would create the culturally competent care plans in this facility. During an interview on 10/24/24 at 2:02 PM, Staff U, Social Worker stated she would complete the family history, advanced directives, guardian and the long term or short term to return home, That is all I do for the care plan.

Based on observations, clinical record review, and staff interviews, the facility failed to assist a resident with changing their clothing after food spilled on their pants and shirt during a meal (Resident #8) for 1 out of 3 residents reviewed. The facility reported a census of 56 residents. Findings include: The Minimum Data Set, dated dated [DATE], for Resident #14 revealed diagnoses of Huntington's disease, muscle wasting and anxiety disorder. The MDS identified the resident dependent on a wheelchair for mobility. The Care Plan, Date Initiated: 10/6/23, included a Focus area to address Activities for Daily Living (ADL's). Interventions included, in part; Eating - I am substantial assist x 1 (one staff), Upper Body Dressing - I am dependent assist x1, and Lower Body Dressing - I am dependent assist x 1 with a Date Initiated: 10/6/23. During an observation on 10/22/24 at 9:06 AM, Resident #14 assisted to his room by Staff S, Certified Nursing Assistant (CNA) after breakfast. Spilled food noted on Resident #14 shirt and pants. After exiting the room, Staff S stated staff assists Resident #14 to eat, and she provided pericare after assisting the resident to bed. Resident #14 dressed in same clothing after cares. During an observation on 10/22/24 at 1:10 PM, after lunch Resident #14 in bed. Resident wearing same shirt and pants, with additional food spilled from the noon meal. During an interview on 10/23/24 at 12:58 PM, Staff B, Certified Medication Aid, (CMA) stated staff should change a resident's clothes after a meal if it is dirty. During an interview on 10/23/24 at 2:53 PM, Staff F, CNA stated staff should change resident's clothes anytime they have food on them. I wouldn't want to walk around with food on my clothes and they shouldn't either. During an interview on 10/23/24 at 1:15 PM, the Director of Nursing (DON) stated her expectation was for the staff to change resident's clothes if dirty.

Based on observation, staff interview, and clinical record review, the facility failed to provide continued assessment for Resident #23 after an episode of excessive coughing caused by taking medications with a thin liquid, instead of the physician ordered nectar consistency liquid. The facility reported a census of 56 residents. Findings Include: The Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #23 scored a 4 out of 15 on a Brief Interview for Mental Status (BIMS) test, indicating severely impaired cognition. The MDS listed diagnoses included: aphasia (inability to swallow), cerebrovascular accident (CVA-interruption of blood flow to the brain leading to neurological issues), transient ischemic attack (TIA-a brief blockage of blood flow to brain), or stroke, and dysphagia (swallowing difficulties). The MDS identified Resident #23's with a Mechanically altered diet - required change in texture of food or liquids (e.g., pureed food, thickened liquids). The Oral/Dental Status of the resident indicated No natural teeth or tooth fragment(s). A review of the Care Plan Diagnosis section, revealed, in part, PNEUMONITIS DUE TO INHALATION OF FOOD AND VOMIT. A review of Physician Orders revealed an order, dated 4/27/23, for Regular/NAS (no salt added) diet. Level 4 Pureed texture, Level 2 Mildly Thick (Nectar) consistency. The Care Plan, updated on 10/22/2024, included a Focus area to address I am at increased nutritional risk d/t (due to) med dx (diagnosis) of severe protein-calorie malnutrition, dysphagia, underweight, HTN (high blood pressure), HLD (high cholesterol), GERD (gastroesophageal reflux disease, cause of heartburn). An Intervention included, in part: Regular diet, Puree texture, level 2 mildly thick Nectar thick liquids. Date Initiated: 10/27/23. Revision on: 7/8/24. During an observation on 10/23/24 at 8:02 AM, Staff A, Certified Medication Assistant (CMA) administered Resident #23's medications with regular, unmodified consistency water. After the administration, the resident began coughing significantly. Staff A retrieved nectar thickened water to assist Resident #23 with the coughing. Staff D, Licensed Practical Nurse(LPN), commented that Resident #23 was thickened liquids to which staff A replied I know. Staff D then commented she normally administered Resident #23's medications in pudding to prevent him from choking to which Staff A replied that she was not aware of that. Staff D then came over to Resident #23 and asked him if he was ok and wiped his nose and mouth with a tissue. Resident #23 continued to cough and had large amounts of drainage from his mouth and nose. Staff D observed Resident #23 at the nurse's station for approximately 3 minutes until he stopped coughing. The resident then continued down the hall to his room. During an interview on 10/23/24 at 8:13 AM, Staff A, CMA stated that she provided Resident #23 with non-thickened liquids. Staff A was aware that Resident #23 had a thickened liquid diet order but she was not aware that he normally received his pills with pudding. Staff A stated she normally mixed his Miralax (stool softener) with water to dissolve the Miralax and then added a thickened supplement to it afterwards but was running low on the supplement so she forgot to thicken the liquid. During an interview on 10/23/24 at 8:30 AM, Staff D, LPN stated that the pudding was just a personal preference for the resident and that she believed that the resident has had Speech Therapy change his liquid consistency several times. Staff D noted that there was an area on the electronic MAR that documented resident preferences that was put into place for agency staff. During an observation on 10/23/24 at 8:32 AM, Resident #23 while in his room, sat in his recliner. His face appeared bright red, and he had large amounts of secretions coming from his mouth and nose. When the State Agency (SA) asked the resident if he was ok, he shook his head no and pointed to his chest and stated he felt like something was stuck. The SA informed Staff D, LPN of the findings. Staff J, Director of Nursing (DON) and Staff K, Regional Director of Clinical Services (RDCS) accompanied Staff D into Resident #23's room. On 10/23/24 at 8:37 AM, Staff D, LPN brought in a basin and equipment for vital signs (thermometer, blood pressure cuff, pulse oximeter, stethoscope). Staff D listened to the resident's lung sounds on his back, and obtained a blood pressure, and temperature. The resident stated that he did not feel better. When Staff J, DON asked the resident if he felt short of breath, he shook his head no. On 10/23/24 at 8:42 AM., Staff J, DON asked the resident if he felt like he had something stuck in his throat and he responded yes. On 10/23/24 at 8:45 AM, the resident continued to have a cough and runny nose and stated he did not feel well. On 10/23/24 at 8:48 AM, Staff J, DON and Staff K, RDCS cleaned up the resident and asked him to take a deep breath and cough several times. At this time Staff J left the room and called the physician to notify him of the resident's status. On 10/23/24 at 8:53 AM, the resident took one drink of thickened liquids and began coughing. Staff K, RDCS stated to call the physician and Staff J, DON said that she had already called. The resident coughed up a large amount of secretions after he took one drink. On 10/23/24 at 8:54 AM, Staff D, LPN left the room for one minute and came back in with new orders from the physician for a two-view chest x-ray and orders for temperature and lung sounds every shift for the next three days. On 10/23/24 at 9:26 AM, via phone, Staff R Registered Dietician (RD) stated Resident #23 had an order for nectar thick liquid which was in place since April of 2023. She stated she would absolutely not be ok with him receiving thin liquids since he had dysphagia (difficulty swallowing) and could aspirate (inhale food or liquids into the lungs). On 10/23/24 at 9:53 AM, the resident sat in his recliner watching TV with no obvious signs of distress observed at this time. On 10/23/24 at 9:56 AM, the Certified Dietary Manager (CDM) stated Resident #23 had always received thickened liquids. On 10/23/24 at 10:39 AM, the DON stated residents should receive the ordered liquid consistency and Resident #23's order was nectar thick. She stated (after a coughing episode) she expected the nurse to complete a full respiratory assessment to include vitals, an oxygen level, and a check for cyanosis (blue color to the skin). She stated she expected the nurse to notify the provider and check on them every 15-30 minutes. She stated she expected staff to stay with him if they thought something was stuck (in the throat). On 10/30/24 at 12:35 PM, Staff N, Speech Therapist stated that she believed that Resident #23 was a high risk for aspiration as that was why he was ordered for a mechanically altered diet. He did not have any teeth and she recommended that he be provided with nectar thickened liquids at all times. 35434 The facility policy, revised February 2021, titled Change in a Resident's Condition or Status, Policy Interpretation and Implantation section, directed staff, in part, to: 1. The nurse will notify the resident's attending physician or physician on call when there has been: a. accident or incident involving the resident; d. significant change in the resident/s physical/emotional/mental condition; 2. A significant change of condition is a major decline or improvement in the residents status that: a. requires interdisciplinary review and/or revision of the care plan; 3. Prior to notifying the physician or healthcare provider, the nurse will make a detailed observation and gather relevant and pertinent information for the provider, including information prompted by the SBAR (Situation, Background, Assessment, Recommendation) communication form. 9. If a significant change in the resident's physician or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA (Omnibus Budget Reconciliation Act) - federal law aimed to improve quality of care in long term care facilities) regulations governing resident assessments and as outlined in the MDS RAI (Resident Assessment Instrument) Instruction Manual.

Based on observation, clinical record review and staff interviews, the facility failed to ensure safe wheelchair transport for 1 of 1 residents reviewed (Resident #12). The facility reported a census of 56 residents. Findings include: Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 scored 00 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. The MDS indicated the resident utilized a wheelchair for mobility, and had not attempted to self propel due to medical condition or safety concerns. Review of the Care Plan for Resident #12 dated 6/13/22, revised 6/6/23 revealed, I am at risk for falls. The Intervention dated 5/26/23 revealed, Keep my w/c (wheelchair) pedals off due to my like to self propel. An observation on 10/22/24 at 3:18 PM revealed Staff A, Certified Medication Aide (CMA) pushed Resident #12 while the resident's feet were off of the pedals of the wheelchair, and were below the level of the wheelchair pedals. On 10/22/24 at 3:21 PM, Resident #12 observed pedaling herself in her wheelchair in the common area. On 10/22/24 at 3:43 PM, Staff B, CMA observed assisting Resident #12 to move while the resident was in their wheelchair. One of the resident's feet observed to drag on the floor at the time of the observation. During an observation on 10/22/24 at 4:14 PM. Staff C, CNA (Certified Nursing Assistant)/CMA assisted Resident #12 from dining room while Resident #12 present in their wheelchair. The resident's feet were not on the wheelchair pedals, and both feet slid across the floor while the staff member assisted the resident. On 10/22/24 at 4:19 PM, Staff C observed assisting the resident back into the dining room, and the resident's feet slid across the floor not on the foot pedals. During an interview on 10/23/24 at 2:18 PM, Staff E, CNA queried about where feet were to be when assisting resident in wheelchair, and acknowledged on pedals. During an interview on 10/23/24 at 2:58 PM, Staff F, CNA acknowledged resident's feet should be no the foot pedals when resident assisted in wheelchair. During an interview on 10/24/24 at 3:32 PM, the Director of Nursing (DON) explained she had been given misinformation from the previous DON that staff could be present on the side to assist for residents who could self propel, and explained not allowed to do anything without foot pedals.

Based on clinical record review and staff interviews, the facility failed to revise a Care Plan to address the need for supervised visits, following an allegation of abuse perpetrated by a family member. (Resident #1) The facility reported census was 58. Findings include: According to a Minimum Data Set (MDS) with a reference date of 1/9/24, Resident #1 had a Brief Mental Status (BIMS) score of 15 indicating an intact cognitive status. Resident #1 required dependent assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #1's diagnosis included Cerebrovascular accident (stroke), left hemiplegia, atrial fibrillation and gastroesophageal reflux disease. In an interview on 4/8/24 at 1:37 p.m. the Director of Nursing (DON) stated on the evening of 1/7/24 he received a call from his overnight nurse (Staff A) reporting an allegation made by Resident #1, that bruising discovered on her right arm that evening was caused by her spouse grabbing her that day and telling her she was costing him too much money. Resident #1 stated her spouse can be mean. The DON stated he notified the police, the Department of Health and Human Services (DHS) and made a self report to the Department of Inspections, Appeals and Licensing (DIAL). The DON stated he then notified the spouse and informed him of the allegation and that he would be unable to visit. The DON stated the spouse stated Resident #1 was upset because he wouldn't take her home and stated she had made similar allegations when she was in the hospital. The DON stated the next day he called the hospital and spoke with a case manager, who confirmed Resident #1 had made an allegation of abuse by her spouse, but noted it was not substantiated. The DON stated they initiated supervised visits in which either a nurse or social worker would provide line of sight supervision while Resident #1 and her spouse visited in the dining room. The DON stated the intervention was in the care plan. The reviewed Nursing Assignment sheets dated 1/15/24 to 2/23/24 documented that the spouse and Resident#1 had supervised visits. In a follow up interview on 4/8/24 at 4:45 p.m. the DON stated following further review of the events, line of site supervision during visits was provided throughout the remainder of Resident #1's stay. The DON stated the supervision interventions were not added to the care plan or Kardex. Review of Resident #1's Care Plan found no interventions to address the need for supervised visitations following an allegation of abuse perpetrated by a family member.

