Every finding on record at Riverview Estates

The facility identified a census of 27 residents, with three residents reviewed for abuse, neglect, and exploitation. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 2 and R1 remained free from verbal and mental abuse. This placed R2 and R1 at risk for continued abuse, embarrassment, humiliation, and decreased quality of life due to impaired psychosocial well-being. Findings included: - R2 ' s Electronic Medical Record (EMR) documented R2 had diagnoses of multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and pain. R2's Quarterly Minimum Data Set, (MDS) dated [DATE], documented R2 had a Brief Interview for Mental Status score of 15, which indicated intact cognition. The MDS documented R2 had an indwelling urinary catheter (a tube inserted into the bladder to drain the urine into a collection bag) and was always incontinent of bowel. The MDS documented R2 as dependent on staff for all his activities of daily living (ADL) except for eating. The ADL Functional/Rehabilitation Potential Care Area Assessment, (CAA) dated 12/23/24, documented R2 as at risk for continued functional decline due to his diagnosis of MS and chronic pain. R2 was dependent on staff assistance for ADLs, including transfers and hygiene needs. R2 could feed himself finger foods but usually required staff assistance with his meals. R2 had severe contractures (abnormal fixation of the joints or muscles) of his hands and legs due to MS. R2 ' s Care Plan interventions dated 10/06/23 directed staff to know R2 was incontinent of bowel and staff were to check and change R2 every two to three hours. The plan directed staff to not rush R2, allow extra time to complete ADLs, and have a consistent approach among caregivers. The plan directed staff to allow R2 to have control over situations, establish a trusting relationship with R2, and encourage R2 to become involved in social interactions. The Facility Incident Report, dated 05/28/25, documented on 05/26/25, R2 was scheduled to have a bath. Certified Nurse Aide (CNA) O had two orientees, CNA P and CNA Q, go with her to R2 ' s room to train them on how to transfer and bathe R2. The report documented CNA P reported while they assisted R2 in his bed, R2 was incontinent of stool, which was normal for him. The report documented CNA O stated to R2, You are going to clean my shoes, you are going to buy me new shoes, you need to stop pooping so we can get you in the shower chair, and Oh, that ' s great. You ' re still pooping. The report documented R2 apologized repeatedly. The report noted after R2 ' s shower, the CNAs transferred R2 back to his room in the shower chair, CNA O stopped at the nurse ' s desk and told the staff present R2 pooped in the bathhouse, and it needed to be cleaned up. The report recorded R2 was interviewed and stated he felt embarrassed by what CNA O said to him. The report documented after questioning, CNA O admitted she said some of the things reported, but she was joking, and said she felt R2 knew she was joking. The report documented the facility terminated CNA O from employment. CNA P ' s Witness Statement, notarized on 05/27/25, documented at 03:00 PM, CNA O, CNA P, and CNA Q were getting R2 up for his shower. The statement noted when staff placed R2 in the lift sling, R2 began having bowel movements. CNA P stated CNA O started making remarks to R2 stating, You are going to clean my shoes, and You are going to buy me new shoes. CNA P stated CNA O kept repeating the comments and R2 kept saying, I ' m so sorry girls. CNA P documented CNA O glared at R2 whenever he looked at her. CNA P documented that CNA O then said, You need to stop pooping so we can get you in the shower, and Oh that ' s great. You are still pooping. CNA P noted the three CNA staff got R2 cleaned up and into the shower, R2 started to have incontinent stools again, and CNA O stated, You need to stop pooping. It ' s going all over the place,. CNA O kept giving R2 dirty looks. CNA P wrote when CNA O finished with R2 ' s shower, CNA O pushed R2 back to his room and then stopped at the nurse ' s desk and announced in front of everyone that R2 pooped again after the shower, and it needed to be cleaned up. CNA O ' s Witness Statement, notarized on 05/27/25, documented on 05/26/25 she assisted R2 to the shower. CNA O wrote she showed the other CNAs how to get R2 into the shower chair, R2 was incontinent of bowel movement at that time and asked if it got on their shoes. CNA O noted she jokingly replied, Yes, but they are washable and everyone laughed. CNA O documented that R2 kept apologizing, and CNA O reassured R2 that it was okay because her shoes and clothes were washable. On 06/02/25 at 11:30 AM, R2 sat up in bed with a neck pillow behind his neck and watched a program on his iPad. R2 had contractures to his bilateral hands but was able to use a stylus to run the iPad. R2 stated he had no control over his bowels and when staff assisted him up in the lift for transfers, he was always incontinent of stool. R2 confirmed the things CNA O said to him, and he stated she made him feel bad and humiliated in the shower room that day. R2 said everyone else at the facility treated him very well. On 06/02/25 at 11:45 AM, CNA P stated that R2 was such a sweet man, and he had no control over his bowels due to his diagnosis of MS. CNA P stated that making R2 feel bad for something he had no control over was wrong. CNA P stated she recently received education on ANE and reporting suspected abuse or neglect immediately. On 06/02/25 at 11:55 AM, Administrative Nurse D stated there were several times CNA O would say things to other staff, would have to be redirected not to say things like that, then she would say she was just joking. Administrative Nurse D stated at first, CNA O would not admit what she said to R2, but then CNA O did finally admit what she said after she already filled out her Witness Statement. Administrative Nurse D stated this kind of behavior of staff degrading residents would not be tolerated by any of the staff working at the facility, CNA O was terminated from employment, all staff were assigned ANE education in Relias (a training portal) and received the education verbally before working their next shift. The facility ' s Abuse, Neglect, and Exploitation Policy, revised 04/12/22, documented the facility had developed and implemented this policy and procedure to prohibit abuse, neglect, exploitation, or misappropriation of property by any perpetrator, including but not exclusive to any staff member or volunteer of the facility or any contracted agency staff, vendors, family member or visitors of the elder or other elders, or any other elders. Facility staff will not allow others to use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. - R1 ' s Electronic Medical Record (EMR) documented R1 had diagnoses of Alzheimer ' s disease (progressive mental deterioration characterized by confusion and memory failure), dementia (progressive mental disorder characterized by failing memory, and confusion), major depressive disorder (major mood disorder which causes persistent feelings of sadness), psychosis (any major mental disorder characterized by a gross impairment in reality perception), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), restlessness, and agitation. R1's Significant Change Minimum Data Set (MDS) dated [DATE] documented R1 had a Brief Interview for Mental Status (BIMS) score of three, which indicated severely impaired cognition. The MDS documented R1 had physical behaviors directed toward others during the observation period. The MDS documented R1 required the use of a wheelchair pushed by staff for locomotion and required maximum staff assistance for all her activities of daily living (ADL). The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 03/24/25 documented R1 had a diagnosis of Alzheimer ' s disease and was alert and oriented to herself only. The CAA noted R1 was placed on hospice care due to Alzheimer ' s disease and was at risk for impaired cognition related to end-of-life care. The CAA documented R1 could become agitated with staff when she was in pain, she required substantial assistance due to total dependence with ADL care and was non-ambulatory. The Psychosocial Well-Being CAA, dated 03/24/25, documented R1 did not do well with groups of people or loud noises and would become agitated. The CAA documented R1 was offered one-on-one activities from staff as she would allow. The Communication CAA, dated 03/24/25, documented R1 ' s diagnoses of Alzheimer ' s disease and major depressive disorder increased R1 ' s risk for impaired communication. The CAA documented R1 was not always able to communicate her needs to staff. The CAA documented R1 typically showed agitation when she needed something. R1 ' s Care Plan documented R1 could have behaviors of cussing and hitting, which typically occurred during baths and bowel movements. The plan directed staff R1 liked to listen and sing to country music (03/27/25). The plan directed staff to explain to R1 step by step what staff were doing when providing care, as this helped calm R1 down to know what was going to happen (11/13/24). The plan directed staff to provide R1 with a calm environment when she was agitated (12/13/23). The plan directed staff to provide R1 maximum to total assistance for all her cares (12/13/23). The Facility Incident Report, dated 05/05/25, documented on 05/01/25 at approximately 07:00 PM, Certified Nurse Aide (CNA) M and CNA N provided peri-care and bedtime care for R1. The report noted R1 became agitated, and CNA N attempted to calm R1 by assuring her cares were almost done. The report documented that CNA M stated, No [R1], I ' m going to make this take longer just to [expletive] you off. The report documented CNA N reported the occurrence to LN G at 07:15 PM and Licensed Nurse (LN) G reported the incident to Administrative Nurse D. The facility told CNA M to immediately exit the facility. The report documented CNA M refused to write a statement and was terminated from employment on 05/02/25. CNA N ' s Witness Statement, notarized on 05/05/25, documented while providing care to R1, CNA M told R1 to shut up. CNA N stated she told R1 they were almost done, and CNA M stated, No, R1. I ' m going to make this take longer just to [expletive] you off. CNA N stated she stayed quiet, she and CNA M exited R1 ' s room together, and CNA N reported the incident to LN G. On 06/02/25 at 10:00 AM, R1 sat in a recliner in the day room, watched a western on TV, and fidgeted in the recliner, restless. R1 would not answer questions or communicate. On 06/02/25 at 10:30 AM, CNA N stated that R1 was easy to take care of and was very sweet. CNA N stated that R1 did not like to be exposed for long periods of time when cares were provided, but if R1 started to get agitated, she was easily redirected. CNA N stated the facility provided education regarding ANE and knew if she saw or heard something, she would report it immediately. On 06/02/25 at 10:45 AM, LN H stated that R1 was easy to care for and easily redirectable. LN H stated she was educated regarding ANE and knew to report any possible instances of abuse immediately to administrative staff and to keep residents safe. On 06/02/25 at 11:30 AM, Administrative Nurse D stated the incident of verbal abuse by CNA M was unacceptable. Administrative Nurse D said CNA M refused to provide a witness statement regarding the incident and refused to talk to administrative personnel about the incident. Administrative Nurse D stated the facility assigned ANE training to all staff in Relias (a training portal), and the facility verbally educated staff on all shifts until all staff were trained. The facility ' s Abuse, Neglect, and Exploitation Policy, revised 04/12/22, documented the facility had developed and implemented this policy and procedure to prohibit abuse, neglect, exploitation, or misappropriation of property by any perpetrator, including but not exclusive to any staff member or volunteer of the facility or any contracted agency staff, vendors, family member or visitors of the elder or other elders, or any other elders. Facility staff will not allow others to use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The facility identified the above deficient practices and implemented immediate corrective actions, which were all completed on 05/31/25 and included: All nursing staff re-educated on recognizing and reporting abuse, neglect, and exploitation, and the CNA perpetrators were terminated from employment. Due to the corrective action completed before the onsite survey, the citation was deemed past noncompliance at a G scope and severity to represent R2's actual psychosocial harm evidenced by embarrassment and humiliation.

The facility had a census of 23 residents. The sample size included 12 residents, with 12 residents reviewed for neglect. Based on record review and interview, the facility failed to prevent the neglect of Resident (R) 26, when staff failed to timely and competently assess and provide care for R26, who had a known history of sepsis (a life-threatening systemic reaction that developed due to infections which cause inflammation throughout the entire body). On 01/05/25 at 06:58 PM, R26 struggled to talk and drink liquids. Licensed Nurse (LN) H contacted the on-call physician and reported R26 acted similar to the last time R26 was septic. Based on this information, the physician ordered one gram of Rocephin (an antibiotic) every 24 hours for seven days and stated if R26 did not show any signs of improvement, or her condition worsened, then LN H was to send R26 to the emergency room . On 01/06/25 at 02:55 AM, R26 had oxygen on at two liters per minute, with shallow, labored respirations. R26's skin was pale and moist to the touch. R26 had the head of her bed elevated to 30 degrees due to respirations with coarse lung sounds throughout. R26 did not respond when staff called her name, nor did she communicate with staff and LN H failed to call the physician or send R26 to the ER. Just over 2 hours later, at 05:10 AM, Certified Nurse Aide (CNA) M called LN H to R26's room and R26 had no pulse and no respirations. These failures ultimately resulted in R26's expiration at the facility on 01/06/25 sometime between 02:55 AM and 05:10 AM and placed R26 in immediate jeopardy. Findings included: - R26's Electronic Medical Record (EMR) documented diagnoses of sepsis, ulcer of the esophagus (the tube that carries food and liquids from the mouth to the stomach) with bleeding, fracture (broken bone) of shaft of the right humerus (upper arm bone), and age-related osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk). R26's Care Plan, dated 11/22/24, directed staff to assist with activities of daily living (ADL) as needed and staff was to notify the resident's physician of any changes in condition. The care plan directed staff to monitor and report signs of respiratory distress. The Progress Note, dated 01/03/25 at 09:25 PM, documented during care for R26 the nurse noted a bulge in her right mid-lower abdomen. The area was soft to the touch but had a ridge in the circumference of the bulge measuring 10 centimeters (cm) in diameter. R26 denied any pain with it or when gently touched. No further assessment of this concern was documented. The Progress Note, dated 01/04/25 at 05:25 AM, documented blood pressures today of 107/52 millimeters of mercury (mmHg) and 90/53 mmHg (normal for a person over [AGE] years old would be 140/80 mmHg), pulses of 58 and 103 beats per minute (normal range 60-100 bpm). R26 was very lethargic and took only two bites of the noon meal. R26 refused to come out of her room for supper. LN H notified the physician who stated her vital signs (blood pressure and pulse) were within normal limits. The physician-directed staff to notify her primary physician of her condition by fax. The Progress Note, dated 01/05/25 at 12:24 AM, documented R26 complained of increased pain and the scheduled Percocet (narcotic pain relief drug) was not effective in pain management this evening. The Progress Note, dated 01/05/25 at 06:58 PM, documented R26 was hypotensive (low blood pressure) with tachycardia (rapid heartbeat greater than 100 beats per minute - bpm). R26 was struggling to talk and drink liquids. The note stated LN H contacted the physician and informed him R26 acted similarly the last time she was septic. The physician ordered R26 to have one gram of Rocephin every 24 hours for 7 days and if R26 did not show any improvement, or her condition worsened send her to the emergency room (ER). On 01/06/25 at 01:50 AM, vital sign documentation revealed R26's blood pressure was 94/46 mmHg, pulse 131 bpm, and respirations were 18 breaths per minute. On 01/06/25 at 02:52 AM, vital sign documentation revealed R26's blood pressure was 95/55 mmHg, pulse 77 bpm, and respirations were 22 breaths per minute. The Progress Note, dated 01/06/25 at 02:55 AM, documented R26 required oxygen supplementation at two liters per minute due to her respirations were shallow and labored. R26's skin was pale and moist to the touch. R26 refused fluids and pursed her lips tight when oral care was offered. The note documented LN H elevated the head of her bed due to respirations with lung sounds, which were course throughout. R26 did not respond to staff when they called her name, but she repeatedly shook her head no. On 01/06/25 there was no further assessment of R26 documented until 05:10 AM. The Progress Note, dated 01/06/25 at 05:10 AM, documented a CNA (certified nurse aide) M called LN H to R26's room. R26 had no pulse and no respiration. On 03/19/25 at 11:16 AM, Administrative Nurse D stated she was unaware of the bulge the nurse noted in the resident's abdomen on 01/03/25. Administrative Nurse D verified there was no further follow-up of that issue. Administrative Nurse D verified on 01/06/25 at 02:55 AM, that staff should have called Emergency Medical Services (EMS) or the physician when R26 worsened per the physician's order eight hours earlier. The facility's Standards of Care policy, dated 09/18/21, stated the Lippincott Manual for Nursing Procedures (7th edition) would serve as the basis for standard nursing practice. The policy stated it would not replace the responsibilities of professional nursing education and policies, protocols or guidelines may be developed by the facility to specifically address the long-term care environment. Nurses were to refer to the [NAME] for standards of care, utilize, and revise as needed under the guidance of the director of nursing and the infection preventionist. The facility's Admission Assessment and Follow Up policy, dated September 2012, directed nursing staff to notify the supervisor and attending physician of immediate needs the resident may have and report any other information in accordance with facility policy and professional standards of practice. The facility's Abuse and Neglect- Clinical Protocol, dated March 2018, stated the nurse would assess the resident and document related findings. The physician, staff, and management would identify situations that could be construed as neglect. The physician would provide adequate documentation regarding significant negative outcomes that have resulted from a resident's underlying medical illness or conditions, despite appropriate care. The medical director would advise staff and management on ways to ensure that basic medical, functional, and psychosocial needs were being met and that potentially preventable or treatable conditions affecting function and quality of life were addressed appropriately. The facility failed to prevent the neglect of R26, when staff failed to timely and competently assess and provide care for R26, who had a known history of sepsis. On 01/05/25 at 06:58 PM, R26 struggled to talk and drink liquids. LN H contacted the on-call physician and reported R26 acted similar to the last time R26 was septic. Based on this information, the physician ordered one gram of antibiotic every 24 hours for seven days and stated if R26 did not show any signs of improvement, or her condition worsened, then LN H was to send R26 to the emergency room . On 01/06/25 at 02:55 AM, R26 had oxygen on at two liters per minute, with shallow, labored respirations. R26's skin was pale and moist to the touch. R26 had the head of her bed elevated to 30 degrees due to respirations with coarse lung sounds throughout. R26 did not respond when staff called her name, nor did she communicate with staff and LN H failed to call the physician or send R26 to the ER. Just over 2 hours later, at 05:10 AM, CNA M called LN H to R26's room and R26 had no pulse and no respirations. These failures ultimately resulted in R26's expiration at the facility on 01/06/25 sometime between 02:55 AM and 05:10 AM and placed R26 in immediate jeopardy. The following citations represent the findings of a partial extended annual survey. On 03/19/25 at 05:41 PM Administrative Staff A received a copy of the Immediate Jeopardy Template and was informed of the immediate jeopardy for Resident (R) 26. The facility completed the following corrective actions to remove the immediacy for R26: Immediate education regarding F600 began 03/19/25 and was completed 03/20/25 at 12:30 PM. Nursing staff were not allowed to work until they were educated on the policy and clinical protocols for assessing residents and notification to the physician upon changes in condition. On 03/20/25, an onsite verified the completion of the corrective actions to remove the immediacy. After the immediacy was removed the deficient practice remained at a scope and severity of G to represent the actual harm to R26.

The facility had a census of 23 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to properly date opened bags of food with the open date and the expiration date. This practice placed the 23 residents at risk for foodborne illness and poor-quality food. Findings included: - On 03/13/25 at 08:20 AM, an inspection of the facility kitchen cold storage revealed the #4 upright freezer had seven opened, undated bags of frozen vegetables and potato items. The #5 freezer contained an opened box of hamburger patties with the plastic bag open to the air and undated. On 03/13/25 at 08:20 AM, Dietary Staff BB verified the bags were undated or the date was not readable. She stated the marker staff used for frozen foods was not appropriate as the ink rubbed off. The facility's Food Receiving and Storage policy, dated October 2017, stated foods would be received and stored in a manner that complied with safe food handling practices. The policy stated all foods stored in the refrigerator or freezer would be covered, labeled, and dated with a use-by date. The freezer must keep frozen foods solid, and wrappers of frozen food must stay intact until thawing, opened containers must be dated and sealed or covered during storage. The facility failed to properly date opened bags of food with the open date and the expiration date. This deficient practice placed the 23 residents at risk for foodborne illness and poor-quality food.

The facility had a census of 23 residents. The sample size included 12 residents. Based on observation, record review, and interview, the facility failed to adhere to infection control for enhanced barrier precautions (EBP - an infection control intervention designated to reduce transmission of resistant organisms that employs targeted gown and glove used during high contact resident care activities), for Resident (R) 13 who had Influenza A (a contagious viral infection of the nose, throat and lungs that is spread from person to person through respiratory droplets). This placed the residents at increased risk for infection. Findings included: - On 03/13/25 at 09:30 AM, observation revealed License Nurse (LN) I entered the room of R13, who was on Droplet Precautions EBP. Observation revealed a sign posted on the resident's door of the resident's room giving instruction on personal protection equipment (PPE - gown and gloves). The PPE equipment and supplies were located in an over-the-door hanging container in the resident's room. Continued observation revealed LN I entered the resident's room and donned only gloves. LN I sat down beside the resident while she was in bed and began to talk to her about how she was feeling and conversing back and forth. LN I was in the room for approximately eight minutes when LN J observed LN I in the resident room and explained to LN I the resident required staff and visitors to don a gown due to R13 being on contact and droplet precautions. LN I stood up and went to the PPE that was stored on the resident's door and donned a gown then sat down next to the resident in her bed and started talking to her again. On 03/19/25 at 09:45 AM, Administrative Nurse D verified R13's room door had a Contact Isolation sign posted on the door and instructions for wearing appropriate PPE. Administrative Nurse D verified the resident's door had a sign that stated, Contact Precautions and anyone entering the room should wash their hands, don gloves, and a mask. The sign did not indicate to wear a gown. Administrative Nurse D stated she would discuss the Isolation precautions with Administrative Nurse E, the Infection Preventionist, and verify the Isolation Precautions the resident should be on due to the resident had been diagnosed with Influenza A. Administrative Nurse D stated she would wear a gown if the resident had droplet precautions. On 03/19/25 at 01:00 PM, Administrative Nurse E verified after reviewing the infection control protocol Droplet Precautions and Contact Precautions that the staff should wear PPE when providing care for R13 which would include washing hands, donned gloves, mask, and gown. Administrative Nurse E stated she obtained the signs and the guidelines from the CDC website. Administrative Nurse E said the facility would do some education with the staff regarding EBP and wearing PPE for resident care. The facility's Enhanced Barrier Precautions policy, dated March 2024, documented EBP's are utilized to reduce the transmission of multi-drug resistant organisms (MDROs) to residents. EBP was used as an infection prevention and control intervention to reduce the transmission of multi-drug resistant organisms (MDROs) to residents. EBPs employ targeted gown and gloves used in addition to standard precautions during high-contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied prior to performing the high-contact resident care activities (as opposed to before entering the room) PPE is changed before caring for another resident. Face protection may be used if there is also a risk of splash or spray. Examples of high-contact residents are activities requiring the use of gowns and gloves for EBP's including: Dressing Bathing/showering Transferring Providing hygiene Changing linens Changing briefs or assisting with toileting Device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator.); and Wound care (any skin opening requiring a dressing). The facility's Isolation-Categories of Transmission-Based Precautions, policy, dated September 2020, documented that Transmission-Based Precautions were initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory-confirmed infection, and is at risk of transmitting the infection to other residents. Standard precautions are used when caring for residents at all times regardless of their suspected or confirmed infection status. Transmission-based precautions are additional measures that protect staff, visitors, and other residents from becoming infected. These measures are determined by the specific pathogen and how it is spread from person to person. The three types of transmission-based precautions are contact, droplet, and airborne. The Centers for Disease Control and Prevention (CDC) maintains a list of diseases, modes of transmission, and recommended precautions. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for any type of precautions. a. The signage informs the staff of the type of CDC precautions, instructions for the use of PPE, and/or instructions to see a nurse before entering the room. b. Signs and notifications comply with the resident's right to confidentiality or privacy. When transmission-based precautions are in effect, non-critical resident-care equipment items such as a stethoscope, and digital thermometer would be dedicated to a single resident when possible. If re-use of items is necessary, then the items would be cleaned and disinfected according to current guidelines before use with another resident. Droplet Precautions are implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets (large particles that can be generated by the individual coughing, sneezing, talking, or by performance of procedures such as suctioning). Residents on droplet precautions are placed in private room if possible. Mask are worn when entering the room. Gloves, gown, and goggles are worn if there is a risk of spraying respiratory secretions. The facility failed to ensure staff applied the appropriate PPE required for EBP for R13. This placed the resident at increased risk for infection.