Based on observation, clinical record review and resident and staff interviews, the facility failed to provide catheter cares, grooming and personal hygiene needs for 1 of 3 residents reviewed. (Resident #3) The facility census was 58. Findings include: The Admission Minimum Data Set (MDS) with a reference date of 3/17/24, documented Resident #3 had a Brief Mental Status (BIMS) score of 15 which indicated an intact cognitive status. Resident #3 required dependent assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #3's diagnosis included congestive heart failure, atrial fibrillation, renal insufficiency, arthritis and morbid obesity. The MDS documented that the resident had always been incontinent of urine and bowel. Resident #3 had a Foley catheter. During observations on 4/11/24 from 7:40 a.m. through 1:50 p.m. Resident #3 was not provided catheter care, grooming or personal hygiene services. Observation on 4/11/24 at 8:40 a.m. found Resident #3 sitting up in bed with her room tray on bedside table. Resident #3 stated staff assisted her up in bed this morning, but did not provide any peri cares or catheter cares. Resident #3 stated she was not feeling well and felt ignored. Resident #3 stated she requests bed baths because of her perineal sores and the Hoyer sling irritating them when transferred, but states she does not get them regularly and does not refuse baths. During an observation on 4/11/24 at 10:30 a.m. Resident #3 stated there has been no one this morning checking or cleaning her catheter or providing her peri cares, oral cares, grooming or change of clothes. Observation on 4/11/24 at 11:00 a.m. noted Resident #3 was receiving therapy at this time in her room. Was transferred from her bed into her recliner. Pleasant affect. Resident #3 stated she was wearing the same gown as she has for the past few days. Observation on 4/11/24 at 1:50 p.m. Resident #3 was transferred from her recliner back into bed by therapy staff. Resident #3 stated therapy staff are the only ones that can transfer her. Resident #3's catheter bag was emptied by aide. Resident #3 stated no one has cleaned her catheter tubing today or provided basic grooming needs like a wet cloth to wash her face or hands. Resident #3 stated she is still wearing her original brief that was put on her last night. In an interview on 4/15/24 at 8:53 a.m. the Director of Nursing (DON) stated staff are to provide activity of daily living cares, oral hygiene, dressing, grooming and preferably catheter cares in the morning of each day and as needed throughout their shift. Catheter care includes cleaning the tubing at least once a shift and as needed if it becomes visibly soiled. Cares should include offering a wash cloth to wash the resident's upper torso, face and hands, perineal care and a change into a fresh brief and clothing.

S483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; Based on clinical record review and staff interviews, the facility failed to ensure residents receive adequate services (bathing) to maintain their personal hygiene needs for 3 of 4 residents sampled. Review of bathing records of four sampled residents found three residents who were not provided bathing opportunities twice per week and two who chronically refused bathing. The facility failed to address the resident's refusals leading to personal hygiene needs being unmet. (Resident #1, #3, #5) The facility reported census was 55. Findings include: 1. According to a Admission Minimum Data Set (MDS) with a reference date of 8/27/23, Resident #1 had a Brief Mental Status (BIMS) score of 15 indicating an intact cognitive status. Resident #1 required extensive assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #1's diagnosis included renal insufficiency and diabetes mellitus. According to Resident #1's bathing records, he was scheduled to have baths on Mondays and Thursdays. Review of bathing records during his stay from 8/21/23 through 9/15/23 noted Resident #1 with 7 opportunities to bath. Resident #1 refused bathing 6 of those opportunities and one opportunity that was not recorded as offered on 9/11/23, indicating no baths, showers, whirlpools or bed baths were provided during his stay. Review of Resident #1's Care Plan found interventions with initiated date of 8/30/23 directing staff to ensure bathing opportunities twice weekly on Mondays and Thursdays, but found no interventions addressing Resident #1's refusals of bathing. 2. According to a Annual Minimum Data Set (MDS) with a reference date of 12/5/23, Resident #3 had a Brief Mental Status (BIMS) score of 12 indicating a moderately impaired cognitive status. Resident #3 required extensive assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #3's diagnosis included renal insufficiency, seizure disorder and chronic obstructive pulmonary disease and diabetes mellitus. According to Resident #3's bathing records, he was scheduled to have baths on Mondays and Thursdays. Review of bathing records 11/30/23 through 2/15/24 noted Resident #3 with 22 opportunities to bath. Resident #3 refused bathing 19 of those opportunities with one in which the bathing was recorded as not attempted (12/4/23), one that was not recorded as offered (1/22/24) and one opportunity in which a bath was provided (1/15/24). The record indicated Resident #1 only received one bath in 75 days. Review of Resident #3's Care Plan found interventions directing staff to ensure assistance of one staff with bathing, but found no interventions addressing Resident #1's chronic refusals of bathing. 3. According to a Quarterly Minimum Data Set (MDS) with a reference date of 11/12/23, Resident #5 had a Brief Mental Status (BIMS) score of 13 indicating a mildly impaired cognitive status. Resident #5 required extensive assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #5's diagnosis included congestive heart failure, obstructive uropathy, bipolar disorder and psychotic disorder. According to Resident #5's bathing records, she was scheduled to have baths on Tuesdays and Fridays. Staff indicated Resident #5 prefers whirlpools. Review of bathing records 10/3/23 through 11/28/23 noted Resident #5 with 17 opportunities to bath. Resident #5 did not have a recorded opportunity on 10/20/23 and 11/24/23. Review of Resident #5's Care Plan found interventions directing staff to ensure assistance of one staff with bathing. In an interview on 2/15/23 at the Assistant Director of Nursing (ADON) stated they usually have a shower aide during the day and showers scheduled in the evening are to be completed by aides working the floor. The ADON stated residents who refuse bathing will usually get reproached and if they still refuse, it is reported to the nurse who is expected to re-educate the resident. The ADON stated those who chronically refuse are offered bed baths. Physicians are notified and attempts to resolve refusals are explored.

Based on medication record review, staff interview and pharmacy recommendations the facility failed to ensure physician review for authorization to extend a psychotropic medication over fourteen (14) days or discontinue for 1 of 5 residents reviewed for unnecessary medications (Resident #8). The facility reported a census of 52 residents. Findings include: The Admissions Minimum Data Set (MDS) for Resident #8 documented a Brief Interview for Mental Status (BIMS) of 11 which indicated moderate cognitive impairment. The MDS further revealed the resident had diagnosis included cancer, malignant neoplasm of pancreas, chronic pain, anxiety and depression. The Care Plan initiated 8/17/23 documented Resident #8 used Clonazepam to manage anxiety. Interventions included pharmacy consultant to review medications monthly and make recommendations to physician as needed. The Medication Administration Record (MAR) documented start date of 9/13/23 for Resident #8 Clonazepam, one (1) milligram tablet by mouth every 8 hours as needed for generalized anxiety. The MAR lacked an end date for the psychotropic medication. The Progress Note dated 9/27/23 titled Pharmacy consultant review recommended a stop date for Clonazepam PRN referring to the as needed order initiated 9/13/23. The Director of Nurses (DON) acknowledged on 10/5/23 at 10:03 AM that the Clonazepam ordered as needed for anxiety is a psychotropic medication should have been discontinued within fourteen days without physician orders to rationalize the extension. The DON acknowledge the pharmacy recommendation was not addressed. The Facility assessment dated [DATE] documented under medications care and practices included, awareness of any limitations of medication. The facility did not provide a specific policy for psychotropic medications.

Based on observation, record review, resident interview and staff interview. The facility failed to provide a therapeutic diet for 1 of 1 resident reviewed on therapeutic diets (Res. #44). The facility reported a census of 52. Findings include: The Admission Minimum Data Set (MDS) for Resident #44 documented a Brief Interview for Mental Status (BIMS) of 10 which indicated moderate cognitive impairment. The MDS further revealed the resident diagnoses included heart failure, renal disease and liver cirrhosis. The Care Plan initiated 8/10/23 directed a diet order for modified renal diet, regular texture, thin liquids. Interventions included provisions of meals within the diet, monitor tolerance of the diet and dietician review of the diet. Physician order dated 8/10/23 documented diet type as modified renal diet. Record review of the menu for 10/3/23 revealed main entree, ham and bean soup. The menu signed by the registered dietician documented ham and bean soup as unsuitable for the modified renal diet and directed an egg salad sandwich substitute. The menu also directed an alternate option of a baked chicken breast for the modified renal diet. On 10/3/03 at 11:30 AM Staff A prepared resident #44 meal that included the ham and bean soup. Staff A relayed the alternative choice on the menu is chicken and relayed they did not have the chicken to offer as a substitute. Record review of the menu for 10/4/23 revealed meatloaf with creamed potatoes and peas. The menu signed by the registered dietician directed alternative for modified renal diet of buttered noodles instead of potatoes and green peas. On 10/4/13 at 12:00 AM the Resident #44 observed eating in the main dining room, plate did not have the modified renal diet alternative for potatoes. Resident's plate included mashed potatoes and carrots with meat loaf. The Dietary Manager (DM) relayed the cooks are instructed to follow individual diet orders and to alert the DM if any issues with food alternatives. The DM acknowledged the physician ordered renal diet was not followed for Resident #44 and the Resident #44 was not given a choice on alternatives. On 10/4/23 at 4:45 PM The administrator acknowledged the cook should have followed the physician ordered meals ordered. The facility policy titled Therapeutic Diets revised October 2017 documented therapeutic diets are prescribed to support the resident's treatment and plan of care and in accordance with his or her goals and preferences.

Based on facility record review, clinical record review, and staff and physician interviews, the facility failed to provide ongoing assessments after observing signs of poor circulation in a foot for 1 of 3 residents reviewed (Resident #5). The facility reported a census of 54 residents. Findings include: The Admission Minimum Data Set (MDS) assessment tool dated 10/21/21 showed Resident #5 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required extensive assistance of staff for transferring, dressing, and hygiene. The Brief Interview for Mental Status (BIMS) scored 4 indicating severely impaired cognition. The Care Plan, dated 12/27/21, documented the resident had an alteration in musculoskeletal status related to right foot drop and needed a right AFO brace (a brace to support the resident's foot in a natural position) placed prior to all transfers. On 12/28/21, a Physical Therapy Treatment Encounter Note revealed Resident #5 cried out in pain when the PTA (Physical Therapist Assistant) scooted the resident's right foot back for proper foot placement. The PTA removed the resident's sock and shoe and observed her right foot to be purplish in color with the foot, ankle, and calf swelling (a potential sign of tissue injury, including blocked arteries). Therapy notified Staff F, Licensed Practical Nurse (LPN). On 12/28/21 at 3:59 p.m., A Progress Note by Staff F, LPN, documented Resident #5 had 2 toes with a blue hue and poor circulation (a potential sign that Resident #5 had blocked arteries in their leg). The note indicated that Staff F added the concern about Resident #5's toes to a list of concerns for the physician to review the next time the physician came to the facility to provide care to residents. Staff F also encouraged Resident #5 to move their right leg. On 12/31/21, a Physical Therapy Treatment Encounter Note recorded the PTA assessed Resident #5's feet and legs when Resident #5 grimaced while the PTA assisted Resident #5 with the placement and removal of the AFO brace and shoes. The nursing staff was aware that Resident #5 had 2 toes which were dark in color (a sign Resident #5 potentially had blocked arteries in their leg). Review of Resident #5's medical record, from 12/28/21 through 1/3/22, revealed the medical record lacked any nursing documentation regarding Resident #5's right foot, especially regarding the appearance or assessment of Resident #5's right foot. Review of the Physical Therapy Treatment Encounter Notes revealed therapy staff did not work with the resident on 1/1/22 or 1/2/22. On 1/3/22, a Physical Therapy Treatment Encounter Note documented Resident #5 complained of pain when therapy staff moved Resident #5's right foot and Resident #5 did not want to bear weight on their right foot. The PTA removed the resident's right sock and shoe and observed the plantar/dorsal (bottom/top) areas of Resident #5's right foot discolored a dark purple. The second and third toes appeared purplish/black (late signs of possible arterial blockage), and the underside of Resident #5's foot contained blisters. On 1/3/22 at 11:42 a.m., a Progress Note by Staff E, Registered Nurse (RN), described Resident #5's right foot as extremely blue, cold, and without palpable pedal pulses (emergent signs of arterial blockage, indicating the foot was not receiving blood flow). The facility staff transferred Resident #5 to the Emergency Department (ED) for further evaluation of Resident #5's right foot. On 1/3/22, the ED Physician Record noted Resident #5 had several black toes with ulcerations and redness noted to the right leg. A Computed Tomography [MEDICATION(S)] (CTA-a CT scan with injection of dye), showed complete blockage of the right iliac, femoral, and popliteal arteries (the major arteries in Resident #5's right leg). The ED Physician's clinical impression included gangrene (death of body tissue due to a lack of blood flow). The ED staff transferred Resident #5 to a second hospital so that a vascular surgeon specialized in treating blocked arteries could evaluate Resident #5 and determine if they could save Resident #5's toes. The hospital Discharge Summaries, dated 1/7/22, listed the reason for admission as critical limb ischemia (blocked blood flow to Resident #5's right leg) and the principal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The vascular surgeon's note indicated that the damage to Resident #5's right foot was likely irreversible. The vascular surgeon discussed the possibility of amputating parts of Resident #5's right foot, but Resident 5's family declined surgery and instead opted to place Resident #5 in hospice care. On 8/24/22 at 3:40 p.m., Staff D, LPN, stated when nursing monitored concerns, they triggered hot charting in the Progress Notes (additional focused charting kept separate so the nursing staff will document more frequently). Staff D did not recall receiving any information about Resident #5's discolored toes, either through nurse-to-nurse report or a staff member reporting a concern to Staff D. If the patients expressed pain to the therapy staff, the therapy staff would notify the nursing staff. On 8/24/22 at 3:42 p.m., Staff G, Certified Nurse Aide (CNA) could not recall any circulation concerns or discolored toes on Resident #5. On 8/24/22 at 3:53 p.m., Staff H, RN, did not recall hearing anything about Resident #5's discolored toes in nurse-to-nurse report prior to the nursing staff sending Resident #5 to the hospital. On 8/24/22 at 5:15 p.m., Staff I, CNA, reported seeing a purple area on the top of Resident #5's foot that had not been there the day prior. Staff I recalled telling the nurse but did not work with the resident after that day. On 8/24/22 at 7:48 p.m., Staff E, RN, felt the poor circulation documented on 1/3/22 came on abruptly. She could not recall hearing anything in shift-to-shift report. On 8/25/22 at 8:38 a.m., Staff J, CNA, could not recall the resident or any discolored feet/toes. On 8/25/22 at 8:56 a.m., Staff K, CNA, described the resident as being cold a lot and but could not recall seeing or hearing about any foot discoloration. The resident wore gripper socks and usually slept in the gripper socks. On 9/6/22 at 9:25 a.m., the Director of Nursing indicated they expected that if the nursing staff received a report of discolored toes or discovered a resident with discolored toes, the nursing staff should check the resident's discolored toes every shift and that the physician would follow-up on any concerns. The nurse practitioner or physician rounded 3 days a week and so they should have seen Resident #5 within a couple of days of the nursing staff writing the progress note on 12/28/21. On 9/7/22 at 8:30 a.m., Resident #5's Primary Care Physician (PCP reported being in the facility on 12/30/21 (2 days after the therapy and nursing staff identified possible concerns with the circulation in Resident #5's foot), but Resident #5's PCP did not see Resident #5 on 12/30/21. Neither Resident #5's PCP, nor Resident #5's PCP's Nurse Practitioner, saw or documented any notes regarding Resident #5's right foot during the 12/30/21 visit. Resident #5's PCP did not believe the nursing staff informed Resident #5's PCP about the concerns regarding Resident #5's foot discoloration. Given Resident #5's history of poor blood flow to their feet and dark, purplish appearing skin on Resident #5's feet, Resident #5's PCP would not have paid much attention to a report of Resident #5 experiencing skin discoloration, unless the resident experienced pain (Resident #5 had pain in their feet, starting on 12/28/21) or the development of sores (Resident #5 developed blisters, a potential start of a sore, on 1/3/22). Resident #5's PCP expected the nursing staff to continue to monitor Resident #5's right foot if they identified concerns and notify Resident #5's PCP of any changes (such as Resident #5 developing blisters on 1/3/22). The facility's Charting and Documentation Policy, revised July 2017, indicated that any changes in the resident's medical, physical, functional, or psychosocial condition shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.