The facility had a census of 23 residents. Based on observation, interview, and record review, the facility failed to perform background checks as required for four employees. The employees were allowed access to residents without knowing if they had been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. This deficient practice placed the 23 residents of the facility at risk for potential abuse, neglect, or exploitation. Findings included: - On 03/18/25 a review of staffing for background checks for facility staff was completed. Upon request and review the facility was unable to provide evidence a criminal background check had been completed before four employees began working around and with residents. The facility records revealed the following staff started employment at the facility before the background checks returned: Certified Nurse Aide (CNA) N started on 07/09/22 and the background check was not verified until 02/04/24. CNA O started on 01/24/24 and the background check was not verified until 02/12/24. Housekeeping Staff U started on 11/05/21 and the background check was not verified until 12/03/24. Maintenance Staff V started on 02/20/24 and the background check was not verified until 02/22/24. On 03/18/25 at 01:39 PM, Administrative Staff A verified the facility had not received the background checks for four staff prior to those staff working in the facility. The facility's Monitoring Background Checks policy, dated 09/06/2021, stated following each background check on each newly hired employee, human resource personnel would routinely check the state website for the results of the checks. The date of the background check, the result, and the date the result was recorded would be tracked. The facility failed to perform background checks as required for four employees who were allowed access to residents without knowing if they had been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law.

The facility had a census of 23 residents. The sample includes 12 residents, with seven residents reviewed for immunizations, Resident (R) 5, R10, R11, R13, R16, R21, and R22, to include pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations. Based on record review and interviews, the facility failed to offer, or obtain an informed declination or a physician-documented contraindication for the pneumococcal PCV20 vaccination per the latest guidance from the Centers for Disease Control and Prevention (CDC). This placed the residents at risk for pneumococcal infection and related complications. Findings included: - Review of R10, R11, R13, R16, and R21 clinical medical records lacked evidence the facility or the resident representative received or signed a consent to receive or informed declination for the pneumococcal vaccine PCV20. Review of R5's electronic health record revealed the resident was admitted to the facility on [DATE]. R5 had not been offered or received a pneumococcal vaccine since admission. Review of R22's electronic health record revealed the resident was admitted to the facility on [DATE]. R22 had not been offered or received a pneumococcal vaccine since admission. On 03/19/25 at 02:00 PM, Administrative Nurse E stated residents are offered the pneumonia vaccines on admission and as indicated. Administrative Nurse E said the facility would sign a consent or deny receiving the vaccine. Administrative Nurse E verified that every resident in the building had not been reviewed to determine if they were eligible to receive the PVC20 vaccine or not. Administrative Nurse E verified they did not have a definitive system in place to determine who was eligible, if they were eligible if they had been offered or declined the vaccinations, and it was something they had recently been working on. On 02/13/25 at 2:35 PM, Administrative Nurse D verified the facility lacked a system in place to identify which residents were eligible for which pneumococcal vaccination. Administrative Nurse D stated they did not have a system in place to identify which pneumococcal vaccine the residents were eligible for or if they were eligible and if so for which one. The facility's Pneumococcal Vaccine policy dated; October 2019 documented all residents were offered pneumococcal vaccines to aid in the prevention of pneumonia/pneumococcal infections. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within thirty days of admission to the facility unless medically contraindicated or the resident has completed the current recommended vaccine series. Assessment of pneumococcal vaccination status was conducted within five working days of the resident's admission if not conducted prior to admission. Before receiving a pneumococcal vaccine, the resident or legal representative receives information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Provision of such education is documented in the resident's medical record. Pneumococcal vaccines are administered to residents per the facilities physician approved pneumococcal vaccination protocol. Residents/representatives have the right to refuse vaccinations. If refused, appropriate information is documented in the resident's medical record indicating the date of refusal of the pneumococcal vaccine. Administration of the pneumococcal vaccines was made in accordance with the current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. The facility failed to offer the PCV20 pneumococcal vaccination for R5, R10, R11, R13, R16, R21 and R22. This deficient practice placed the residents at risk of acquiring, spreading, and experiencing complications from pneumonia.

The facility had a census of 23 residents. The sample included 12 residents with one reviewed for urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). Based on observation, interview, and record review, the facility failed to provide Resident (R) 11 a device to secure the catheter tubing to keep it from pulling and causing discomfort. This deficient practice placed R11 at risk for pain or injury related to the catheter use and R11 developed two open sores related to the catheter rubbing. Findings included: - R11's Electronic Medical Record (EMR) documented diagnoses of an open wound of the penis (male organ with urethra tube which carries urine to outside the body), pain, and Urinary Tract Infection (UTI - an infection in any part of the urinary system). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS documented R11 required maximum staff assistance for toileting, had a urinary catheter, and occasional moderate pain. The MDS documented R11 had no skin issues. R11's Care Plan for urinary catheter, dated 01/03/25, directed staff to provide a 16Fr. (French) 30 cubic centimeters (cc) catheter, and change the catheter per physician's order. The staff were directed to not allow tubing or any part of the drainage system to touch the floor and provide catheter care daily and as needed. The staff were to change the catheter bag weekly, assess the drainage, and record the amount, type, color, and odor. The staff were to observe for leakage and irrigate the catheter only if an obstruction was suspected. The staff were to keep the catheter system a closed system as much as possible, manipulate tubing as little as possible during care, and measure and record the urine output. The staff was to position the catheter collection bag below the level of the bladder and store the collection bag inside a protective dignity pouch. The staff was to use a catheter strap as needed and ensure enough slack was left in the catheter tubing between the meatus (opening on the penis which leads into the body) and the strap. The Physician Order, dated 10/17/24, directed staff to ensure a 16Fr.30 cc catheter was in place. The Progress Note, dated 03/12/2025 at 09:06 AM documented R11's catheter change was completed. When changing the catheter, R11's penis was found to have two sores. The sores were approximately 0.5 centimeters (cm) in diameter. R11's catheter rubbed against the sores. The physician was faxed and the family was notified regarding the issue. The Progress Note, dated 03/17/2025 at 11:43 AM documented R11 denied abuse or neglect and nursing staff reported that catheter tubing was rubbing against the penis area. The note stated licensed nurses were to apply protective barrier cream to the area until healed and after healed to prevent skin impairments. The care plan was reviewed and updated to ensure the catheter tubing was not pressing or rubbing against his perineal area or penis which could cause skin impairments. On 03/19/25 at 12:00 PM, Licensed Nurse (LN) H donned personal protective equipment (PPE) and took gauze, Calmoseptine, and wound cleanser into R11's room. R11 was in bed and LN H performed wound care to the two penis wounds as ordered. R11 had no catheter secure device or strap-on. On 03/19/25 at 12:00 PM, LN H stated that R11 did not leave the device on due to the adhesive. LN H thought he had signed a risk agreement to not wear the securing device. On 03/19/25 at 12:10 PM, Administrative Nurse D verified staff should have placed a secure device for the resident's catheter tubing to prevent pulling on it as care planned and he had no risk agreement to not wear a secure device or strap. The facility's Urinary Catheter Care policy, dated August 2022, directed staff to ensure the catheter remained secured with a securement device to reduce friction and movement at the insertion site. The policy stated staff should record any problems noted at the insertion site such as redness, bleeding, irritation, or pain. The facility failed to provide R 11 a device to secure the catheter tubing to keep it from pulling and causing discomfort. This deficient practice placed R11 at risk for pain or injury related to the catheter use and R11 developed two open sores related to the catheter rubbing.

The facility had a census of 23 residents. The sample included 12 residents. Based on record review and interview, the facility failed to develop a discharge summary that included a complete recapitulation (a concise summary of the resident's stay and course of treatment in the facility) of the resident's stay and post-discharge plan for Resident (R) 27. This placed the resident at risk for receiving inadequate care. Findings included: - R27's Electronic Medical Record (EMR) revealed the resident admitted to the facility on [DATE]. R27's admission Minimum Data Set (MDS), dated [DATE], documented R27 required limited staff assistance with activities of daily living (ADL). The MDS documented there are active discharge plans in place for returning R27 to return to the community. The Activities of Daily Living (ADLs) Care Area Assessment (CAA), dated 12/26/24, documented the resident was recently hospitalized for treatment of pneumonia and would receive physical therapy and occupational therapy. The CAA documented that staff would manage the resident's chronic pain. R27's admission Care Plan, dated 01/03/25, documented the resident was at risk for shortness of air related to respiratory disease. The Care plan documented the resident and the physician fully anticipated her return to the community. The Nurse's Note, dated 01/24/25 at 12:30 PM, documented R27 was discharged from the facility to home. Review of R27's EMR lacked a discharge summary, which included a complete recapitulation of her stay. On 03/19/25 at 08:10 AM, Administrative Staff A verified R27's discharge summary had an incomplete recapitulation of her stay and stated nursing was responsible for completing the discharge summary. The facility's Admission, Transfer, and Discharge policy, dated 08/31/21, documented that when facility staff mandates a transfer out of the facility or discharge from the facility, staff will document the reason(s) for and conditions under which the resident is mandated to transfer out of the facility or to be discharged and the method for transitioning the responsibility for the resident's care from the clinician, organization, program or services to another. In addition, the following documentation requirements include: The resident's response to medical treatment and care. admission information, current medical findings, diet prescribed, the resident's functional status at the time of admission, and the time of discharge. Medical observation and recommendations were made after the initial medical assessment, as well as progress notes that were reported at the time of observation and that described significant changes in the resident's condition. Progress notes recorded at each visit. Compete transfer form and discharge summary. If the resident dies in the facility, the course of events leading to the resident's death. Evidence that the attending physician had reviewed the consulting physician's order for consistency with the interdisciplinary plan of care. Facility staff would document in the clinical record discharge information provided to the resident and the receiving organization, if applicable. Medical findings and diagnosis; a summary of the care, treatment, services provided, and progress reached toward goals. The facility failed to develop a discharge summary that included a complete recapitulation of R27's stay and post-discharge plan. This placed the resident at risk for receiving inadequate care.

The facility had a census of 23 residents. The sample included 12 residents, with two residents reviewed for discharge. Based on observation, record review, and interview, the facility failed to provide Resident (R) 13 with written information regarding the facility's bed hold policy when she was transferred to the hospital. This placed the resident at risk of not being permitted to return and resume residence in the nursing facility. Findings included: - R13's Electronic Health Record (EHR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) with behavioral disturbance, arteriosclerotic heart disease (ASHD - is a condition where the arteries that supply blood to the heart become narrowed and hardened due to buildup of plaque, a sticky substance), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R13's Significant Change Minimum Data Set (MDS), dated [DATE], recorded R13 had severe cognitive impairment (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). The MDS recorded she required extensive staff assistance with transfers and activities of daily living (ADL). The MDS documented the resident received hospice service. The Care Area Assessment (CAA), dated 02/14/25, recorded R13 required partial to dependent assistance with ADLs and mobility and requires substantial assistance of two staff and a sit-to-stand mechanical lift for transfers. The CAA documented the resident had a diagnosis of dementia, was pleasantly confused, and as the disease progress she has functional decline. R13's facility Care Plan, dated 03/04/25, recorded R13 required extensive staff assistance with most ADL care. R13's Care Plan documented the resident had a diagnosis of dementia and required hospice services. The care plan directed the staff to provide comfort and encourage family and friends support system. The care plan directed staff to observe closely for signs of pain and administer medications as ordered. The facility care plan lacked instruction on the services provided by hospice including the frequency and type of support visits, supplies and medical equipment provided by hospice, medications covered by hospice, and the hospice contact information. On 08/19/24 at 05:34 PM, the Nurse's Notes documented the resident had emesis while eating dinner and did not finish eating. On 8/21/24 at 09:17 AM, the Nurses Notes documented the resident continued to refuse to get out of bed. R13's color was pale and had a moist cough, blood pressure 90/60 (normal 120/80), pulse 88 (normal 60-100), and oxygen saturation 89% (normal between 95% and 100%). On 08/21/24 at 12:56 PM, the Nurse's Notes documented R13 admitted to the hospital for dehydration and acute kidney failure. R13's relative was notified. On 08/24/24 at 11:40 AM, the Nurse's Notes documented R13 returned to the facility per facility staff. R13 entered the facility in a wheelchair and staff assistance. Observation revealed R13 was alert to person, fatigued, and weak. The physician ordered Amoxicillin-pot clavulanate (an antibiotic) 875-125 milligrams (mg), one tablet for five days for a diagnosis of pneumonia and dehydration. R13's clinical record lacked a bed hold policy notice. On 03/19/25 at 10:30 AM, Social Service Staff X stated the facility does not provide bed hold notices to the residents or their representative until 10 days after the discharge if they are Medicaid, and at that time would obtain a signed bed hold policy. On 03/19/25 at 10:45 AM, Administrative Nurse D verified the facility lacked evidence of a signed bed hold policy notice that had been verbally acknowledged, provided, or signed by the resident's representative when R13 was transferred and admitted to the hospital on [DATE]. The facility's Bed Hold policy dated 09/06/21 documented before the facility transfers a resident to the hospital or the resident goes on therapeutic leave, the facility would provide written information to the resident and/or the resident representative that specifies the duration of the state bed-hold policy during which the resident is permitted to return and resume residency in the facility; the reserve bed payment policy is the state plan; the facilities' policies regarding bed-hold period, which are consistent with the law permitting the resident to return. The facility will allow the resident whose hospitalization or therapeutic leave exceeds the bed-hold policy under the state plan may return to the facility to the resident's previous room if available or immediately upon the first availability of a bed in a semi-private room if the resident requires the services provided by the facility and is eligible for Medicare skilled nursing services or Medicaid nursing facility services. Prior to transferring a resident to a hospital or if a resident goes on therapeutic leave, facility nursing staff will provide written information to the resident and/or representative and family that specifies: a. The duration of the bed-hold policy under Kansas law and regulations, during which the resident is permitted to return and resume residence in the facility b. The facility's police regarding bed-hold periods. On admission, the resident and/or the representative/legal guardian and interested family member would be provided verbally and a written copy of the bed-hold policy. The bed-hold policy would have information about any charges the resident would incur when out of the facility overnight. The nurses responsible for the preparation of information that would accompany a resident when transferred to another healthcare facility would include the facility policy for retaining the resident's current bedroom while absent from the facility. If the representative or designated family member is not present at the time of transfer to another health care facility, a copy of the policy would be mailed to the resident's representative or designated family member the next working day. It is the responsibility of the facility nurse or Social Service staff to ensure that the resident, the resident's representative, or designated family member are aware of their responsibilities if they wish to hold the bedroom during the resident's absence from the facility. The facility failed to provide R13's representative with a copy of the facility bed hold policy when she was transferred to the hospital. This placed the resident at risk for not being permitted to return and resume residence in the nursing facility.

The facility had a census of 23 residents. The sample included 12 residents. Based on interviews and record review, the facility failed to notify the State Long term Care Ombudsman (LTCO) of Resident (R)13's facility-initiated discharge to the hospital. This placed R13 at risk for impaired rights. Findings included: - R13's Electronic Health Record (EHR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) with behavioral disturbance, arteriosclerotic heart disease (ASHD, is a condition where the arteries that supply blood to the heart become narrowed and hardened due to buildup of plaque, a sticky substance), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R13's Significant Change Minimum Data Set (MDS), dated [DATE], recorded R13 had severe cognitive impairment. The MDS recorded she required extensive staff assistance with transfers and activities of daily living (ADL). The MDS documented the resident received hospice service. The Care Area Assessment (CAA), dated 02/14/25, recorded R13 required partial to dependent assistance with ADLs and mobility and required substantial assistance of two staff and a sit-to-stand mechanical lift for transfers. The CAA documented the resident had a diagnosis of dementia, was pleasantly confused, and as the disease progressed she had a functional decline. R13's Care Plan, dated 03/04/25, recorded R13 required extensive staff assistance with most ADL care. R13's Care Plan documented the resident had a diagnosis of dementia and required hospice services. The care plan directed the staff to provide comfort and encourage family and friends' support system. The care plan directed staff to observe closely for signs of pain and administer medications as ordered. The facility care plan lacked instruction on the services provided by hospice including the frequency and type of support visits, supplies and medical equipment provided by hospice, medications covered by hospice, and the hospice contact information. On 08/19/24 at 05:34 PM, Nurse's Notes documented the resident had emesis while eating dinner and had not finished. On 8/21/24 at 09:17 AM, Nurses Notes documented the resident continued to refuse to get out of bed, color pale, and had a moist cough, blood pressure 90/60 (normal 120/80) pulse 88 (normal 60-100) and oxygen saturation 89% (normal between 95% and 100%.) On 08/21/24 at 12:56 PM, Nurse's Notes documented the resident was admitted to the hospital for dehydration and acute kidney failure. The relative was notified. On 08/24/24 at 11:40 AM, Nurse's Notes documented the resident returned to the facility per facility staff. The resident entered the facility in a wheelchair and staff assistance. Observation revealed the resident was alert to person fatigue, and weak. The physician ordered Amoxicillin-pot clavulanate (antibiotic) 875-125 milligrams (mg), one tablet for five days for a diagnosis of pneumonia and dehydration. R13's clinical record lacked documentation staff notified the LTCO of the resident's discharge from the facility. On 03/19/25 at 08:30 AM, Administrative Staff A stated they did not have any notification to the Ombudsman regarding the residents' discharge. Administrative Staff A stated the facility had started sending the Ombudsman monthly Admission/Leave/Discharges notification in February 2025, after she attended a meeting with the LTCO president and was informed what should be sent to them and the information needed to be sent regarding the discharges from the facility. Administrative Staff A stated it was her understanding they were to notify the Ombudsman only if it was a facility-initiated discharge. The facility's Admission, Transfer, and Discharge, policy, dated 08/31/21, documents that when facility staff mandates a transfer out of the facility or discharge from the facility, staff will document the reason(s) for and conditions under which the resident is mandated to transfer out of the facility or to be discharged and the method for transitioning the responsibility for the resident's care from the clinician, organization, program or services to another. In addition, the following documentation requirements include: The resident's response to medical treatment and care. admission information, current medical findings, diet prescribed, the resident's functional status at the time of admission, and the time of discharge. Medical observation and recommendations were made after the initial medical assessment, as well as progress notes that were reported at the time of observation and that described significant changes in the resident's condition. Progress notes recorded at each visit. Compete transfer form and discharge summary. If the resident dies in the facility, the course of events leading to the resident's death. Evidence that the attending physician had reviewed the consulting physician's order for consistency with the interdisciplinary plan of care. Facility staff would document in the clinical record discharge information provided to the resident and the receiving organization, if applicable. Medical findings and diagnosis; a summary of the care, treatment, services provided, and progress reached toward goals. The policy documented the State Ombudsman would be notified of any/all involuntary discharges for assistance with transition and support of the resident and the representative. The facility failed to notify the LTCO of R13's discharge. This deficient practice placed the resident at risk for impaired rights.