Based on clinical record review, staff interview, CNA job description, and observation, the facility failed to speak to and treat residents in a dignified manner for 3 of 7 residents reviewed (Residents #1, #2, and #3). The facility reported a census of 54 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] listed dementia and [CONDITION(S)] as diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan, dated 8/8/19 stated Resident #3 had impaired cognitive function or thought process and had difficulty expressing herself so needed plenty of time to get words out and reassurance and support if upset. An observation on 8/15/22 at 12:00 p.m. revealed the resident in a wheelchair eating independently. The resident did not respond to any questions. A facility Incident Report dated 7/23/22 at 9:59 p.m. stated Staff A, Certified Nurse Aide (CNA) reported that on 7/22/22 around 11:30 pm, Resident #3 began yelling out Mommy. Staff A heard Staff B, CNA, respond to the resident by screaming, Just shut up. Shut the [OBSCENITY] up. 2. The Quarterly MDS assessment dated [DATE] listed dementia and difficulty in walking as diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan, dated 7/21/22 stated Resident #1 had impaired cognition function or thought process and needed consistent, simple, directive sentences. The resident needed assistance of one staff with a walker for walking. An observation on 8/15/22 at 12:05 p.m. revealed Resident #1 seated in her recliner, wheelchair and walker nearby. Resident #1 could not appropriately answer questions due to confusion. A facility Incident Report dated 7/23/22 at 9:59 p.m. stated Staff A, CNA reported hearing Staff B, CNA, gasp loudly as if she had been startled seeing Resident #1 ambulating toward the dining hall. Staff A witnessed Staff B roughly grab the resident's arm and start pushing the resident towards her room yelling loudly, Go to your room! 3. The Quarterly MDS assessment dated [DATE] listed non-traumatic [CONDITION(S)] as a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan, dated 10/27/21, stated Resident #2 needed assistance with personal hygiene. An observation on 8/15/22 at 11:00 a.m. revealed resident walking independently up and down the halls and not acknowledging any comments or questions. A facility Incident Report dated 7/24/22 at 1:23 p.m. stated a Staff B, CNA, reported during cares that her fingernails scratched the front of Resident #2's right shoulder. Another CNA present stated the CNA's nails, noted to be long and sharp, had scratched the resident's shoulder. On 8/22/22 at 12:35 p.m., Staff A, CNA, stated on 7/22/22 a little before midnight, Resident #3 began moaning Mommy and continued this for over an hour. Staff B, CNA, then went into the resident's room and yelled, Just shut up. Shut the [OBSCENITY] up. A couple of hours later, around 1:30 a.m., Staff A reported she heard Staff B gasp she saw Resident #1 walking unassisted in the hall. Staff A then observed Staff B grab Resident #1's upper arm roughly, and pulling her towards her room, loudly say, Go back to your room right now. On 8/23/22 at 12:00 p.m., Staff C, CNA, stated she reported concerns to her charge nurse that Resident #2 had what appeared to be new scratch marks on him. Staff C noted these marks when she went into Resident #2's room the beginning of the day shift, approximately 10-15 minutes after Staff B, CNA, had left the room on 7/23/22. A Job Description for Certified Nursing Assistant signed by Staff B on 12/6/21 stated functions: a. respond to inappropriate or maladaptive behaviors exhibited by residents in a manner consistent with the care plan or established procedures, and which safeguards resident rights. b. follow residents' rights policies at all times. c. control emotions and behavior so as to protect residents' rights and to respond professional with respect and dignity.

Based on clinical record review, policy review, and staff interview, the facility failed to provide accurate assessment and intervention for 3 of 5 sampled (Residents #1, #2 and #5). The facility failed to ensure residents consumed a meal after staff administered insulin for Resident #1 and Resident #2 and failed to recheck abnormal blood glucose levels for Resident #1, #2 and #5. On 10/17/21, Resident #2 did not eat lunch after the staff administered insulin and his blood glucose level dropped to 38 milligrams/deciliter (mg/dl). The facility lacked documentation staff offered the resident additional food to eat. On 5/11/21, Resident #1 did not eat breakfast or lunch and the nurse administered morning and noon insulin. Resident #1's blood glucose level dropped to 30 mg/dl and required two injections of [MEDICATION(S)]. The facility lacked documentation of physician notification following the [MEDICATION(S)] injections. Resident #1's blood glucose level dropped again in the evening and required Emergency Medical Services to intervene as the facility lacked additional [MEDICATION(S)]. This resulted in Immediate Jeopardy. The facility failed to provide adequate assessments and intervene for Resident #1 and Resident #2's wounds. The facility reported a census of 41 residents. Findings: 1. The Minimum Data Set (MDS) assessment dated [DATE] listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS stated the resident required extensive assistance of 2 staff for bed mobility, transfers, dressing, toilet use, and personal hygiene, and depended completely on 1 staff for bathing. The MDS listed the resident's cognition as severely impaired. The Care Plan dated 2/8/18 documented Resident #1 had diabetes and received insulin and directed the staff to administer diabetes medication and monitor for side effects and effectiveness. The May 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The May 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The record lacked documentation to reflect the staff rechecked Resident #1's blood glucose level to determine the effectiveness of the insulin. The Weights and Vitals Summary dated 5/11/21 6:21 a.m., revealed Resident #1 had a blood glucose level of 103 mg/dl. The May 2021 Documentation Survey Report V2 documented Resident #1 consumed 0-25% of her food at breakfast and lunch. The May 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The Progress Notes dated 5/11/21 revealed the following: a. At 1:15 p.m., Resident #1 in bed sleepy, not talking to staff, and had a blood glucose level of 30 mg/dl. Staff administered [MEDICATION(S)] (injectable medication treat low blood glucose levels). b. At 12:45 p.m., Resident #1 had a blood glucose level of 30 mg/dl. c. At 1:00 p.m., blood glucose level of 37 mg/dl. Staff administered a second dose of [MEDICATION(S)] due to the blood glucose level not increasing above 40. d. At 1:30 p.m., Resident #1 had a blood glucose level of 67 mg/dl. e. At 3:15 p.m., Resident #1 sleepy, blood glucose level 82 mg/dl, and she took a few sips of liquacel (nutritional supplement). f. At 6:00 p.m., Resident #1 had a blood glucose level of 27 mg/dl and the facility obtained an order from the Nurse Practitioner to transfer Resident #1 to the emergency room . g. At 6:38 p.m., an ambulance arrived and treated Resident #1 for low blood glucose level. Resident #1 had a blood glucose level of 164 mg/dl and transferred to the hospital. The Clinical Record lacked documentation to reflect the staff notified the Physician of Resident #1's low blood glucose levels and Resident #1 received [MEDICATION(S)] from 3:15 p.m. until 6:00 p.m. The Discharge Summary (Hospital) dated 5/21/21 documented Resident #1 had a blood glucose level of 26 mg/dl at the facility and Emergency Medical Services treated and transferred to the emergency room . Resident #1 lethargic and barely communicative. The undated Summary Chart for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The procedure directed staff to provide a snack once the blood sugar was 100 mg/dl or higher. During a phone interview on 6/2/21 at 4:04 p.m., the Director of Nursing (DON) stated on the morning of 5/11/21, Staff G cared for Resident #1 and Resident #1 had a blood glucose level of 100 mg/dl. Staff G administered Resident #1's morning [MEDICATION(S)] (64 units) and noon [MEDICATION(S)] (64 units). The DON stated there was a concern because Resident #1 did not eat very much and Staff G administered Resident #1's insulin in the morning and again at noon. The DON stated if the resident's blood glucose level was 100, even though that was not really low, if the resident did not eat, she would have held her morning insulin. She stated the nurse received education and the facility set parameters for giving insulin so this did not occur again. During a phone interview on 6/2/21 at 4:17 p.m., Staff G (Licensed Practical Nurse) stated on 5/11/21, the Nurse Aides did not inform her that Resident #1 did not eat breakfast and stated she administered her morning [MEDICATION(S)] and her noon [MEDICATION(S)]. She stated after the noon dose of [MEDICATION(S)], her blood sugar was subsequently 30 mg/dl so she received [MEDICATION(S)]. She stated the Nurse Aides documented meal intakes and she did not realize Resident #1 did not eat. During a phone interview on 6/3/21 at 8:29 a.m., the DON stated she did not see documentation of physician notification in Resident #1's chart regarding the administration of the [MEDICATION(S)] on 5/11/21. She stated the earliest note she saw was at 5:30 p.m. She stated the staff should notify the physician of the administration of [MEDICATION(S)]. She stated the facility had 2 doses of [MEDICATION(S)] and the resident utilized them both but stated in the future, the facility planned to stock [MEDICATION(S)] for all residents. She stated she did not know if anyone notified the pharmacy of the need to replenish the [MEDICATION(S)] after staff administered it on 5/11/21 but stated she would check. According to the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record lacked documentation to reflect the staff rechecked Resident #1's blood glucose reading and if the insulin was effective. The State Agency informed the facility of the Immediate Jeopardy on June 6/3/21 at 10:00 a.m. The facility removed the Immediate Jeopardy on June 3, 2021 by providing staff education on insulin administration parameters for diabetic residents for physician notification, implemented a system for establishing blood glucose parameters for newly admitted diabetic residents, reviewed all diabetic residents for appropriate blood glucose parameters, pharmacy to provide additional education for insulin administration, and staff education for use of [MEDICATION(S)] including physician notification and follow up. The scope lowered from J to D at the time of the survey after ensuring the facility implemented their policy and procedure. 2. DIABETIC CARE: The MDS assessment dated [DATE], listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS stated the resident required extensive assistance of 2 staff for bed mobility, transfer, dressing, toilet use, and personal hygiene, and depended completely on 1 staff for bathing. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. Care Plan dated 9/14/20 documented Resident #2 utilized insulin related to diabetes and directed staff to monitor for side effects and effectiveness. The Progress Note dated 10/17/20 9:08 a.m., revealed Resident #2 refused the facility breakfast and his wife was bringing him 2 breakfast sandwiches. The Progress Note dated 10/17/21 10:04 a.m. revealed Resident #2 ate 1 plain biscuit. The October 2020 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The Progress Noted dated 10/17/21 2:06 p.m., documented Resident #2 refused lunch because he didn't like it. The facility lacked documentation staff offered the resident something different to eat and lacked documentation of a blood sugar check completed after the resident refused to eat after he received insulin. The Progress Note dated 10/17/21 3:02 p.m., document Resident #2's wife called and stated the resident had slurred speech and requested a blood glucose check. Resident #2 had a blood glucose level of 38 mg/dl at 2:45 p.m. and the nurse gave the resident orange juice and a peanut butter sandwich. At 3:00 p.m., Resident #2 had a blood glucose level of 64 mg/dl. The Progress Note dated 10/17/21 4:15 p.m., revealed the resident told the nurse not to give insulin to someone until after they ate. 3. DIABETIC CARE: The MDS assessment dated [DATE] listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS stated the resident required limited assistance with dressing and toilet use and listed the resident's BIMS score as 14 out of 15, indicating intact cognition. The May 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 5/7/21, the resident's blood sugar was 491 mg/dl at 4:11 p.m. A 5/7/21 5:43 p.m. nursing note stated the resident's blood sugar was 332 mg/dl. The facility lacked further documentation of an additional blood sugar check completed. b. On 5/8/21, the resident's blood sugar was 386 mg/dl at 4:13 p.m. and the entry on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility lacked documentation of an additional blood sugar check completed. c. On 5/11/21, the resident's blood sugar was 425 mg/dl at 4:28 p.m. and 7:35 p.m A 5/11/21 10:29 p.m. nursing note stated the resident's blood sugar was 375 mg/dl. The facility lacked further documentation of an additional blood sugar check completed. d. On 5/12/21 at 4:29 p.m., the resident's blood sugar was 483 mg/dl and at 7:53 p.m., it was 425 mg/dl. A 5/1/21 10:18 p.m. nursing note stated the resident's blood sugar was 342 mg/dl. The facility lacked further documentation of an additional blood sugar check completed. Care plan entries, dated 6/28/18, stated the resident had diabetes and received insulin. The entries stated the resident would have no complications related to diabetes and directed staff to monitor for and document the side effects and effectiveness of the medication. The facility policy Blood Glucose Monitoring, dated January 2015, stated each resident should have individualized high and low parameters designated for physician notification. The facility policy Change of Condition/Hot Chart Protocol, dated January 2015, stated a condition change was a change from normal status and directed staff to notify the physician as appropriate The facility policy General Wound and Skin Care Guidelines dated January 2015, directed staff to carry out wound treatments and inform the physician of any changes in wound status. During an interview on 5/24/21 at 11:22 a.m., Staff H RN stated she would always recheck a blood sugar if it was over 400 mg/dl. During an interview on 5/24/21 at 2:37 p.m. the DON stated staff should notify the physician if they administered sliding scale insulin and the blood sugar did not decrease to under 300 mg/dl. She stated if a resident did not eat after giving insulin, staff should follow up. She stated staff should ensure residents ate when they received insulin. During an interview on 5/25/21 at 11:20 a.m., the DON stated she did not locate any additional documentation regarding assessment and intervention of the above resident's abnormal blood sugars or skin treatments. The Nurse Consultant was present during this interview and stated the facility created parameters for all residents on insulin for staff to follow. During an interview on 6/1/21 at 12:17 p.m., the DON stated it was her expectation staff should complete wound care per the orders and document this. 4. WOUND CONCERN: A Skin Evaluation: Non-Pressure sheet dated 4/13/21 revealed Resident #1 had a wound on the back of the right ankle which measured 5.6 cm(centimeters) x 4.8 cm x 0.2 cm(length x width x depth). The April 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A 4/15/21 physician's visit note stated the resident went to the ER due to pain associated with RLE (Right Lower Extremity) arterial disease. A 4/16/21 10:27 a.m. nursing note stated the resident had odorous green/brown drainage to the RLE. A 4/20/21 Wound Evaluation stated the resident had an area on the right heel 5.03 cm x 4.7 cm x 0.5 cm and it was deteriorating. A 4/24/21 9:56 a.m. nursing note stated the resident had an Unna boot(a compression dressing made of layers of gauze) in place to the RLE and stated staff changed the boot due to multiple wounds draining green drainage. A 4/27/21 Wound Evaluation stated the right heel wound was 5.83 cm x 6.06 cm x 0.3 cm. A 5/4/21 Wound Evaluation stated the right heel wound was 6.79 cm x 6.7 cm x 0.4 cm and was deteriorating. A 5/9/21 9:40 a.m. nursing note stated the resident's RLE had a large amount of green drainage and a foul odor. A 5/11/21 Wound Evaluation stated the right heel wound was 6.81 cm x 5.27 cm x 0.5 cm and had exposed tendon. The facility lacked documentation of physician notification of the drainage and foul odor to the RLE on 4/16/21, 4/24/21, and 5/9/21 and lacked documentation of physician notification of the wound increasing in size and deteriorating during the time frame of 4/13/21-5/11/21. A 5/11/21 6:38 p.m. nursing note stated the resident went to the emergency room for low blood sugar. A 5/12/21 hospital Consultation report stated the resident's right lower extremity had necrotic(dead) tissue as well as maggots within the wound itself. A 5/21/21 hospital discharge summary stated the resident was septic (having harmful microorganisms in the blood) and had wounds to the RLE positive for proteus mirabilis and citrobacter (types of bacteria). The note stated the resident's wounds were debrided (the removal of tissue or foreign objects from a wound) by surgery and the resident received antibiotics. A 2/9/18 care plan entry stated the resident had a pressure injury to her right lower extremity previously diagnosed as peripheral arterial disease. A 2/4/8 entry stated the resident's skin integrity would improve and an 11/2/17 entry directed staff to monitor the resident's skin and report any concerns to the nurse. During an interview on 5/24/21 at 11:22 a.m., Staff H RN (Registered Nurse) stated Resident #1's wounds had dark green and brown drainage and an odor. She was not sure if the physicians knew about this but stated they should have. During an interview on 5/24/21 at 2:37 p.m., the DON stated if a resident's wound had green drainage, staff should notify her or the physician. During an interview on 5/25/21 at 11:46 a.m., Staff A (Nurse Aide) stated Resident #1's leg wounds would leak through the bandage every day to her bed. He stated the drainage smelled and was greenish yellow. During a phone interview on 6/2/21 at 8:35 a.m., the surveyor requested the DON provide all provider notifications of Resident #1's wound status for April and May 2021. On 6/2/21 at 3:11 p.m. and 4:38 p.m., the DON sent the surveyor documents via email regarding Resident #1 including physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . During a phone interview on 6/3/21 at 12:21 p.m., Staff I (Doctor of Osteopathic Medicine) stated he would want to know if a wound had green drainage and if staff did not notify the physician, it could cause more of an infection. 5. WOUND CONCERN: Nursing Skin Evaluation: Non-Pressure sheet dated 9/30/20, revealed Resident #2 had 1 centimeter (cm) by 1 cm area of moisture induced excoriation with a pink/red wound bed on the left side of his anus. A 10/6/20 Nursing Skin Evaluation: Non-Pressure, stated excoriation to the left buttock remained. A 10/13/20 Nursing Skin Evaluation: Non-Pressure stated excoriation to the left buttock remained and the current treatment would continue. A 10/20/20 Nursing Skin Evaluation: Non-Pressure stated excoriation to the left buttock remained and the current treatment would continue. The October 2020 Treatment Administration Record (TAR) listed a 9/30/20 order for [MEDICATION(S)] barrier film to the left side of the anus twice daily and prn until healed. The TAR documented the resident received the medication until 10/13/20 but lacked documentation of a treatment to the area carried out from 10/14/20-10/22/20(the resident's discharge). The facility lacked documentation the resident received any additional medication to the anal/buttock area from 10/14/20 until his discharge on 10/22/20. A 10/22/21 nursing note stated the resident discharged from the facility. Care plan entries, dated 9/30/20, stated the resident had an open area near the anus and directed staff to apply barrier cream to the buttocks/ anus as needed due to incontinence related excoriation.

Based on record review, observations, and staff interviews, the facility failed to ensure the resident environment remained as free from accident hazards as possible for 2 of 12 residents sampled (Residents #3 and #7). Specifically, the facility failed to implement a system to ensure gaps in side rails were not large enough to create the risk for entrapment for Residents #3 and #7. The failure to ensure the side rails did not have a large gap which the resident could become entrapped put Residents #3 and #7 at risk of serious injury, impairment, or death due to entrapment within the gap, placing the residents in immediate jeopardy. The facility reported a census of 55 residents. Findings include: 1. Review of the Food and Drug Administration's (FDA) Hospital Bed Safety Workgroup article, Clinical Guidance For the Assessment and Implementation of Bed Rails In Hospitals, Long Term Care Facilities, and Home Care Settings, dated [DATE], indicated, in pertinent part, .Use of bed rails should be based on patients' assessed medical needs and should be documented clearly and approved by the interdisciplinary team .Bed rail use for patient's mobility and/or transferring, for example, turning and positioning within the bed and providing a hand-hold for getting into or out of bed, should be accompanied by a care plan .Inspect, evaluate, maintain, and upgrade equipment(beds/mattresses/bed rails) to identify and remove potential fall and entrapment hazards and appropriately match the equipment of patient needs, considering all relevant risk factors .If it is determined that bed rails are required .The mattress to bed rail interface should prevent an individual from falling between the mattress and bed. Maintenance and monitoring of the bed, mattress, and accessories such as patient/caregiver assist items .should be ongoing . According to the FDA's Guidance for Industry and FDA Staff article, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, issued [DATE], For [AGE] years, FDA has received reports in which vulnerable patients have become entrapped in hospital beds while undergoing care and treatment in health care facilities. The term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. FDA received approximately 691 entrapment reports over a period of [AGE] years from [DATE] to [DATE]. In these reports, 413 people died , 120 were injured, and 158 were near-miss events with no serious injury as a result of intervention. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. Entrapments have occurred in a variety of patient care settings . An undated facility document entitled Bed Rails listed the following guidelines: 1. All residents will be evaluated for the appropriateness for use of bed rails prior to initiation on admission. 2. Ongoing use of bed rails will be evaluated quarterly, change in condition, and with change of equipment. 3. Evaluations will include risk of entrapment. 4. Risks and benefits of bed rail usage will be discussed with resident and family representative and informed consent will be obtained prior to usage. 5. Care Plan will address bed rail usage and reason for device. 6. Assure that the bed's dimensions are appropriate for the resident's size and weight. 7. Follow the manufacturer recommendations and specifications for installing and maintaining bed rails. The MDS(Minimum Data Set) assessment tool, dated [DATE], listed [DIAGNOSES REDACTED]. The MDS stated the resident required supervision and setup assistance for eating, limited assistance of 1 staff for bed mobility, and extensive assistance of 1 staff for transfers, walking, dressing, toilet use, personal hygiene, and bathing. The MDS stated the resident did not utilize a bed rail and listed the resident's BIMS(Brief Interview for Mental Status) as 8 out of 15, indicating moderately impaired cognition. The MDS stated the resident had 1 fall without injury since the previous assessment. A care plan entry, dated [DATE], stated the resident had 2 ,[DATE] side rails up to promote independence with bed mobility. The care plan stated the resident had falls on [DATE] and [DATE] and had difficulty walking and weakness. The resident's Side Rail Rationale Screen, dated [DATE], stated the resident: a. had an alteration in safety awareness related to cognitive decline b. had a history of [REDACTED].>c. had difficulty with balance or poor trunk control e. took medication that would require increased safety precautions f. expressed a desire to have the side rails up while in bed to promote independence An observation on [DATE] at 3:08 p.m. revealed the resident lying on the back in bed resting on his/her elbows. One side of the bed was against the wall and both sides of the bed had side rails up covering ,[DATE] of the length of the bed. An observation on [DATE] at 3:42 p.m. revealed the resident remained in bed with both side rails up. An observation on [DATE] at 3:53 p.m. revealed Staff E CNA(Certified Nursing Assistant) assisted the resident out of the bed. During an observation on [DATE] at 2:45 p.m., the surveyor was able to place her head completely through 2 vertical bars of the side rails in between the top bar of the side rail and the top of the mattress of the resident's bed. During an observation on [DATE] at 9:00 a.m., Resident #3's bed was outside with no mattress. The vertical slats of the bed measured 8 inches. The Maintenance Supervisor was present and concurred with the surveyor approximately how high a mattress would reach. The space between where the top of the mattress would be and the top rail measured 9 inches. A [DATE] facility document entitled Bed Evaluation revealed staff initials on the following dates: [DATE], [DATE], [DATE], and [DATE]. The form did not describe what the bed evaluation entailed. A facility document entitled Physical Plan Preventative Maintenance dated [DATE], stated the facility must conduct regular inspection of all bed frames, mattresses and bed rails, if any, as part of regular maintenance program to identify areas of possible entrapment. A facility Quality Improvement Project Plan, dated [DATE], stated all resident's beds would be assessed to ensure the side rail measurements were within the regulatory standards of 4 ,[DATE] inches and the facility would replace all beds with more than the allotted spacing. During an interview during initial tour on [DATE] at 1:45 p.m., the DON(Director of Nursing) stated the resident did not speak and was not interviewable. During an interview on [DATE] at 2:49 p.m., the DON stated she thought the gap between side rails should be no greater than 8 inches. She stated the facility did not have a physician's orders [REDACTED]. During an interview on [DATE] at approximately 3:30 p.m., the Nurse Consultant stated the facility removed the resident's bed. During an interview on [DATE] at 10:47 a.m., Staff H CNA(Certified Nursing Assistant) stated she saw the resident scoot down in bed to the end but did not see the resident attempt to crawl over the side rails. During an interview on [DATE] at 10:51 a.m., Staff G CNA stated she saw the resident sit up in bed but did not see him/her attempt to get out of bed. During an interview on [DATE] at 9:57 a.m., the Maintenance Supervisor stated he thought the requirements for the bed rail measurements were to be no greater than 8 inches between bars. He stated he started measuring the bed rails around the beginning of the year and was using 8 inches as the guideline. 2. The Quarterly Minimum Data Set (MDS- a federally mandated resident assessment tool) with an assessment reference date of [DATE] revealed a BIMS (Brief Interview of Mental Status) of 3 which indicated severe long and short term memory deficits. Resident # 7 required extensive assistance from 2 staff for bed mobility, transfers, dressing, personal hygiene, and toilet use. The MDS documented complete incontinency of both bowel and bladder. The resident only understood verbal communications and could reply appropriately on a limited basis. The assessment documented height and weight as 4 foot 8 inches and 122 pounds. Active [DIAGNOSES REDACTED]. The plan of care with a problem onset date of [DATE] directed facility staff to supply the resident with a pressure reduction mattress and 2 half side rails to promote independence and bed mobility. Resident # 7 became a Hospice patient for comfort cares on [DATE]. The facility's Side Rail Rational Screen with an assessment date of [DATE] indicated side rails would provide safety and promote independence of movement for the resident. Resident # 7's poor visual acuity and decreased hearing complicated communication and understanding. A fracture to the right ankle and decline in overall function increased the risk of falls. The plan of care documented only 1 staff person needed to assist with transfers and personal cares. The Fall Risk Assessment completed on [DATE] revealed a score of 16. A score of 10 or above indicated a high risk for falls. An observation on [DATE] at 12:10 P.M., found Resident # 7 in bed with the head of the bed elevated approximately 30 degrees. The resident laid on the left side. A Hospice representative sat in a chair by the head of the bed. A tan overlay air pad could be seen over the mattress on the bed. On [DATE] at 12:25 P.M., Staff I and Staff J (certified Nursing Assistants) provided cares for Resident # 7 and positioned the resident on the right side with a body pillow behind, and the head of the bed up approximately 30 degrees. At 1:05 P.M. on [DATE], Staff J repositioned the resident higher in bed (slid down) on his/her back and rolled the bed up to the 60 degree range. This placed the resident's head 18 to 20 inches from the top of the mattress. Around 1:10 P.M., as Staff J attempted to give the resident nourishment, this Surveyor sat on the right side of the bed by the upper side rail. Resident # 7's eyes unfocused and calling for mom and dad. The upper half bed rail measured approximately 2 foot horizontally and 1 foot 6 inches vertically with the upper bars 4 inches apart and the lower bar to the mattress/frame 7.5 inches. A tan overlay air pad laid on top of the mattress and raised the resident approximately ,[DATE] to 1 inch. The head of the bed touched the wall and the sides extended out into the room. Observations of the dark blue/black mattress at the half way point between the upper and lower rail from top of the bed to the bottom displayed a worn and frayed area brown in color and approximately 8 inches wide. The raised upper half rail angled higher at the center point of the bed where the mattress bends when the head of the bed is raised. When the head of the bed is raised, the blue/black mattress crushed down to around a half inch in depth. The area where the mattress met the bend of the bed when raised to the 60 degree range left a gap under the lowest bed rail bar to the mattress of 7.5 inches by 10 inches from the end of the bed rail (toward the center of the bed) to the mattress angles upward to form a V shape opening. A review of the medical record nursing notes of [DATE] and [DATE] revealed: [DATE] at 12:10 P.M., Resident # 7's bed in high fowler position (60 to 90 degrees for the head of the bed). The resident's wrists and hands twitching. [DATE] at 1:30 P.M. The bed still is the high fowler position. [DATE] at 08:30 A.M., the resident repositioned and the head of the bed left in a high fowler position. [DATE] at 11:30 A.M., Resident # 7 yelling and restless. The restlessness continued through 12:30 P.M. A more recent Safe Bed Environment Evaluation form dated [DATE] (due to a bed change) provided an assessment of factors including the resident being non-ambulatory, consciousness fluctuation, a history of falls, poor bed mobility and balance, effects of medications, and a [DIAGNOSES REDACTED]. The screen failed to identify the resident's compromised visual acuity along with a decrease in cognitive ability and safety awareness. Interventions included bed positioning devices, body pillows, wedges, and one way slides for beds. Hospice would deliver bed half rails appropriate to this particular bed. (Delivered on [DATE]). On [DATE] the facility contacted the resident's representative by phone concerning the Bed Rails Informed Consent and Release form and documented an agreement to utilize side rails on the bed. Observation of Resident # 7 in the bed supplied by Hospice on [DATE] at 11:40 A.M. found the bed and rails to fit together without gaps or possible entrapment issues. The facility Administrator and Director of Nursing were informed of the Immediate Jeopardy on [DATE] at 11:00 A.M., due to the risk of entrapment for Resident # 3 by the use of a full bed rail which did not meet the requirement of only 4.75 inches between rails; and Resident #7's side rail gap of 7.5 by 10 inches when the head of the bed was in the raised position. The facility failed to identify the potential for side rail entrapment. The Immediate Jeopardy was abated on [DATE] at 1:30 pm and lowered to a D level scope and severity by implementation of the following actions: On [DATE] the facility educated and demonstrated to staff side rail assessments and measurements according to FDA guidelines. The facility informed staff all residents have been evaluated to ensure their safety and to relay concerns to the Administrator and or DON. The facility developed a process for monitoring residents bed dimensions based on zones (according to the FDA's Guidance for Hospital Bed System Dimensional) ; and mattress conditions (including overlay mattress and or pressure relieving mattress that can compress and make a gap between side rails and bed rails larger). Staff were informed to let the Administrator and the DON know if they had any concerns with bed rails safety for residents. The Maintenance Supervisor was provided education of safe measurements for side rails gaps and increase risk of entrapment for residents. The facility determined monthly checks will be completed and reviewed at safety meetings. Staff not present at the [DATE] in-service were required to review Side Rail Regulations instruction sheet and complete demonstration prior to beginning their shift. The facility's bed rails guidelines was updated to include : a). All residents will be evaluated for the appropriateness for bed rails prior to initiation on admission. b). Ongoing use of bed rails be evaluated quarterly, change in condition and with the change of equipment. c). Evaluations will included risk for entrapment. d). Risk and benefits of bed rail usage will be discussed with resident and family representative and informed consent will be obtained prior to usage. e. Care plan will address bed rail usage and reason for device. f. Assure that the bed's dimensions are appropriate for the resident's size and weight. g. Follow the manufacture's recommendations and specifications for installing and maintaining bed rails. Staff will document bed rail evaluations.