The facility had a census of 23 residents. The sample size included 12 residents. Based on record review and interview, the facility failed to notify Resident (R) 26's physician or family when staff noted an abnormal bulge in R26's right abdomen on 01/03/25. The facility nursing staff also failed to notify the physician on 01/06/25 when R26 had a further deterioration in condition with shallow, labored respirations. R26's skin was pale and moist to the touch, and she had coarse lung sounds throughout. R26 did not respond when staff called her name, nor did she communicate with staff. LN H failed to call the physician or send R26 to the ER at that time. This deficient practice placed R26 at risk for serious health consequences. Findings included: - R26's Electronic Medical Record (EMR) documented diagnoses of sepsis, ulcer of the esophagus (the tube that carries food and liquids from the mouth to the stomach) with bleeding, fracture (broken bone) of shaft of the right humerus (upper arm bone), and age-related osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk). R26's Care Plan, dated 11/22/24, directed staff to assist with activities of daily living (ADL) as needed and staff was to notify the resident's physician of any changes in condition. The care plan directed staff to monitor and report signs of respiratory distress. The Progress Note, dated 01/03/25 at 09:25 PM, documented that during care for R26 the nurse noted a bulge in her right mid-lower abdomen. The area was soft to the touch but had a ridge in the circumference of the bulge measuring 10 centimeters (cm) in diameter. R26 denied any pain with it or when gently touched. No further assessment of this concern was documented. The Progress Note, dated 01/04/25 at 05:25 AM, documented blood pressures today of 107/52 millimeters of mercury (mmHg) and 90/53 mmHg (normal for a person over [AGE] years old would be 140/80 mmHg), pulses of 58 and 103 beats per minute (normal range 60-100 bpm). R26 was very lethargic and took only two bites of the noon meal. R26 refused to come out of her room for supper. LN H notified the physician who stated her vital signs (blood pressure and pulse) were within normal limits. The physician-directed staff to notify her primary physician of her condition by fax. The Progress Note, dated 01/05/25 at 12:24 AM, documented R26 complained of increased pain and the scheduled Percocet (narcotic pain relief drug) was not effective in pain management this evening. The Progress Note, dated 01/05/25 at 06:58 PM, documented R26 was hypotensive (low blood pressure) with tachycardia (rapid heartbeat greater than 100 beats per minute - bpm). R26 was struggling to talk and drink liquids. The note stated LN H contacted the physician and informed him R26 acted similarly the last time she was septic. The physician ordered R26 to have one gram of Rocephin every 24 hours for 7 days and if R26 did not show any improvement, or her condition worsened send her to the emergency room (ER). On 01/06/25 at 01:50 AM, vital sign documentation revealed R26's blood pressure was 94/46 mmHg, pulse 131 bpm, and respiration were 18 breaths per minute. On 01/06/25 at 02:52 AM, vital sign documentation revealed R26's blood pressure was 95/55 mmHg, pulse 77 bpm, and respirations were 22 breaths per minute. The Progress Note, dated 01/06/25 at 02:55 AM, documented R26 required oxygen supplementation at two liters per minute due to her respirations were shallow and labored. R26's skin was pale and moist to the touch. R26 refused fluids and pursed her lips tight when oral care was offered. The note documented LN H elevated the head of her bed due to respirations with lung sounds, which were coarse throughout. R26 did not respond to staff when they called her name, but she repeatedly shook her head no. On 01/06/25 there was no further assessment of R26 documented until 05:10 AM. The Progress Note, dated 01/06/25 at 05:10 AM, documented a CNA (certified nurse aide) M called LN H to R26's room. R26 had no pulse and no respiration. On 03/19/25 at 11:16 AM, Administrative Nurse D stated she was unaware of the bulge the nurse noted in the resident's abdomen on 01/03/25. Administrative Nurse D verified there was no further follow-up of that issue and she would expect nursing to follow up with further assessment. Administrative Nurse D verified on 01/06/25 at 02:55 AM, that staff should have called Emergency Medical Services (EMS) or the physician when R26 worsened per the physician's order eight hours earlier. The facility's Standards of Care policy, dated 09/18/21, stated the Lippincott Manual for Nursing Procedures (7th edition) would serve as the basis for standard nursing practice. The policy stated it would not replace the responsibilities of professional nursing education and policies, protocols or guidelines may be developed by the facility to specifically address the long-term care environment. Nurses were to refer to the [NAME] for standards of care, utilize, and revise as needed under the guidance of the director of nursing and the infection preventionist. The facility's Admission Assessment and Follow Up policy, dated September 2012, directed nursing staff to notify the supervisor and attending physician of immediate needs the resident may have and report any other information in accordance with facility policy and professional standards of practice. The facility failed to notify R26's physician or family when staff noted an abnormal bulge in R26's right abdomen on 01/03/25. The facility nursing staff also failed to notify the physician on 01/06/25 when R26 had a further deterioration in condition with shallow, labored respirations. R26's skin was pale and moist to the touch, and she had coarse lung sounds throughout. R26 did not respond when staff called her name, nor did she communicate with staff. LN H failed to call the physician or send R26 to the ER at that time. This deficient practice placed R26 at risk for serious health consequences.

The facility had a census of 23 residents. The sample included 12 residents with one reviewed for hospice (a type of health care that focuses on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure coordinated care and services provided by the facility with the care and services provided by hospice for Resident (R) 13. This placed the residents at risk for inadequate end-of-life care. Findings included: - R13's Electronic Health Record (EHR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) with behavioral disturbance, arteriosclerotic heart disease (ASHD - is a condition where the arteries that supply blood to the heart become narrowed and hardened due to buildup of plaque, a sticky substance), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R13's Significant Change Minimum Data Set (MDS), dated [DATE], recorded R13 had severe cognitive impairment. The MDS recorded she required extensive staff assistance with transfers and activities of daily living (ADLs). The MDS documented the resident received hospice services. R13's facility Care Plan, dated 03/04/25, recorded R13 required extensive staff assistance with most ADL care. R13's Care Plan documented the resident had a diagnosis of dementia and required hospice services. The care plan directed the staff to provide comfort and encourage family and friends' support system. The care plan directed staff to observe closely for signs of pain and administer medications as ordered. The facility care plan lacked instruction on the services provided by hospice including the frequency and type of support visits, supplies and medical equipment provided by hospice, medications covered by hospice, and the hospice contact information. Review of R13's clinical record revealed the resident was admitted to hospice care on 03/04/25. The facility had a plan of care provided by hospice in the electronic health record. On 03/13/25 at 12:45 PM, R13 was dressed in street clothes in a recliner in her room. R13 was talking about house insulation coming down and the house was very cold, continued to talk but had word salad. On 03/19/25 at 10:30 AM, Administrative Nurse D verified the facility lacked specific information on the facility care plan that coordinated with the hospice care plan. The facility's Hospice Program policy, dated July 2021, documented hospice services are available to residents at the end of life. The facility has an agreement in place with at least one Medicare-certified hospice to ensure that residents who wish to participate in a hospice program may do so. When a resident has been diagnosed as terminally ill, the Director of Nursing Services would contact the hospice agency and request that a visit/interview with the resident/family be conducted to determine the resident's wishes relative to participate in the hospice program. It is the responsibility of the hospice to manage the resident's care as it relates to the terminal illness and related conditions, including: Determining the appropriate hospice plan of care. Change the level of services provided when it is deemed appropriate. Provide medical direction, nursing, and clinical management of the terminal illness. Provide spiritual, bereavement, and/or psychosocial counseling and social services as needed; and Providing medical supplies, durable medical supplies, durable medical equipment, and medications necessary for the palliation of pain and symptoms. In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with hospice representatives and ensure the level of care provided is appropriately based on the individual resident's needs. Coordinated care plans for the resident's hospice services would include the most recent hospice plan of care as well as the care and services provided by the facility including the responsible provided and discipline assigned to specific tasks, in order to maintain the resident's highest practicable physical, mental and psychosocial well-being. The coordinated care plan would reflect the resident's goals and wishes, as stated in his/her advanced directive and during ongoing communications with the resident's representative, including: a. Palliative goals and objectives. b. Palliative interventions. c. medical treatment and diagnostic tests. The coordinated care plan would be revised and updated as necessary to reflect the resident's current status. The facility failed to coordinate care between the facility and the hospice provider for R13, who received hospice services. This deficient practice placed her at risk for inadequate end-of-life care.

The facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to employ a full time certified dietary manager for the 31 residents who resided in the facility and received meals from the facility kitchen. This placed the residents at risk for inadequate nutrition. Findings included: - On 06/05/23 at 11:30 AM, review of the posted Noon Meal Sheet revealed it consisted of crumb-topped baked fish, tater tots, Brussel sprouts, coconut creme pie and garnished lemon wedge. On 06/05/23 at 9:00 AM, observation revealed Dietary Staff (DS) BB in the kitchen overseeing the preparation of the noon meal. On 06/05/23 at 09:10 AM, DS BB verified she was uncertified. On 06/08/23 at 10:00 AM, Administrative Staff A verified Dietary Staff BB had no dietary manager certification; Dietary Staff BB had completed the course but had not taken the test. The facility's Food and Nutrition Services Staff Policy, revised October 2017, documented the food services department would be staffed by food and nutrition services personnel who have demonstrated the skill and competency to carry out the functions of the department. The facility failed to employ a full time Certified Dietary Manager, for the 31 residents who resided in the facility and received meals from the kitchen. This placed the residents at risk for receiving inadequate nutrition.

The facility had a census of 31 residents. The sample included 12 residents with one reviewed for urinary tract infection (UTI-an infection in any part of the urinary system}. Based on observation, record review, and interview the facility staff failed to change gloves when providing incontinent cares for Resident (R) 16 and continued to provide care with the same soiled gloves. This placed R16 at risk for infection Findings included. - R16's Electronic Medical Record (EMR) documented R16 had diagnoses of UTI and retrocede (condition when the tissue wall which separates the rectum from the vagina is weakened and leads to the vaginal wall to bulge). R16's Quarterly Minimum Data Set (MDS), dated [DATE], documented R16 had a Brief Interview of Mental Status (BIMS) score of three, which indicated severely impaired cognition. The MDS documented the resident required extensive staff assistance with dressing, toilet use and independent with rest of activities of daily living (ADLs). The MDS noted R16 had a UTI. The UTI Care Plan, revised 04/25/23, documented the resident received UTIStat ( nutritional supplement) routinely to prevent UTI re-occurrence. The care plan instructed staff to provide perineal (private area) care as soon as possible after incontinent episodes and be sure to cleanse the perineal area well from front to back. The care plan instructed staff to encourage fluid intake, monitor R16's vital signs, for presence of fever, encourage prompt , complete bladder emptying, ensure meticulous personal hygiene especially after elimination, assess R16 for signs and symptoms of UTI and report them to the physician. The plan instructed staff to use principles of infection control and universal/standard precautions when providing R16 perineal care. The Physician Order, dated 05/18/23, instructed staff to administer ceftriaxone (antibiotic medication), 500 milligrams (mg), twice a day for seven days for UTI. The urine cultures on the following dates documented R16 had a UTI and listed an antibiotic to treat the UTIs: 12/16/22 12/24/22 05/17/23 On 06/06/23 at 12:33 PM, observation revealed Certified Nurse Aide (CNA) M assisted R16 to the bathroom with stand by assist. CNA M cued the resident to pivot transfer using a walker to the toilet, then applied gloves and offered to assist R16 in pulling down R16's pants and incontinent brief. R16 refused and then removed her wet incontinent pad, rolled it up, and handed it to CNA M. CNA M then discarded it in the trash, CNA M assisted the resident in removing the wet incontinent brief, provided incontinent care to the area, then without changing gloves, placed a new incontinent brief, and assisted R16 in pulling up her pants. CNA M also touched R16's pants, and bath robe with the soiled gloves, then removed and discarded the gloves. On 06/06/23 at 12:33 PM, CNA M verified she had not changed her gloves after providing incontinent cares and stated she should have. On 06/08/23 at 09:30 AM, Administrative Nurse D stated staff should change gloves after they provide perineal care and before continuing to provide care. Upon request the facility did not provide a policy for incontinent cares. The facility staff failed to change gloves after providing perineal care for R16 and continued to provide care with the same soiled gloves. This placed the resident at increased risk for infection.