Based on observation, record review and staff interviews, the facility failed to provide adequate supervision and planned assistive devices to protect a resident from hazards to self for 3 of 4 residents reviewed (Residents #1, #3 and #5). The facility reported a census of 55 residents. Findings include: 1. Resident #1 had a MDS (Minimum Data Set) assessment (MDS) assessment tool with a reference date of 10/13/15. The MDS indicated the resident required extensive assistance with transfers, dressing, toilet use and personal hygiene needs. The MDS identified Resident #1 had [DIAGNOSES REDACTED]. A score of 3 identified severe cognitive impairment. Resident #1's Fall Risk Evaluation noted a score of 18 on 10/13/15. A score of 18 reflected the resident to be at high risk for falls. The Care Plan identified a problem with the resident at risk for falls on 7/21/15. The approaches included and directed the staff on 10/27/15 that the resident used a tab alarm while in the chair and in bed. The Nurse's Notes dated 12/9/15 at 3:00 p.m. reflected the staff found Resident #1 lying on his/her back, yelling, my left hip hurts. The staff notified the ambulance service and had Resident #1 transferred to the hospital at 3:35 p.m. At 7:00 p.m. the facility nurse contacted the hospital and was told the resident had a fractured left hip and would be admitted . Radiology report dated 12/9/15 identified Resident #1 sustained a fractured neck left femur (hip). In an interview on 12/29/15 at 12:40 p.m. Staff C, certified nurse aide, stated she was assigned to Resident #1's hall on 12/9/15 day shift. At around 1:00 p.m. she assisted Resident #1 into bed. Staff C stated the bed alarm was present and functioning at that time. Staff C stated Resident #1 was known to get up unassisted, but she had never known Resident #1 to shut off an alarm. In an interview on 12/29/15 at 10:57 a.m. Staff D, nurse manager, stated on 12/9/15 she was summoned to Resident #1's room. Resident #1 had fallen in his/her bathroom. Staff D attended to Resident #1's needs and had the resident transported to the hospital for further evaluation. Following the incident, Staff D inquired as to what happened. Staff D stated she and Staff E had checked on Resident #1 at shift change around 1:40 p.m. and Resident #1 had been in bed and the bed alarm was functioning (Central Hall Alarm List indicated Resident #1's alarm checked by Staff D and Staff E at shift change). After the fall, the staff checked the alarm and found the alarm to be in off position. Staff D stated she thought there was an alarm on Resident #1's recliner and it was turned off as well. Staff D concluded Resident #1 had turned off his/her alarms. On 12/29/15 at 9:25 a.m. Staff F, certified nurse aide, was interviewed and stated she had worked a double on 12/9/15 and at the beginning of the 2:00 p.m. to 10:00 p.m. shift, she was assigned to Resident #1's hall. Staff F stated at 2:30 p.m. she entered Resident #1's room and picked up a meal tray. Resident #1 was sitting in his/her recliner with legs elevated. Staff F delivered the meal tray to the kitchen and upon returning to the hall a family member informed her someone had fallen. Staff F discovered Resident #1 lying on the bathroom floor. Staff F stated there was no alarm sounding and there was no alarm in Resident #1's chair. Resident #1's roommate stated Resident #1 had grabbed his/her chair which was positioned next to his/hers, pulled self out of the recliner and made his/her way to the bathroom. On 12/28/15 at 3:27 p.m. Staff B, certified nurse aide, stated she was called into Resident #1's room following his/her fall on 12/9/15. Staff B stated she couldn't recall having any contact with Resident #1 prior to the fall. Staff B stated Resident #1 was known to get up unassisted and on occasion shut off his/her alarms. Staff B stated other than placing the alarm boxes out of Resident #1's sight, she knew of no other interventions which addressed Resident #1's ability to turn off alarms. In an interview on 12/29/15 at 9:25 a.m. Staff G, certified nurse aide, indicated Resident #1 was known to get up unassisted now and then, but he/she never was known to shut off his/her alarm. In an interview on 12/29/15 at 10:41 a.m. the Director of Nursing (DON), stated the fall involving Resident #1 on 12/9/15 was investigated. The DON concluded Resident #1 had gotten out of bed and into his/her recliner before eventually getting up and going to his/her bathroom and falling. The bed alarm was turned off and the DON thought the chair alarm was turned off as well. According to her staff, Resident #1 was capable of turning off his/her alarms. 2. Resident #3 had a MDS assessment with a reference date of 9/28/15. The MDS identified the resident had a BIMS of 3. A score of 3 identified the resident had a severe cognitive impairment. The MDS reflected the resident required extensive assistance with transfers, dressing, toilet use and personal hygiene needs. The MDS reflected the resident had frequent incontinent episodes of bowel and bladder. Resident #3's [DIAGNOSES REDACTED]. The resident ' s Care Plan identified a problem with the resident at risk for falls. The approaches included and directed staff to assist the resident with ambulation and the resident used the top two side rails to assist with bed mobility and safety. The resident had a pressure alarm located on the bed and chair. The incident report dated 11/4/15 at 2:25 a.m. reflected the staff located Resident #3 lying on the floor beside his/her bed and was incontinent of bowel and bladder. Resident #3 sustained no injury. Resident #3's bed alarm was not sounding at the time of the fall. The cord was halfway unplugged from the alarm box. A new alarm was obtained for Resident #3. Review of the Central Hall Alarm List identified Resident #3's alarm had not been checked at shift change on 11/4/15. The incident report dated 11/15/15 at 12:45 a.m. reflected staff found the resident lying on the floor beside his/her bed and had been incontinent of bowel and bladder. Resident #3 sustained no injury. Resident #3's alarm box was flashing, but not sounding. A new alarm was obtained for Resident #3 and a clip alarm was also added. Review of the Central Hall Alarm List indicated Resident #3's alarm was checked at shift change on 11/15/15. On 12/28/15 at 10:45 p.m. Staff H, Registered Nurse, was interviewed and stated on 10/1/15, Resident #3 had a fall. It was one of his/her first falls and at that time an alarm was added as a safety intervention. On 11/4/15 a second fall occurred. Resident #3 had been discovered by an aide. The alarm was not sounding and upon inspection the cord was dislodged due to a clip being broke which holds the cord in place. Staff H exchanged the alarm. Staff H indicated the alarm was working at shift change (not documented). A third fall occurred on 11/15/15. The alarm failed to sound, although the light was flashing. At shift change checks, Staff H admitted she did not activate the alarm to see if it would sound. Staff H stated she sometimes does the alarm checks by herself and not with the off going nurse. 3. Resident #5 had a MDS assessment with a reference date of 12/10/15. Resident #5 had a BIMS score of 2. A score of 2 identified the resident as severely cognitively impaired. The MDS indicated Resident #5 required extensive assistance with transfers, dressing, toilet use and personal hygiene needs and physical help in part of bathing activity. Resident #5 was determined frequently incontinent of bowel and bladder. Resident #5's [DIAGNOSES REDACTED]. The resident ' s Care Plan identified the resident had a problem with a history of falls. The approaches directed the staff that the resident had a pressure alarm on the bed and a clip alarm when in a chair and Dycem in the chair to prevent resident from sliding out. Observation on 12/28/15 at 8:30 a.m. found Resident #5 sitting at the dining room table for breakfast. Observation identified the resident without a clip alarm. At 11:00 a.m. Resident #5 sat in a chair during an activity. Observation identified a clip alarm attached to the chair, but not to Resident #5. On 12/28/15 at 11:20 a.m. Staff E, Registered Nurse, stated Resident #5 requires the use of an alarm at all times. When pointed out Resident #5 did not have his/her alarm on, Staff E went over to Resident #5 and attached the clip alarm to the resident.