The facility had a census of 31 residents. The sample included 12 residents with one reviewed for Preadmission Screening and Resident Review (PASSAR-short series of questions designed to determine whether or not a more in-depth assessment for mental health services is required). Based on observation, record review and interview the facility failed to conduct a PASSAR Level II (an in-depth assessment for the purpose of determining whether the individual requires the level of services provided by a nursing facility or the level of services provided in a specialized program for persons with mental illness or developmental disabilities) for Resident (R)18 when it was noted on the PASSAR I R18 needed further evaluation (Level II). This placed the resident at risk for unmet needs. Findings included: - R18's Electronic Medical Record (EMR) documented R18 had diagnoses of paranoid schizophrenia (a thought process believed to be heavily influenced by anxiety or fear to the point of irrational thinking with a psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought) and bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods). R18's Quarterly Minimum Data Set (MDS), dated [DATE], documented R18 had a Brief Interview of Mental Status (BIMS) score of 14 which indicated intact cognition. The MDS documented R18 received an antipsychotic medication for seven days during the lookback period. R18's Mood Care Plan, dated 05/09/23, instructed staff if R18 felt tired or had little energy, due to not moving around enough, encourage her to participate in activities, or ride the exercise bike, take R18 outside, and provide comfort measures before she retired. R18's Hallucinations Care Plan, dated 05/09/23, documented R18 at times made statements or ask questions that are not reality and instructed staff to documented when she makes these comments. The care plan documented R18 received antipsychotic medications for paranoid schizophrenia and instructed staff to watch R18 for side effects from the medications. The care plan asked staff not to talk about R18's previous spouse with her. The care plan documented at times R18 would hit herself or yell and curse and instructed staff to distract R18 from hallucinations by having her watch television and painting and tell her not to hit herself. The PASAAR I, dated 05/15/18, documented R18 indicated a need for further evaluation. R18's clinical record lacked evidence further evaluation was provided. The facility was unable to provide evidence a PASSAR Level II was requested and provided as indicated from the PASSAR I. On 06/05/23 at 01:12 PM, observation revealed R18 sat quietly in a black recliner in the living room area by the entrance door, with her eyes closed. On 06/07/23 at 02:30 PM, Licensed Nurse (LN) G stated R18 had behaviors which included closing blinds in her room and delusions (altered reality that is persistently held despite evidence or agreement to the contrary, generally in reference to a mental disorder). LN G stated staff opened the blinds when R18 was not in her room and said staff went along with R18's delusions or tried to redirect her to an activity. On 06/7/23 at 12:30 PM, Administrative Nurse D stated she was not employed with the facility at the time of R18's PASSAR I assessment and said she was unaware R18 needed a follow up assessment. Administrative Nurse D stated she could not find R18's PASAAR II. Administrative Nurse D stated she talked to staff at the agency which provides the PASSAR assessment, per telephone, and it was relayed to her that facility staff should have sent documentation to the appropriate state designated authority regarding R18's need for a PASAAR II evaluation. The facility's Admission Criteria Policy, revised March 2019, documented all new admissions and readmissions are screened for mental disorder (MD) intellectual disabilities (ID) or related disorders (RD) per the Medicaid PASAAR process. If a level I scree indicated the individual may meet the criteria for a MD, ID or RD, he or she is referred to the state PASARR representative for the level II (evaluation and determination ) screening process. The admitting social worker is responsible for making referrals to the appropriate state- designated authority. The facility failed to ensure R18 received a PASSAR II evaluation when R18's PASSAR I recommended the resident had a need for further evaluation. This placed R18 at risk for unmet needs.

The facility had a census of 31 residents. Based on observation, record review, and interview the facility kitchen staff failed to provide food prepared by methods that conserve nutritive value, flavor and appearance, when dietary staff failed to follow a recipe while preparing two residents' pureed diets. This placed the residents at risk for impaired nutrition. Findings included: - On 06/06/23 at 10:44 AM, Dietary Staff (DS) CC, with Dietary Manager (DM) BB overlooking, stated the facility had two residents with pureed diets, and one with a mechanical soft diet. DS CC placed three cups of diced chicken into the blender container with one cup chicken broth, one tablespoon (TB) thickener and blended the contents to consistency of pudding without following a recipe. DS CC placed it in a metal pan, covered, and placed on the steam table. Further observation revealed DS CC placed six ounces of peas, unmeasured water from the sink, one TB thickener, and blended to the consistency of pudding without following recipe. On 06/06/23 at 10:44 AM, DS CC verified she had not followed a recipe and stated sometimes she followed one depending on what food it was. She said she knew some of the recipes by heart. On 06/06/23 at 11:00 AM, DS BB stated staff should follow a recipe when preparing residents pureed diet. DS BB stated she had the recipes out earlier. Upon request the facility did not provide a pureed diet recipe policy. The facility kitchen staff failed to follow a recipe when preparing two residents' pureed diet. This placed the residents for impaired nutrition.

The facility identified a census of 30 residents with three residents reviewed for falls. Based on record review and interview, the facility failed to follow Resident (R) 1's care plan and provide her with the correct supervision resulting in a fall with injury. On 01/05/23 at approximately 07:50 AM, Certified Nurse Aide (CNA) M assisted R1 to the toilet and placed all of R1's clothing in the bathroom with her, and then shut the curtain to the bathroom. R1 reached down to pick up a sock on the floor, fell to her left side, sustained skin tears to her left hand and elbow, a minimally displaced zygomatic arch (the bone that forms the prominent part of the cheek and the outer side of the eye socket) fracture (broken bone), and soft tissue swelling overlying the left orbit (the socket of the skull in which the eye and its appendages are situated). The facility failed to follow R1's care plan which documented the staff were not to leave R1 unattended in the bathroom and R1 required limited to extensive staff assistance for dressing. This deficient practice placed R1 at risk for falls and pain. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of hypertension (high blood pressure), peripheral vascular disease (PVD, abnormal condition affecting the blood vessels), and anemia (condition without enough healthy red blood cells to carry adequate oxygen to body tissues). The Admission Minimal Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderately impaired cognition. The MDS documented R1 required extensive assistance of one staff for toileting, dressing, hygiene, bathing, bed mobility, and transfers. The MDS further documented R1 was unsteady and required staff assistance for stability during transitions (moving from a seated to standing position, walking, turning around and facing the opposite direction, moving on and off the toilet, and surface-to-surface transfers). The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 01/03/23, documented R1 had forgetfulness and nursing staff were to cue and re-orientate R1 as needed. The Activities of Daily Living (ADL) CAA, dated 01/03/23, documented R1 required limited to extensive assistance with ADLs and was at risk for decline in ADL function, pain incontinence, and falls due to requiring assistance with function of daily cares. The Fall CAA, dated 01/03/23, documented R1 had impaired balance which put R1 at risk for falls. The Fall CAA also documented R1 could make unsafe decisions putting her at risk for falls. The Activities of Daily Living Care Plan, dated 09/26/22, directed staff that R1 required limited to extensive assistance of one to two staff for bed mobility, transfers, ambulation, locomotion, dressing, toileting, hygiene, and bathing. The Decision-Making Care Plan, dated 09/26/23, directed staff to provide R1 supervision with decision making to allow her to be safe and to function at the highest level possible. The Fall Care Plan, dated 12/05/22, directed staff to not leave R1 unattended in the bathroom while she used the toilet. The John Hopkins Fall Risk Scale, dated 01/03/23 documented R1 had a fall risk score of 19 which indicated R1 was a high risk for falls. The Witness Report, dated 01/05/23, documented CNA M stated he was picking up clothes while R1 got dressed in the bathroom. While hanging the clothes up, CNA M heard a crash. CNA M stated he turned around and saw R1 on the floor. CNA M turned on the bathroom call light and asked R1 what had happened. R1 told CNA M that she was reaching for her sock and leaned too far and fell . CNA M noted R1 had newly opened skin tear on the back of her hand. CNA M stated he ran to get the licensed nurse and when they got back to the room blood was pooling under R1's left elbow. CNA M stated that staff took R1's vital signs and sat her in a wheelchair. The Hospital Radiology Report, dated 01/05/23, documented R1 had sustained a minimally displaced left zygomatic arch fracture with soft tissue swelling overlying her left orbit. The Facility Incident Report, dated 01/06/23, documented R1 had a history of falls and was on the shooting star program and staff were to check on R1 frequently. On the morning of 01/05/23, CNA M reported that he was in R1's bedroom and had assisted R1 to the bathroom and onto the toilet. CNA M stated he had placed R1's clothing in the bathroom and closed R1's bathroom curtain for privacy. CNA M reported while R1 was in the bathroom he was hanging up R1's clothing and heard a noise coming from the bathroom. CNA M then observed R1 on the bathroom floor. CNA M notified licensed nursing staff. Licensed nursing staff observed R1 on the bathroom floor on her left side. Licensed nursing staff observed red drainage from R1's left hand and elbow. R1 had range of motion within normal limits and staff assisted R1 to a standing position and was full weight bearing without pain. Staff provided treatment to R1's left arm and elbow and licensed nursing staff noted R1's left eyebrow had bruising and swelling. R1 stated that she was reaching for her sock and leaned forward too far and fell . Neurological checks were initiated, and staff transferred R1 to the local hospital for evaluation. The Nursing Department Communication Form, dated 02/13/23, documented all care plans must be followed as the care plan interventions are stated. If a resident is care planned not to be left unattended whether that be in the bathroom, wheelchair, dining room etc. not leaving unattended entails the following: the nursing staff member must be present at all times. Nursing staff member must always have visualization on the resident. If a resident is not to be left unattended in the bathroom, and the resident requests the bathroom curtain be closed for privacy, and that the staff member resides on the other side of the curtain, nursing staff needs to immediately notify licensed staff by way of activating the call light system and not leaving the resident so that licensed staff can intervene at that time. Licensed staff need to educate and encourage residents that a staff member needs to be present at all times on any item that is mentioned in the care plan that is not to be left unattended. Failure to follow the plan of care can be considered abuse and/or neglect and have disciplinary action. The communication form/education was only signed by CNA M on 02/13/23. On 02/14/23 R1 was unavailable for observation or interview. On 02/14/23, CNA M was unavailable for interview. On 02/14/23 at 11:30 AM, Administrative Staff A reviewed R1's care plan directive which indicated not to leave R1 unattended and said CMA M was still in R1's attendance as he never left her room. Administrative Staff A stated it depended on what definition was used for unattended. On 02/14/23 at 11:35 AM, Administrative Nurse D stated that she expected all of the staff at the facility to follow the residents care plan. Administrative Nurse D verified that education regarding following care plans had only been given to CNA M. The facility's Fall and Fall Risk Policy, revised April 2018, documented staff will identify pertinent interventions to try and prevent falls and to address the risks of significant consequences of falling. Staff will try various relevant interventions until falling reduces or stops or until a reason is identified for fall continuation. The facility failed to provide adequate supervision, ADL assistance, and follow R1's care plan, to prevent a fall with a facial fracture for R1.

The facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to prepare, store, distribute, and serve food under sanitary conditions for the 31 residents in the facility, who received their meals from the facility kitchen. Findings included: - On 10/19/21 at 08:10 AM, during initial tour, observation revealed the following: 2- eight by eight-inch square air vents located in front of exhaust hood and stove with rust stains noted on the grill. 2- eight by eight-inch square air vents located between the food preparation table and the dishwasher with rust stains noted on the grill. 1 - 24 inch by 24-inch square air vent located between the food preparation table and the hot warming well cart with brown greasy substance and gray fuzzy substance on the grill. The two foot by five-foot fluorescent light, located above the food preparation area with a three inch by five-inch section of the plastic light cover missing and the fluorescent bulbs exposed. Continued observation of the stove hood revealed the water three sprinkler spigots had gray fuzzy substance covering the spigot top, side and the pipes connecting the system. Continued observation revealed the next cleaning date for the hood by the commercial cleaning system was July 2021 (approximately three months earlier.) On 10/19/21 at 11:40 AM, Dietary Staff (DS) BB verified the missing plastic cover on the overhead fluorescent light fixture, dirty stove hood and the dirty rusted ceiling register/vents. DS CC verified the stove hood had not been cleaned July 2021 and the company was contacted and would be to the facility to clean the hood in the next few weeks. The facility's Cleaning Rotation policy, dated 2016, documented equipment and utensils would be cleaned according to the following guidelines, or manufactures instructions. The policy documented the oven hood would be cleaned at least once a month, and lacked cleaning instructions for the overhead fluorescent light fixtures, and the register or grills in the ceiling. The facility failed to prepare, store, distribute and serve food under sanitary conditions for the 31 residents residing in the facility, who received meals from the facility kitchen.

The facility identified a census of 31 residents. Based on observations, interviews, and record review, the facility failed to provide comfortable sound levels to allow for privacy and unwanted noise for the overhead intercom paging system. This placed all residents at risk for unwanted noise/sound levels in the facility. Findings included: - On 10/26/21 at 01:20 PM and 03:00 PM, observation revealed the office staff made generalized announcements on the overhead paging system that started off as a shrill noise followed by the announcement that pertained to staff and not the residents. On 10/27/2021 at 09:58 AM, observation revealed the office staff announced on the overhead paging system, morning meeting activity room, morning meeting activity room. At 10:15 AM, observation revealed the office staff announced on the overhead paging system, [NAME] you have a call on 800, [NAME] you have a call on 800. At 10:56 AM, observation revealed the office staff announced on the overhead paging system, [NAME] call [NAME], [NAME] call [NAME]. At 11:11 AM, observation revealed the office staff announced on the overhead paging system, Care Plan meeting in Medical Records office, Care Plan meeting in Medical Records office. At 03:30 PM, observation revealed the office staff announced on the overhead paging system, [NAME] park on 800, [NAME] park on 800. On 10/28/21 at 01:01 AM, observation revealed the office staff announced on the overhead paging system, [NAME] please come to the business office, [NAME] please come to the business office. At 11:33 AM, observation revealed the office staff announced on the overhead paging system, [NAME] you have a park on 800, [NAME] you have a park on 800. On 10/26/21 at 04:30 PM, Resident (R) 182 asked the surveyors if anything could be done about that Foghorn, intercom system. R182 stated it was a very loud noise sound that went off frequently during the day. On 10/28/21 at 03:30 PM, Administrative Staff A stated the intercom paging system had been in the building for years and verified it was very loud and noisy and they needed to get something to replace the system. Upon request the facility lacked an overhead paging system policy. The facility failed to provide a comfortable sound level intercom paging system which allowed staff to communicate with other staff in the building. This placed residents at risk for excess noise and an uncomfortable home like environment.

The facility had a census of 31 residents. The sample included 12 residents with one reviewed for pressure ulcers (PU) (injuries to skin and underlying tissue resulting from prolonged pressure on the skin). Based on observation, interview, and record review, the facility failed to evaluate Resident (R) 11's PUs on her buttocks and toes each week from April to July 2021. Findings included: - R11's Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of 99, short and long term memory problems. The MDS documented R11 required staff supervision for eating, extensive assistance of two staff for most activities of daily living (ADLs) and total staff assistance for toileting. The MDS documented R11 weighed 104 pounds and had two unstageable pressure ulcers (ulcers covered with slough (dead tissue) or eschar (dead tissue) that were present on admission. Pressure relief measures included air mattress overlay on bed, repositioning, PU care, and nutrition program. The Pressure Ulcer Care Plan, dated 08/23/21, documented the resident at risk for skin breakdown related to the need for assistance with bed mobility, positioning and incontinence, directed staff to ensure feet positioned properly in foot protectors so that the resident's toes were not pressed against the foot protectors or other surfaces that could cause pressure to her toes, and pressure relieving heel protectors to bilateral feet. The Care Plan directed staff to use a sheet and bed spread only over feet, drape covers over foot board to keep pressure off toes, reposition every one to two hours per tissue tolerance, and maintain offloading positioning while in bed. Use moisture barrier or Vaseline to perineal area/buttocks after perineal care. The nurse would report any signs of skin breakdown (sore, tender, red, or broken areas) to the resident's physician. Pressure reducing cushion in wheelchair and weekly nurse skin inspection. Pressure ulcer to the resident's second toe on her left foot and staff would attempt to keep the resident's blankets and socks from coming in contact with her feet as she would allow. The resident frequently refused to go without socks. Nursing would use aseptic techniques (applying the strictest rules to minimize the risk of infection) when performing dressing changes. Assess pain and observe wound and surrounding skin for redness, swelling, severe pain, warmth, increased drainage, and report to the physician. The nurse would assess condition of surrounding skin and report emergence of skin excoriation (abrasion of skin) to the resident's physician. The nurse would record the color, consistency, and location of exudate (drainage). The 09/30/21 update directed staff to use a turn sheet when repositioning the resident and air mattress overlay on the pressure reducing mattress. Skin Assessment documentation revealed the following: 04/14/21 - scabbed areas on second and third right toes. 0.3 centimeter (cm) x 0.3 cm. Open coccyx (area of the small triangular bone at the base of the spinal column) 0.5 cm x 0.5 cm, no further assessment information. 04/21/21 - open buttocks area, no further assessment information. 04/28/21 - ointment to buttocks, no further assessment information. 05/05/21 - open area on buttocks, no further assessment information. 05/12/21 - reddened buttocks, no further assessment information on condition of toes. 05/19/21 - open area on buttocks, no toe issues, no further assessment information. The Progress Note, dated 05/26/21 at 04:28 PM, documented R11 had scabs on the mid-section knuckle of her second left toe and end of third toe. The nurse documented the area was measured and appeared to possibly be from pressure and staff notified the physician. The Skin Assessment, dated 06/02/21, documented sheering (friction) to coccyx, second right toe scabbed, no further assessment information. The Skin Assessment, dated 06/16/21, documented no areas of concern. The Skin Assessment, dated 06/24/21, documented the left second toe with a 1 cm x 1 cm Stage 2 PU (partial-thickness skin loss into but no deeper than the second layer of skin, including intact or ruptured blisters and abrasions), with no further assessment information. The Skin Assessment, dated 07/07/21, documented 1 cm x 1 cm stage 3 (involves the full thickness of the skin and may extend into the subcutaneous (third or innermost layer of skin), with 50% slough. On 10/26/21 at 01:48 PM, observation revealed R11 lying in bed, feet elevated, and the blanket draped over a foot cradle on bed. On 10/28/21 at 08:46 AM, observation revealed Licensed Nurse (LN) H checked the resident's skin and found the second left toe had a dry scab on the last joint. Further observation of both feet revealed no redness and the coccyx area revealed no open skin or redness. On 10/26/21 at 03:30 PM, Administrative Nurse D verified she was aware of the lack of wound assessment details and had educated staff to document wound measurements and assessments. The facility's Skin Assessment and Surveillance including Pressure Ulcer Risk policy, dated 06/09/21, documented all wounds would be documented in observation skin assessment for each skin injury type and location. Wound surveillance would occur weekly and as needed, until healed and include redness, drainage, odor, wound stage, dimensions and healing process. The policy stated staff would document interventions to prevent skin injury from occurring again in the care plan. The facility failed to evaluate/assess the condition of R11's pressure ulcers to determine what further treatment was needed, placing the resident at risk for continued wounds.