Based on observations, record review, and staff interviews, the facility failed to assess and prevent the development of new or recurring skin issues Resident # 8, #2, #3). The sample consisted of 14 residents. The facility reported a census of 54 residents. Findings include: 1. Resident #8 had a quarterly MDS (Minimum Data Set) assessment, with a reference date of 07/19/2013. The MDS revealed a BIMS (Brief Interview of Mental Status) score of 12. A score of 12 identified moderate impairment for cognitive function. The resident required the extensive assistance of 2 staff members for bed mobility, transfers, toilet needs, and personal hygiene. Resident # 8 had frequent episodes of urinary incontinency and was a significant risk for skin pressure areas. The resident had [DIAGNOSES REDACTED]. The Care Plan with a problem onset date of 03/30/2013 directed facility staff to reposition the resident with the assistance of 2 people, reassess pressure ulcers at least weekly, and determine the resident ' s risk status quarterly and as needed. The Care Plan also directed the nursing assistants to check the resident's skin with baths and cares and to report findings to the nurse. Nursing staff needed to measure wounds weekly, record, report any declines to the physician, treat as ordered, seat the resident on the Roho cushion in the chair, and place the resident in bed at least 1 hour every shift. A Physician's telephone order dated 9/23/2013 at 5:00 P.M. ordered Sensi cream (a skin barrier cream) to be topically applied to Resident # 8's buttocks daily. Previous orders for areas of skin break down were: 4/24/2013--a fax informing the Physician of a 1 centimeter split in the reddened abdominal fold area, a 3 centimeter spilt near the groin, a 1 centimeter long by 0.2 centimeter wide open area on the left gluteal crease, and a 3 centimeter by 0.5 centimeter open area on the right gluteal crease. 4/28/2013--a fax to the Physician requesting a Roho pressure relieving cushion for the resident's recliner and zinc for the buttocks and coccyx areas. 5/22/2013--a fax informing the Physician of a 0.3 centimeter open area to the left gluteal fold and 2 pinpoint areas on the right gluteal fold. Asked to continue treating the coccyx, abdominal fold, and groin area with zinc even though the fax documented them as healed. 6/06/2013--a fax to the Physician requesting to discontinue the [MEDICATION NAME] and just use Zinc to all area twice a day for 2 weeks topically (not identifying what all areas are). The Physician approved the order. 6/17/2013--a fax to the Physician to change a treatment to all areas of the bottom because zinc not affective. 6/18/2013-a fax to the Physician requesting a treatment for [REDACTED]. The Physician gave approval. 7/16/2013--a fax sent to the physician requesting to use Meplix Border as needed each day to the coccyx and buttocks and discontinue current treatment being used. The Physician gave approval. 8/11/2013---a fax sent to the physician requesting to use Sensi Cream to the gluteal, coccyx, and perineal areas until healed instead of the zinc. The Physician gave approval to change. The faxes demonstrated Resident #8 had a repeated pattern of skin breakdown with no interventions culminating into any [MEDICATION NAME] prevention of skin break down. During an observation on 9/23/2013 at 11:50 A.M., Staff C and Staff K (both Certified Nursing Assistants) ambulated Resident #8 from a recliner in the lounge to the shower room. After standing the resident in front of the toilet, the aides lowered the resident's slacks and brief and assisted the resident to be seated on the toilet. Resident #8's brief had no urine or feces present but displayed a small red stain towards the back of the brief. Staff G (Licensed Practical Nurse) entered the shower room, washed her hands and donned gloves. As the aides cleansed the resident's perineal areas, observations of the groin, around the penis, scrotum, and perineal creases revealed areas to be beefy red in color. Resident # 8 yelled out that it hurt when the aides cleansed these areas. The left mid-inner buttock displayed a Stage II area with slight red drainage. The nurse (Staff G) measured the area as 0.6 by 0.9 centimeters. After the aides finished perineal cares for the resident, Staff G changed her gloves and placed Sensi cream on one glove. She spread the Sensi cream over the entire left buttock and groin area and removed her gloves. The aides finished dressing the resident and ambulated the resident to the dining room for lunch. A review of the Wound/Skin Healing Record entry for 9/23/2013 revealed the measurements documented for the left Stage II buttock area to be different that when Staff G measured it during cares (06 by 0.9 centimeters became 0.7 by 0.5 centimeters with no red drainage). During an interview on 9/26/2013 at 11:30 A.M., the facility Medical Director was interviewed and stated the resident had redness present in the private/perineal areas because of being constantly incontinent. The Medical Director commented he deferred to the nurses when it came to what treatment they felt was best for the resident. At the end of the conversation, the physician stated he was a wound specialist at a wound clinic. 2. Resident #2 had a quarterly MDS (Minimum Data Set) with a reference date of 07/02/2013 which revealed a BIMS (Brief Interview of Mental Status) score of 15. A score of 15 identifies no cognition problems. The MDS reflected the resident required the extensive to total assistance of 2 plus staff members for bed mobility, transfers, toilet needs, and personal hygiene. The MDS reflected Resident # 2 utilized a Foley catheter for bladder elimination and had risk for skin pressure areas. The Care Plan with a goal date of 07/16/2013 directed facility staff to reposition the resident frequently, use heel lift while in bed, use pressure relieving device to bed/chair, and assess the resident's risk status quarterly and as needed. The plan also directed the nursing assistants/nurses to check the resident's skin with baths and cares, to notify the physician of reddened or broken skin. A note added on 07/16/13 instructed staff to be careful when moving abdominal folds related to pain. A note added on 08/24/13 instructed staff to provide treatment to coccyx as ordered to prevent further breakdown. A note dated 09/04 instructed staff to keep resident's body positioned with pillows on each side. Notations added on 09/24/13 instructed staff to provide treatment to abdominal excoriated areas as ordered by the physician and to keep the resident off the right side so air could get to the folds. The resident's physician history and physical with date of service listed as 01/03/13 documented the resident to have a significant history of [MEDICAL CONDITION] caused by chronic rash (Hidradenitis suppurativa) is a chronic skin disease characterized by recurrent boil-like lumps (nodules) under the skin. The nodules are inflamed and painful. They tend to break open, causing abscesses that drain fluid and pus), under the abdominal folds and under the breast. The history identified the resident's abdomen to be morbidly obese with a large pannus (excessive skin and fat at the end of the abdomen) noted with a large umbilical hernia. The history and physical noted the skin to be without any acute rash or [MEDICAL CONDITION]. The facility Admission Resident Assessment noted the resident had several bruised areas to arms as well as reddened areas to the abdominal folds that measured 36 by 23 centimeters. The areas had a dusky appearance with a yeasty odor. The staff had documented the resident's buttocks were reddened with spotty areas. An area on the coccyx measured 8 by 5 centimeters (did not indicate if the area had opens areas). The Physician order [REDACTED]. A Physician's notification fax order dated 9/24/2013 informed the physician the resident had an excoriated reddened area (large) under the abdominal fold that has green drainage. The fax noted the area had a towel for a barrier. The staff requested using an Interdry Age towels to the abdominal fold to whisk moisture. The staff asked for any other ointment or treatment and noted the resident had requested Lortisone (steroid skin) cream. The fax had been returned to the facility on [DATE] at 1:08 p.m. with a notation that stated okay for all above. Previous orders for areas of skin break down were: 06/12/2013--a fax informing the Physician of excoriation of the resident's right arm pit that measured 11 by 9 centimeters. The fax requested an order for [REDACTED]. 07/23/2013--a fax to informing the Physician of a left gluteal fold and thigh being red. Had been using Zinc Oxide to areas, area not healing and asked for something different, possibly [MEDICATION NAME] with border, change daily until area healed. Return fax date 07/24/13 at 9:53 a.m. confirmed change. 7/23/2013--a fax to the Physician to request the use of [MEDICATION NAME] (an anti-fungal powder used to whisk excess moisture from skin) for use under breast bilaterally daily as needed, and a request to use Zinc Oxide to the abdominal folds two times daily and as needed. The return fax dated 07/24/13 at 9:53 a.m. confirmed the request. 8/11/2013--a fax to the Physician to request use of Sensicream skin protectant to abdomen, coccyx gluteal folds and periarea until healed instead of Zinc. A return fax dated 08/12/13 at 2:25 p.m. approved the order for staff to change the treatment. 8/22/2013--a fax to the Physician for treatment to a 3 by 0.2 centimeter open area to the coccyx and requested an order for [REDACTED]. A return fax dated 8/23/13 at 1:05 p.m. contained a notation that gave approval by the Physician. 9/16/2013---a fax notifying the Physician of an area to the lower back measured 1.5 by 0.5 centimeters and asked to use [MEDICATION NAME] Foam (an absorbent foam pad that absorbs wound exudate. The interface gels upon contact with the wound exudate with creates a moist wound environment and has a waterproof barrier that allows the user to shower and bathe) to be changed every three days. The fax had been returned on 09/18/13 at 12:28 p.m. directing staff to use [MEDICATION NAME] (an adhesive patch that helps keep wounds moist so they heal more quickly. These patches are commonly used to treat pressure sores, ulcerations, small surgical incisions,[MEDICAL CONDITION] lacerations that are healing slowly) and change every 48 hours. The faxes demonstrate a repeated pattern of breakdown for Resident #2 with no interventions culminating into any [MEDICATION NAME] prevention of skin break down. Review of the residents skin condition record for non-pressure ulcer skin conditions revealed: On 06/29/13 - 3 cm by 3.2 cm (centimeter) area to the left thigh, with red wound bed had been noted. Subsequent weekly skin assessments were documented as: 07/02/13 - 3 cm by 3.5 cm with red wound bed 07/09/13 - 2.2 cm by 3.1 cm with red wound bed 07/16/13 - 12 cm by 12 cm with red wound bed, no open areas 07/23/13 - 12 cm by 11.8 cm with red wound bed 07/30/13 - 10 cm by 10.2 cm with red wound bed 08/05/13 - 10 cm by 10.9 cm with red wound bed white center using [MEDICATION NAME] dressing 08/12/13 - 9 cm by 10 cm with red wound bed white center 08/20/13 - 8.9 cm by 8.9 cm with red wound bed 08/26/13 - 8.6 cm by 9.8 cm with red wound bed 09/02/13 - 8.0 cm by 9.0 cm with red wound bed using [MEDICATION NAME] dressing 09/09/13 - 7 cm by 8.8 cm with red wound bed no open area excoriated 09/16/13 - 8 cm by 8 cm with red wound bed no open area 09/23/13 - 8 cm by 8 cm with red wound bed There was no documentation that the Physician had been notified of the worsening area or request for change of treatment for [REDACTED]. On 09/16/13 a skin condition record for non-pressure ulcer skin conditions noted a 1.5 cm by 0.5 cm red area to the lower back had been documented. The 09/23/13 note documented the area as 1 cm by 0.3 cm with red wound bed. There were no skin sheets regarding the skin breakdown under the resident's abdominal fold and no documentation of a treatment for [REDACTED]. During an observation on 9/24/2013 at 8:25 a.m., Staff C, CNA (Certified Nursing Assistant) entered the resident's room as Staff N, CNA exited the room carrying a plastic bag out of the room. Staff N returned without the bag and awakened the resident as Staff C washed her hands. Staff N washed her hands and donned gloves. The staff had supplies (wet disposable wash cloths and clean incontinency pad) on the bedside table. The staff assisted the resident to roll to the left side. The resident had been lying on a bedpan and had a ring around the buttocks. The staff avoided answering when asked how long the resident had been on the bedpan. The resident had dried feces on the right hip. Staff N removed the bedpan and placed the pan in a plastic bag. The bedpan had nothing in it. Staff N obtained a wet disposable cloth and attempted to clean the dried feces from the resident's hip and buttock, rubbing it with several of the disposable cloths until the area was clean. Staff C directed Staff N to change gloves, which she did, washing hands prior to donning the new gloves. Staff C lifted the resident's large pannus (abdominal fold). The area had a terry cloth hand towel placed between the folds. The cloth was saturated with greenish colored drainage. When asked where the substance was coming from, Staff A, MDS Coordinator observing the cares, stated the resident had a great deal of moisture between the folds and requested the terry cloth towels to catch the moisture. The resident voiced complaints of pain, cautioning the staff to be careful and asking them not to use the disposable cloths on the area. The area under the towel had a dark reddened excoriated area across the entire right side of the abdomen on both sides of the folds. Staff C exited the room and returned with a basin of water and terry washcloths. Staff C placed the cloths in the basin of water. Staff C washed her hands and donned clean gloves. Staff C again held the resident's pendulous pannus up as Staff N used the wet washcloths and began cleaning the reddened area with the cloths, patting the area with the cloths rather than rubbing, trying to remove a white cream that had dried on the areas of the skin. The area appeared moist and seeping. The rash had a blister like appearance. The staff did not dry the area after cleansing with the wet washcloths. The resident continued to complain of discomfort and stating he/she was tired of this area hurting all the time, while the staff continued cleansing the area. The resident stated he/she did not know why they couldn't use the other medication on the area, instead of the white cream they were using and felt it didn't help. When Staff A asked if he/she were talking about the medication the resident had used at home, the resident confirmed that is what she/he meant. Staff A stated that they had asked the physician and he felt she did not need that particular medication at this time. Staff A stated she would fax the physician and ask for a different treatment than what they were presently using for the area. Staff A also noted the Physician would be making rounds on Thursday and she would make sure the resident was on his rounds list. The staff assisted the resident to the left side, propping the abdominal folds with pillows to open the right side up to expose the area to the air to assist with drying. Staff C stated that the resident would be having a whirlpool later in the day and would be able to soak the area. At 9:45 a.m. the Assistant Director of Nursing, Staff A was interviewed and stated she had faxed the physician and asked for a different treatment for [REDACTED]. On 09/24/13 at 3:30 a.m. Staff A noted that she had faxed the physician as well as called the office to inform him of the excoriated area and asked for a new treatment, but had not had a reply as yet. 3. Resident #3 had a quarterly MDS assessment with a reference date of 7/23/2013. The assessment reflected the resident did not have cognitive deficits but required staff supervision with bed mobility, transfers, toilet needs, and eating. The MDS indicated Resident #3 had occasional bladder incontinence and frequent bowel incontinence. The Care Plan with a goal date of 11/11/2013 reflected the resident demonstrated independence in the bedroom, sleeps in the recliner, requires assistance of one with bathing and personal hygiene needs. The Care Plan instructed staff to provide the resident with incontinence pads and assistance with changing and to assist with perineal cleansing as needed. An added notation dated 08/06/13 reflected the resident was usually independent with toileting. The Care Plan instructed staff to monitor for changes in condition that may warrant increased supervision/assistance. The Care Plan directed staff to assess the resident ' s skin and record any skin breakdown on pressure/non pressure form and if no healing in two weeks, notify the physician for need of a new treatment. The Care Plan instructed the nursing assistants to check the resident ' s skin with bath/cares and report the findings to the nurse. A Nurse ' s Note entry dated 09/09/13 at 9:40 p.m. reflected the resident complained of bottom hurting. An assessment revealed excoriation identified in the gluteal fold which measured 10 cm by 3 cm and a pressure ulcer on left buttock measured 0.5cm by 0.3 cm. The area was cleansed and barrier cream applied. The notes reflected, the physician had been notified per fax. A Nurse ' s Note dated 09/11/13 at 10:30 a.m. documented the facility received a telephone order to apply Sensicream to excoriated buttocks two times daily until healed. A Nurses ' s Note dated 09/25/13 at 10:45 a.m. noted a 8 cm by 4.5 cm purple bruise to right upper buttock had been found during a treatment. The resident denied pain to the area and denied knowing the area had been bruised. The Nurse ' s Notes reflected the area had been covered by [MEDICATION NAME] dressing which is changed every three days. The notes reflected the resident up and independent in room and refuses care from CNA staff unless incontinent. The treatment record for September 2013 instructed staff to apply Sensicream to excoriated buttocks, two times a day until healed and apply Aqualcel foam dressing to the left buttock every three days. The treatment record instructed staff to apply [MEDICATION NAME] powder under both breast and abdominal folds two times each day. A review of the skin condition record for non- pressure ulcer skin conditions: 09/09/13 - excoriation to the gluteal fold 10 cm by 3 cm with a red/pink wound bed, area cleansed and barrier cream applied. Doctor notified. 09/16/13 - 14.8 cm by 4 cm with red wound bed, no treatment documented 09/23/13 - 8 cm by 5 cm with red wound bed. There were no skin assessment sheets available regarding the excoriated areas to the resident's breast and/or abdominal folds. Observation on 09/23/13 at 9:30 a.m. during the initial facility tour, revealed the resident sitting in a recliner dozing but awakened when entered room. The resident spoke with the MDS Coordinator and Surveyor when they entered the room. The MDS Coordinator stated the resident spends the majority of the time in the room and sleeps in the recliner. Observations on 09/24/13 at 7:30 a.m. revealed the resident sleeping in the recliner chair. At 11:10 a.m. Staff O, RN and a Student Nurse entered the resident room to provide treatment to the resident's skin areas that had skin breakdown. The resident sat in the recliner dozing. Staff O stated she would be putting [MEDICATION NAME] powder under the resident's breast and between the skin folds where the resident had excoriated areas. Staff O washed her hands and donned gloves. Staff O picked up the powder. The Student Nurse pulled up the resident's clothing. The resident pulled up her/his left breast which showed slight red excoriation at the skin fold. Staff O sprinkled the powder on the area and spread out the powder with her gloved hand. Staff O removed her gloves, donned new gloves. The resident pulled up her/his right breast which had excoriation present. Staff O sprinkled the powder over the area and spread it with her gloved hand. Staff O removed the gloves, washed hands and donned new gloves. The Student Nurse assisted the resident to pull down her/his slacks and lifted the abdominal folds. The skin had mostly cleared. Staff O sprinkled the [MEDICATION NAME] on the skin and spread it along the skin fold. Observations on 09/25/13 at 9:30 a.m. revealed Staff O, RN to the resident ' s room to provide dressing change to the pressure area on the resident's left buttock. Resident had a large (approximately 8 cm) dark purple bruise on the right upper buttock. When the bruise had been brought to the attention of Staff O and asked how the resident obtained the bruise, Staff O stated that she usually does not change the resident's dressing, that it is usually performed by the Wound Nurse. Staff O stated she had not been aware of the bruise. Staff A, MDS Coordinator, observing the cares stated she would look into how the resident obtained the bruise. Staff O continued changing the dressing, after removing the old dressing, At 3:45 p.m. when asked if she had discovered any explanation regarding how the resident may have acquired the bruise, Staff A stated she had contacted the Wound Nurse who had stated the resident did not have the bruise when she had last changed the resident ' s dressing. The CNA responsible for the resident cares (Staff N and Staff K) denied knowledge of the bruise stating the resident will sometimes sit on the arm of the recliner and has been bruised before from doing so. The clinical record revealed no problems with skin bruising obtained from the recliner chair arm.

Based on observation, record review, and staff interviews, the facility failed to ensure two residents (Resident #1, #7) received nursing services and consistent interventions for the care and prevention of pressure areas and failed to demonstrate safe infection control techniques when performing wound care. The standard sample included 14 residents, including 6 residents with pressure sores. The facility reported a census of 54 residents. Findings included: The following descriptions reflect the stages of pressure ulcers: Stage 1-Intact skin with non-blanchable redness of a localized area, usually over a bony prominence. Stage 2-Partial thickness loss of dermis, presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open ruptured blister. Stage 3-Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Stage 4-Full thickness tissue loss with exposed bone, tendon or muscle. 1. Resident #1 had an annual Minimum Data Set (MDS) assessment, with a reference date of 06/18/13, reflected the resident required extensive to total assistance for bed mobility, toileting, and hygienic cares, was frequently incontinent of bladder but always continent of bowel. The MDS identified Resident #1 had no pressure ulcers but at risk for the development of pressure ulcers. The resident's Care Plan identified the resident at risk for pressure ulcers and instructed staff to reposition the resident frequently with two person assist to avoid skin friction/shearing, utilize a pressure relieving device in the chair, to transfer with a mechanical lift to avoid skin friction/shearing, daily observation of skin with routine care, provide full skin evaluation weekly with shower/bath place boots (heel protectors) to feet and legs bilateral, provide heel cushion on bed and provide treatments per physician order. The Care Plan instructed staff on 06/21/13 to provide treatment to a Stage II ulcer on the coccyx as ordered by the physician. A late entry by Staff A, MDS Coordinator on 09/25/13 noted the wound had healed on 07/16/13. An entry dated 09/05/13 directed the staff to get the resident up last, lay the resident down first after meals, and position for healing. An entry dated 09/07/13 noted [MEDICATION NAME] foam dressing to coccyx was discontinued. A late entry dated 09/25/13 and effective 09/07/13 noted a new physician's order [REDACTED]. On 09/25/13 at 9:40 a.m. Staff Q, Registered Nurse (RN), prepared to perform a treatment to the resident ' s pressure ulcer located on the coccyx area. Staff C, CNA entered the room to assist. Staff Q, washed her hands and prepared supplies. Staff Q cut tape and hung four pieces on her name badge and onto the shirt. Staff Q opened a package of 4 by 4 gauze sponges and placed them on a paper towel onto the top surface of the supply cart. Staff Q removed a tube of ointment and placed on towel ([MEDICATION NAME]). Staff Q washed her hands and donned gloves. Staff C assisted the resident to turn onto his/her left side. Staff Q removed the old dressing from the resident's coccyx area. The pressure ulcer wound had an appearance of being black and necrotic. The area measured approximately 6 to 7 centimeters. The resident had been incontinent of bowel and had feces on the rectum. Staff C picked up a package of wet disposable cloths and proceeded to clean the feces from the rectal area. Staff Q, without removing her gloves, removed a measuring device from the cart and measured the wound, stating the wound measured 3.2 cm by 2.5 cm by 2 cm depth. Staff Q picked up the medication ointment tube and squeezed the ointment onto the 4 by 4 gauze sponge. Staff Q placed the gauze over the pressure ulcer, pulled tape off of her shirt/name tag and placed over the gauze. Staff Q did not cleanse the wound prior to placing the new dressing and medication on the area and did not change her gloves between removing the dirty and placing the clean. The [MEDICATION NAME] Ointment medication is made to debride and remove necrotic tissue. The medication should not be used on healthy skin. When asked how long the area had been necrotic the staff replied that it had started a couple of weeks ago as just a narrow slit, and just worsened very quickly. Staff Q stated they have used three different treatments but the ulcer continues to worsen. When asked if the physician has seen the area, Staff Q stated that she would have thought so since he makes rounds every week. On 09/26/13 at 10:45 a.m. Staff O, RN, stated that the expectation for wound care is to clean the wound prior to administering the treatment, Staff O stated that is what we usually do. Review of the resident ' s Braden Scale- For Predicting Pressure Sore Risk dated 06/1/13 revealed the resident's assessed score was 12 (total score of 12 or less represents high risk). Review of the resident's admission assessment, dated 6/13/2013 documented the resident had a 1 cm (centimeter) by a 1.4 cm Stage II pressure ulcer to the coccyx. The admission Nurse ' s Note dated 06/13/13 at 10:00 a.m. documented the 1.0 cm by 1.4 cm Stage II decubitus on coccyx. A description of the area revealed sloughing with black in the center. The notes reflected the resident to be totally incontinent and required total assist for all activities of daily living. There were no pressure ulcer skin healing records supplied for review of the above pressure ulcer. A hospice progress note dated 07/16/13 noted the coccyx ulcer had healed. A physician order [REDACTED]. A clarification of the above order: use Zinc Oxide cream daily to coccyx area and groin excoriation until healed. Review of the Nurse ' s Notes for September 2013 revealed: 09/17/13 at 10:15 a.m. staff documented a new order received via phone call from physician for [MEDICATION NAME] Foam dressing to coccyx area with red slough. 09/18/13 at 1:30 p.m. continues with decubitus of coccyx, area and dark black in color, new order received for Xerderm cream (no such medication), cover with dry gauze, and change daily. Previous order for [MEDICATION NAME] discontinued. (Contacted the Director of Nursing regarding what treatment had been used since Xerderm did not exist. The Nurse Consultant contacted the Pharmacist. The medication was determined to be Xenerderm.) 09/21/13 at 10:00 a.m. area to coccyx worsened, dark in color with slough, green drainage noted, started new treatment two days ago, treatment provided per order. 09/23/13 at 3:00 a.m. resident incontinent of urine, dressing to coccyx changed due to soiling. Ulcer black and neurotic but improving with cream. 09/25/13 at 1:00 a.m. resident had been incontinent of urine, changed and repositioned, dressing changed to coccyx, necrotic tissue present, some drainage (no description of drainage or amount). 10:00 a.m. dressing change to coccyx, drainage presented necrotic tissue present, and area measured 3 cm in length, 2.5 cm wide and 2 cm in depth. Review of pressure ulcer notes revealed: Right heel 08/22/13 - Stage I pressure ulcer discovered to the right posterior heel. Measured 3 cm by 3.5 cm, no exudate, odor, wound bed normal. No treatment documented. (Staff would not be able to see the wound bed of a Stage I pressure ulcer). 08/26/13 -area measured 3 cm by 3.5 cm, no exudate, odor, wound bed black/brown (eschar). No treatment noted. Area described as unstageable. 09/02/13 - area measured 3 cm by 3.3 cm, wound bed remained black/brown (eschar) treatment -skin prep. 09/09/13 - area measured 2.3 cm by 2.4 cm, wound bed brown, treatment heel lift, skin prep, and boots. Notation site improved. 09/16/13 - area measured 2.3 cm by 2.4 cm, depth of 1 cm, wound bed light brown, notation no change. 09/23/13 - area measured 0.5 cm by 0.9 cm, wound bed red, notation of improved and healing. Coccyx 09/05/13- onset Stage II pressure ulcer to coccyx measured 5 cm by 1 cm, wound bed with granulation tissue, surrounding tissue/wound edges with peripheral tissue [MEDICAL CONDITION], no treatment noted on sheet. On 9/5/2013, a Physician Notification form identified the doctor was informed of an open area approximately 5 cm by 1 cm clean, and staff questioned what treatment the physician would like to order. The fax reflected the doctor was informed that staff used a barrier cream. Physician responded okay. 09/09/13 - Stage II, 2.4 cm by 1 cm, no drainage, odor, wound bed slough, surrounding skin color red, wound edges with [MEDICAL CONDITION]. Notation" open area, redness around 7 cm by 4 cm. (The Physician had not been informed of the swelling and surrounding redness) 09/16/13 - Stage II, 3 cm by 1.5 cm, wound bed black/brown (Eschar), surrounding skin color red, with peripheral tissue [MEDICAL CONDITION]. A notation stated area deteriorated and unstageable. The Nurse ' s Notes of 6:00 p.m. reflected the Physician was notified. The note reflected no new orders received. 09/23/13 - Stage II, 4 cm by 3.4 cm, surrounding skin color red with peripheral tissue [MEDICAL CONDITION], response to treatment deteriorated, notation that area unstageable. 09/07/13 - a Physician order [REDACTED]. 09/16/13- Physician notified of area to coccyx larger in size, and (currently) using [MEDICATION NAME] foam to area. Asked for order to use [MEDICATION NAME]. Physician gave approval. 09/17/13 - Physician notified of coccyx area noted to have necrotic/blackened area near center and requesting an order to start Xerderm cream (no such medication) and cover with dry gauze, change daily. Physician gave approval. 9/21/2013-The Nurse ' s Notes reflected the area to the coccyx had worsened and dark in color with green slough drainage noted. The nurse notified Hospice and sent a fax to the physician. Will continue current treatment and monitor. 09/23/13 new open area 1.0 cm by 0.2 cm Stage II discovered to left inner buttock, wound bed normal for skin, surrounding skin red with peripheral tissue [MEDICAL CONDITION] to wound edges. The Physician was notified. The physician progress notes [REDACTED]. The physician discontinued the prior dressing, instructed staff to continue to offload wound and noted that the wound will most likely never heal due to end of life condition with poor nutritional status. The facility Guidelines for Wound Care instructed staff to: 1. Cleanse the wound with a wound cleanser 2. Measure the wound 3. Debride if the wound if greater than 25% necrotic tissue 4. Assess the wound based on characteristic: wound depth (or necrotic tissue) and exudate level 5. Choose appropriate primary and secondary dressing from the chart. On 09/26/13 at 11:20 a.m. the facility Medical Director was interviewed and stated he feels the reason the facility seems to have a large percentage of pressure ulcers may be due to the larger geriatric, bariatric and hospice residents with chronic health issues. The Medical Director stated some of the residents with chronic skin issues have issues related to non- compliance with the treatment modalities and failure to conform with repositioning advice by the staff. The Medical Director acknowledged that good assessment skills by the nursing staff are pertinent in prevention and treatment of [REDACTED]. 2. Resident #7 had an annual MDS assessment, with a reference date of 7/02/2013. The MDS revealed the facility staff provided total assistance with bed mobility, transfers, personal hygiene, and toilet use. The MDS did not evaluated the bowel and bladder status of the resident except to note the presence of supra pubic indwelling urinary catheter. Skin issues included a Stage IV pressure ulcer. [DIAGNOSES REDACTED]. The plan of care with an problem onset date of 1/12/2012 directed facility staff to avoid friction with transfers, use a turn sheet on the bed, reassess pressure ulcers at least weekly, place on a low air mattress, turn and reposition frequently, report any red or open areas of skin to the nurse with baths and cares and continue to treat the Stage II pressure ulcer acquired in the hospital. During an observation on 9/24/2013 at 2:50 P.M., Staff F (Licensed Practical Nurse) entered the resident's room with the treatment cart. After washing her hands, placing treatment items on a clean barrier on top of the treatment cart, and changing gloves, Staff F cleansed scissors with alcohol and cut a piece of the Aquarelle pad and placed it in a plastic medication cup. Resident # 7 laid in the bed on the right side. Staff F removed the dressing covering the Stage IV pressure area on the left gluteal/buttock area. Staff F changed gloves and then utilized a measuring strip measured the Stage IV pressure ulcer to be 2.5 centimeters by 2.6 centimeters. Staff F did not measure the depth of the wound. On 7/11/2013, Resident # 7's facility transfer form to the hospital documented the resident's skin condition as fair. The transfer form did not mention any pressure areas. A consultation report from the hospital stay dated 07/11/2013 mentioned a decubitus ulcer of the left hip but did not identify the stage of the ulcer. The consultation did not mention a Stage IV pressure ulcer on the left gluteal/buttock area. A hospital nursing note of 7/19/2013 documented obtaining left buttock pressure ulcer cultures but did not document the stage of the wound. On 7/24/2013, Resident # 7 returned to the facility. The Resident Assessment-Data Collection Form/Initial Care Plan form documented a left gluteal 4 centimeter by 3 centimeter open area along with several scratches on the left buttock. The first documentation of the pressure area after the resident's return from the hospital revealed to be 7/30/3013 (6 days after the resident's return to the facility). The nursing note documented a stage IV pressure area of the left hip and an area to the coccyx. The note also documented red buttocks and a linear open area to the left gluteal. A nursing note of 8/05/2013 documented a Stage II coccyx area and a Left hip (Stage IV) area 3 centimeters by 2 centimeters, but no left gluteal/buttock area. Confused documentation of the actual location of the Stage IV pressure ulcer continued throughout the record. Some documentation (such as the admission assessment) identified the area as the left gluteal and others the left hip. A Pressure Ulcer Healing Record with an onset date of 7/24/2013 for a left hip, Stage IV pressure ulcer dated the first entry as7/30/2013 (6 days later). The Stage IV pressure ulcer measured 3 centimeters by 2 centimeters with a depth of 1.4 centimeters. A nursing note dated 8/26/2013 documented the left hip as 2 centimeters by 1.5 centimeters without any depth being documented. On 9/09/2013, the facility measured the Stage IV left hip pressure area as 2 centimeters by 1.2 centimeters with a depth of 2 centimeters and notified the Physician the area had enlarged. On 9/16/2013, a nursing note identified an area (did not identify location) as not as deep and smaller with green drainage. On 9/23/2013, a nursing note documented green hip drainage and noted the Physician verbalized this was normal on 9/16/2013. Prior to entering the hospital on [DATE], the facility documented a Stage IV left buttock pressure ulcer area with an onset date of 1/12/2013 and last measured on 7/9/2013 as 0.6 centimeters by .2 centimeters with no depth recorded. The facility documentation and landmark identification of Resident # 7's wound areas was conflicting and incomplete. With no documentation of the wound areas prior to going to the hospital, the Stage IV pressure area (identified 6 days after the resident's return to the facility) identified the pressure area condition worsened during that timeframe.

The following deficiency relates to complaint # -C and -I. Based on record review and staff interviews, the facility failed to provide prompt and thorough assessment and intervention for Resident #1's complaint of mouth pain and oral drainage leading to oral cavity mucositis (mouth inflammation) with hospitalization . Concerns were identified for one (1) of four (4) residents. The facility reported a census of 60 residents. Findings include: According to the Minimum Data Set (MDS) assessment with assessment reference date of 12/8/10, Resident #1 had short and long term memory problems and modified independence for cognitive skills for daily decision making. Resident #1 required total dependence with physical assist of two staff for bed mobility, transfers and toilet use and extensive assistance dressing, eating, personal hygiene and bathing. Resident #1's [DIAGNOSES REDACTED]. The MDS established the resident on a schedule pain medication and did not received prn (as needed) pain medication. According to dental care notes dated 12/8/10, the resident had no oral [MEDICAL CONDITION], swelling, or bleeding noted during the assessment and his/her gums were intact. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. In an interview on 1/24/11 at 2:42 p.m. Staff F (CNA) indicated she was working the evening shift on 1/5/11 when she and another aide were getting Resident #1 up for supper. Resident #1 complained that his/her tongue was sore. Staff F was unable to inform the nurse (Staff A) at that time and proceeded to take Resident #1 to the dining room. Resident #1 hardly ate anything and after supper was returned to his/her room. While brushing his/her teeth, Resident #1 complained of feeling ill and spit out the tooth paste. Later that evening, alarms sounded in Resident #1's room. Resident #1 was agitated and confused and trying to get out of bed. Staff assisted Resident #1 from his/her bed to the nurse's station. Staff F noticed some drainage coming from Resident #1's mouth and reported to Staff A at that time about Resident #1's earlier complaint of mouth pain. Staff A and Staff F attempted to examine Resident #1's mouth, but he/she was being very uncooperative. Staff F indicated that Staff A was planning on leaving a note for Resident #1's doctor who would be visiting the next day. In an interview on 1/25/11 at 10:23 a.m. Staff A (LPN) indicated she was working the evening shift on 1/5/11 and at around 9:30 p.m. she was summoned to Resident #1's room by Staff G. Resident #1 was agitated and insisting on getting out of bed. Resident #1 was assisted out of bed and brought to the front lobby area. Staff F indicated Resident #1 had earlier complained of mouth pain. Staff A attempted to assess Resident #1's mouth, but Resident#1 was uncooperative and would not talk. Staff A indicated she reported Resident #1's condition and behavior to the overnight nurse, Staff H. In an interview on 1/25/11 at 10:15 a.m. Staff H (RN) indicated she was working the overnight shift on 1/5/11 and was unaware Resident #1 complaining of mouth pain earlier that evening. Staff H denies receiving any report from Staff A regarding Resident #1's condition and notes the first time she was aware of any concerns regarding Resident #1 was when she read Staff B's nurse's notes on 1/6/11. In an interview on 1/24/11 at 11:05 a.m. Staff I (CNA) indicated she was working the day shift on 1/6/11 and provided care to Resident #1. Staff I indicated that morning she noticed Resident #1's lips had dry skin on them, but wiped off clean with a wet wash cloth. Staff I indicated she reported her observations to the nurse (Staff C). Staff I indicated Resident #1 did not complain of mouth pain to her. In an interview on 1/24/11 at 2:42 p.m. Staff F (CNA) indicated she was working the evening shift on 1/6/11 and noticed Resident #1's left lower lip appeared sore and pussy. Staff F encouraged Resident #1 to come to the dining room for supper and Resident #1 refused. Finally Staff F was able to get Resident #1 to the nurse's desk where she told Staff B that Resident #1's mouth was sore and he/she was refusing to eat. In an interview on 1/24/11 at 2:20 p.m. Staff B (RN) indicated she had overheard Staff A and Staff F talking about Resident #1's sore mouth and of yellow drainage noted on the side of Resident #1's lips on the evening of 1/5/11 and that Resident #1 had been uncooperative with allowing Staff A to assess his/her mouth. On 1/6/11 Staff B was working the evening shift and was approached by Staff F and asked to look at Resident #1's mouth. Resident #1 was complaining of mouth pain and Staff B noticed yellow drainage coming from the left inside corner of his/her mouth. Staff B indicated Resident #1 would not open his/her mouth wide enough to do a good oral examination. Staff B contacted the physician office at 4:10 p.m. and left a message reporting Resident #1's complaint of mouth pain and yellow drainage, but did not speak to anyone directly or receive a return call on 1/6/11. In an interview on 1/24/11 at 11:25 a.m. Staff J (CNA) indicated she was working the day shift on 1/7/11. That morning, she and Staff K were getting Resident #1 up for the day. Staff J noticed a "cold sore" in the corner of Resident #1's lips and reported it to the nurse (Staff C). In an interview on 1/24/11 at 11:35 a.m. Staff K (CNA) indicated she was working the day shift on 1/7/11. That morning, she and Staff J were getting Resident #1 up for the day. Resident #1 was tired so Staff K swabbed her mouth out. Staff K didn't notice anything wrong with his/her mouth, but did notice dried blood in the corner of his/her mouth. Staff K reported her observations to Staff C. In an interview on 1/25/11 at 9:15 a.m. Staff C (RN) indicated on 1/7/11 at around 6:30 a.m. she noticed Resident #1 with brown crusty appearing lips. Staff C cleansed Resident #1's lips with a warm wash cloth and swab. Staff C found Resident #1's lower lip to be raw and applied Vaseline. Staff C contacted Resident #1's physician and obtained an order to apply Vaseline on his/her lips as needed and for mouth rinses with normal saline after meals and as needed. Staff C indicated she completed rinses after breakfast and before and after lunch that day. Staff C indicated she only saw sores on Resident #1's lip and not in his/her mouth. Physician order [REDACTED]. Signature of nurse receiving order is Staff C. Treatment Record for Resident #1 for January 2011 indicated transcription of 1/7/11 order for Vaseline and normal saline rinses beginning on 1/7/11. Vaseline initialed on 1/7/11 by Staff C and mouth rinse initialed on 1/7/11 by Staff A.There is no indication in the nurse's notes or treatment record that Resident #1 received mouth rinses after breakfast and before and after lunch on 1/7/11 as Staff C stated in her statement. There is also no documented indication that Resident #1 received any mouth rinses other than what Staff C identified she did on 1/7/11. In an interview on 1/25/11 at 10:23 a.m. Staff A denied ever being informed of Resident #1's brown drainage or change in condition by Staff D. Staff A also noted she was unaware of the new treatment orders for Resident #1 on 1/7/11 and noted her initials on Resident #1's treatment record for 1/7/11 for a mouth rinse was placed there in error. Staff A indicated she did not know of the as needed mouth rinse for Resident #1. In an interview on 1/24/11 at 3:22 p.m. Staff D indicated she worked the evening shift on 1/7/11 and was getting Resident #1 prepared for supper. Resident #1 was refusing to wash his/her face or brush his/her teeth. This was unusual for Resident #1. Staff D then noticed brown "ooze" coming from Resident #1's mouth. Staff D wiped the drainage from Resident #1's mouth with a wash cloth and showed Staff A the substance and reported Resident #1's change in behavior. Staff A stated okay. In an interview on 1/25/11 at 9:30 a.m. Staff L (CNA) indicated she was working the day shift on 1/8/11. Staff L indicated Resident #1 was up and very talkative that morning and mentioned his/her lips were chapped. Staff L noted Resident #1 ate well that day and the day was uneventful.(According to the daily diet monitoring record showed Resident #1 only consumed 25% of his/her breakfast and lunch mea for this day.) In an interview on 1/24/11 at 4:00 p.m. Staff E (LPN) indicated she was working the day shift on 1/8/11 and was unaware of Resident #1's condition or of the new treatment orders obtained on 1/7/11. In an interview on 1/24/11 at 4:00 p.m. Staff G (CNA) indicated she was working the evening shift on 1/8/11. Staff G indicated she went to Resident #1's room before supper and found him/her sitting at his/her sink. Resident #1 indicated he/she had not brushed his/her teeth because his/her mouth was sore. Resident #1 allowed Staff G to rinse his/her mouth out with warm water and then mouth wash. Staff G then took Resident #1 to the dining room for supper. Resident #1 was refusing to eat anything, but finally agreed to eat a mandarin orange. Staff G indicated Resident #1's family member arrived and Resident #1 told the family member that his/her mouth was sore. In an interview on 1/24/11 at 2:42 p.m. Staff F (CNA) indicated she was working the evening shift on 1/8/11. During supper, Resident #1's granddaughter arrived and Resident #1 complained of his/her mouth hurting. The family member asked what was being done and Staff F indicated she did not know and referred the family member to Staff A. In an interview on 1/25/11 at 10:23 a.m. Staff A indicated she was working the evening shift on 1/8/11. During supper, Staff F and a family member of Resident #1 approached her and asked what was being done about Resident #1's sore mouth. Staff A indicated she knew nothing of any new treatment orders. Staff A examined Resident #1's mouth and noticed what appeared to be blisters and an active infection. A physician was contacted and Resident #1 was transferred to the hospital. The hospital history and physical dated 1/8/11 indicated Resident #1 was admitted to the hospital for tongue pain and oral infection. The report documented upon arrival, s(he) had a substantial amount of purulent fluid (pus) mixed with blood on his/her left side of his/her tongue. The hospital report documented there was numerous of blisters noted on the right half of his/her tongue and sores along the length of the resident ' s tongue on both the right and left side. The report documented currently, several of the blisters are apparent as well as numerous erosion and ulcers. The hospital report documented the resident ' s tongue had significantly debrided and cleaned up since presenting to the emergency room . Staff interviews and record review showed Resident #1had mouth pain and did not receive a thorough assessment to address his/her complaint of mouth pain and oral drainage until partially assessed on 1/7/11. Staff interviews and record review determined Resident #1 never received the treatment for [REDACTED].