The facility had a census of 27 residents. The sample included 12 residents of which 3 were reviewed for pressure ulcers. Based on observation, record review and interview, the facility failed to provide necessary treatment and services to prevent 1 of 3 sampled residents, #20, from developing an avoidable, unstageable pressure sore on his/her left heel and pressure ulcers on his/her buttocks. The facility failed to complete thorough and timely skin assessments for 2 of 3 sampled residents, Resident #2, who developed an unstageable pressure sore on his/her left foot instep (the arched middle part of the foot between the toes and ankle), and Resident #3, who developed unstageable pressure sores on his/her buttocks. Findings included: - Resident #20's 12/01/2014 physician orders [REDACTED].(a progressive disorder of the nervous system marked by tremor, muscular rigidity, and slow imprecise movement). The quarterly (MDS) Minimum Data Set assessment, dated 9/24/2014, indicated the resident had severely impaired cognition, and required extensive assistance of 2 staff with (ADLs) Activities of Daily Living for transfers, walking in his/her room, toilet use, bed mobility, and total dependence with dressing and personal hygiene. The MDS indicated the resident had no skin conditions, no pressure ulcers, no venous or arterial ulcers, received application of ointment not on the feet, and had a pressure reducing device to his/her bed and chair. The 2/05/2014 skin (CAA) indicated the resident had a potential for pressure ulcers and was at risk for skin breakdown due to decreased mobility and urinary incontinence. The CAA indicated the nurse would complete weekly skin assessments and the staff would reposition the resident every two hours. The 2/03/2014 dietary assessment indicted the resident received a low concentrated sweet diet with regular texture and fluids, and no reported problems with chewing or swallowing. The 7/03/2014 Braden assessment scale, for predicting pressure sore risk, revealed a score of 14, which indicated he/she was at moderate risk. The 12/02/2014 dietary assessment indicated the resident's weight was 217#, and he/she had skin issues on his/her buttocks. The registered dietician recommend, a CBC (complete blood count) blood laboratory test and CMP (comprehensive metabolic panel) blood test due to the resident's medication of [MEDICATION NAME] (medication to control high blood sugar) and B 12 (vitamin supplement for brain and nervous system). The 9/25/2014 care plan indicated the resident required extensive assistance of 1-2 staff with bed mobility, and total assistance with toileting and dressing. The care plan indicated the resident had the potential for skin breakdown and directed the staff to reposition him/her every two hours and check for his/her needs every 1-2 hours. The care plan directed the nurse to complete weekly skin assessments and to notify the physician of any skin issues. The care plan indicated the resident required extensive assistance with eating. The 11/08/2014 updated care plan indicated the staff apply pressure relieving boots on the resident's feet. The 10/27/2014 at 7:15 AM, nurse's notes indicated the nurse aide assisted the resident with breakfast and noted an area to his/her left foot. The notes revealed the nurse assessed the resident and observed a 1.5 (cm) centimeter raised area to the inner area of his/her left heel and the nurse applied an adhesive dressing to protect the area. The 11/08/2014 at 2:00 PM, nurse's notes skin assessment indicated the resident had two small reddened open areas on his/her buttocks. (The notes had no further documentation of the location, measurements, or specific characteristics of the open area). Review of the medical record revealed no documentation of further assessment of the resident's newly developed soft area on his/her buttocks or notification of the physician for a treatment order or a care plan update. The 11/18/2014 at 6:00 AM to 6:00 PM, nurse's notes indicated the nurse aide observed the resident's heel and called the nurse, who completed an assessment. The notes revealed the physician saw the resident at the facility and he/she ordered moon (pressure relieving) boots for the resident while in bed. The notes had no further documentation of the location, measurements, or specific characteristics of the open areas or notification of the physician for a treatment order or a care plan update. The 12/07/2014 untimed, nurse's notes indicated the resident had soft black eschar (dead tissue) on his/her left heel that had cracked open, and no drainage noted. The staff were to use a pillow under his/her heels to prevent pressure breakdown. The notes had no further documentation of the location, measurements, or specific characteristics of the open areas or notification of the physician for a treatment order or a care plan update. The 12/17/2014 at 11:40 AM, nurse's notes indicated the physician saw the resident was seen at the facility. The 12/17/2014 physician's orders [REDACTED]. The weekly skin integrity review sheets documented the following: 10/29/2014 - Skin dry 11/08/2014 - Two small open areas on the resident's buttocks 11/12/2014 - Skin intact 11/18/2014 - No weekly skin assessment 11/19/2014 - Skin intact 11/22/2014 - Rash and redness on both lower legs 11/28/2014 - Open area - reopened buttocks. 12/07/2014 - Documented skin condition dark, blue/black "cracked" open and on the left heel with a measurement of 3.5 cm length x 4.0 cm width. (The above skin integrity sheets lacked documentation regarding the resident's skin conditions, including the specific measurements and clarification of both the buttocks and left heel, and lacked any other measurements to determine the change in size.) The 12/14/2014 at 11:40 AM, nurse's notes verified the physician approved the dietician's recommendation to obtain labs. (12 days after the registered dietician recommendations) Review of the medical records up to 12/17/2014, revealed the staff had not drawn blood laboratory test for CMP and CBC as ordered by the physician 3 days prior. On 12/16/2014 at 8:00 AM, observation revealed the resident, seated in a wheelchair, with a cushion and a pillow in the wheelchair, in the dining room. Further observation revealed his/her feet were directly on the floor with fleeced lined slippers. Continued observation revealed the resident's family member assisted him/her to eat his/her breakfast. On 12/16/2014 at 9:50 AM, observation revealed Nurse Aide C and Nurse Aide G assisted the resident to the bathroom using the sit to stand lift, after toileting, and the staff provided peri care and transferred the resident from the toilet with the sit to stand lift. Observation revealed the resident had an open pinpoint area on the left buttock close to the rectum (the last part of the digestive tract) a pinpoint open area to the left side of his/her coccyx, and Nurse Aide G applied [MEDICATION NAME] ointment (moisture barrier cream) to his/her bottom, and peri area. The staff transferred the resident to his/her bed and observation revealed the resident's left heel had a black area approximately 4 cm x 3 cm with the skin cracked open, no dressing was on or applied to the ulcer and staff placed the residents fleece lined slippers on his/her bare feet. On 12/17/2014 at 12:50 PM, Administrative Nurse A entered the resident room and asked the resident how he/she was doing and the resident responded I hurt. Administrative Nurse A questioned where and the resident mumbled something and Administrative Nurse A stated your bottom?, and the resident stated yes, it hurts. Continued observation revealed the resident had pressure relieving boots on his/her heels. The nurse did not offer or provide any pain medication or visualize the wound or repositioning at this time. On 12/16/2014 at 10:20 AM, the resident's spouse stated he/she developed the open areas on his/her bottom because he/she sits so much and does not get up and walk anymore. The resident's spouse stated he/she is unaware why the pressure area developed on his/her left heel but stated he/she use to wear support hose and tennis shoes. The facility had discontinued the hose and shoes when staff identified the pressure area and placed the resident in protective boots while in bed, and when he/she is up and has pressure on the heels. The resident wears his/her fleeced lined slippers the rest of the time. On 12/16/2014 at 10:30 AM, Nurse Aide C verified the the staff transfer the resident with a total body lift, and stated the resident sits in his/her chair most of the day. The resident's spouse stays at the facility during the day and assisted the resident to eat his/her meals. On 12/17/2014 at 9:45 AM, Administrative Nurse A stated the resident admitted to the facility on [DATE], and the left heel pressure ulcer developed on 12/07/ 2014, and the pressure ulcers on his/her buttocks developed 11/08/2014. Administrative Nurse A verified the resident wore tennis shoes and TED hose until staff noted the ulcer. Administrative Nurse A verified the resident had declined in the last few months and was no longer able to walk. Nurse A verified the lack of assessment and poor documentation of the open areas. On 12/17/2014 at 4:10 PM, Nurse Aide G verified the resident had declined in the last few months, and was unable to stand without assistance, and the staff transferred the resident with a total body lift. The resident was incontinent and staff applied [MEDICATION NAME] barrier ointment on the resident's bottom and perineal area. Nurse Aide G stated the resident wore TED hose and tennis shoes, then developed a pressure ulcer on his/her heel and now used pressure relieving boots in bed and fleece lined slippers at other times. Nurse Aide G verified the resident had a pressure relieving cushion in his/her wheelchair and a pressure relieving mattress on the bed. On 12/22/2014 at 5:05 PM, Physician M verified the resident had a decline in his/her medical condition in the last 2-3 months and spent more time in his/her wheelchair. Physician M verified the resident had a pressure ulcer on his/her left heel, and two open areas on his/her buttocks, and stated he/she would expect the facility to turn/reposition and provide pressure relieving devices for residents with compromised skin. Physician M stated the first notification he/she had received from the facility regarding the open areas was on 12/17/2014 (20 days after the development of a pressure ulcer on the resident's buttocks and 30 days after the development of a pressure ulcer on the resident's left heel), when he/she made rounds. Physician M stated staff notified him/her the resident had blisters on his/her buttocks from being incontinent, and a pressure area on his/her left heel and the facility assured him/her it was from the resident's wheelchair. Physician M stated the facility indicated the resident was in tennis shoes and wore TED hose until 11/18/2014 and the facility initiated moon boots while in bed, and applied [MEDICATION NAME] ointment to his/her buttocks. The facility's 10/2010 Pressure ulcer/Skin breakdown policy indicated the staff would assess residents on admission, and document the residents significant risk factor for developing pressure sores, such as immobility, recent weight loss, and a history of pressure ulcers. The physician and staff will examine the skin of a newly admitted resident for ulcerations or indications of Stage I pressure areas that has not yet ulcerated at the surface. The physician will help identify medical interventions related to wound management, for example treating comorbid medical conditions, managing pain related to wound or to wound management. The physician would help the staff review and modify the care plan as appropriate especially when the wounds are not healing as anticipated or new wounds develop despite existing interventions. The facility failed to provide interventions to prevent the development of avoidable pressure sores to Resident #20's left heel and buttocks, and failed to develop and implement interventions to promote healing and prevent the development of additional pressure ulcers. - Resident #2's most recent (POS) Physician order [REDACTED]. damage to your peripheral (outside) nerves, often causes weakness, numbness and pain). The quarterly (MDS) Minimum Data Set assessment, dated 6/29/14, indicated the resident had intact cognition, was independent with (ADLs) Activities of Daily Living, except required supervision with walking. The MDS indicated the resident had (ROM) Range of Motion impairment in 1 upper extremity and both lower extremities and used a walker and a wheelchair. The MDS indicated the resident was at risk for skin breakdown and treatments included pressure relief devices to bed and chair and application of ointments. The 9/14/14 quarterly MDS indicated the same except no walking during the look back period, the resident had 1 unstageable pressure ulcer (pressure wound with scab or other covering that prevents determination of the depth of the wound) with eschar (dead tissue), and treatments also included pressure ulcer care. The 11/30/14 annual MDS indicated the same and included the pressure ulcer, measured 0.3 (cm) centimeters by 0.3 cm, with eschar (scab). The 12/4/14 (CAA) Care Area Assessment summary for nutrition stated the resident received a soft diet and he/she consumed an average of 79% of the food per meal. The summary stated the resident refused ground meats and ate independently. The summary indicated nursing staff monitored the resident's food and fluid intake daily and his/her weight weekly. The CAA for pressure ulcers indicated the resident was at risk for skin breakdown and had a pressure area to his/her left foot instep. The CAA indicated staff provided daily skin care, to this area and performed weekly skin assessments. The undated care plan directed the staff to perform weekly skin assessments, observe the resident's skin with toileting, dressing, and bathing, notify the physician of any changes in the resident's skin and provide a pressure relief mattress and a pad to his/her chair. The nutritional care plan indicated the same and listed the resident's food likes and dislikes. Review of the current care plan lacked information the resident had a pressure ulcer or any concerns regarding his/her left foot and had no direction to monitor the fit of the resident's shoes or interventions to promote healing. Review of the skin assessments from 8/25/14 through 12/1/14 revealed only the 9/15/14 skin assessment had measurements and wound appearance of the pressure ulcer on the resident's left instep. Review of the medical record revealed no documentation of a weekly skin assessment after 12/1/14 to 12/17/14. On 12/17/14 at 2:05 PM, Nurse I stated the nurses are to assess the resident's skin weekly on Mondays and verified the medical record lacked further information regarding the resident's pressure ulcer on his/her left instep. The 7/16/14 physician's orders [REDACTED]. The 7/17/14 Nutrition Assessment by the dietary manager indicated the resident weighed 121 pounds, had no pressure ulcers, and received a milkshake, twice daily, between meals. The Braden Scale (used to assess the resident's risk for skin breakdown), dated 11/28/14, indicated the resident was not at high risk for pressure ulcers with a score of 19 (12 or less indicates high risk). The Braden scale assessments of 6/30 and 9/21/14 indicated the same. On 12/16/14 at 11:25 AM, observation revealed the resident in his/her wheelchair in the therapy room working with occupational therapy staff. He/She wore black wool looking sandals. On 12/17/14 at 1:27 PM, observation with Administrative Nurse B revealed the wound on the resident's left inner ankle had a 1/4 inch padded dressing with a [MEDICATION NAME] cover. Further observation revealed the wound was closed. On 12/17/14 at 2:05 PM, Nurse I stated the nurses are to assess the resident's skin weekly on Mondays. On 12/17/14 at 2:20 PM, Administrative Nurse B verified the staff are to assess the resident's skin weekly and he/she verified the facility had no record of the skin assessments for the resident's wound from 12/1/14 to 12/17/14 and verified the weekly skin assessments lacked thorough assessment of the resident ' s wound. The facility's 10/2010 Pressure Ulcer/Skin Breakdown protocol stated pressure ulcer treatment required a comprehensive approach, including managing infections, pain and maximizing the potential for healing. The protocol directed the staff to document, in the medial record, all assessment data, such as color, size, drainage, pain, etc.) when inspecting the wound, any problems or complaints made by the resident related to the procedure and resident refusal of the treatment and the reason why and that risks of not complying, benefits of complying and alternatives explained. The facility's 10/2010 Pressure Ulcer Risk Assessment policy stated the staff will assess the resident's skin for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated and document the wound appearance, wound bed, edges and presence of drainage. The facility failed to perform thorough weekly skin assessments for Resident #2's, facility acquired, pressure ulcer on his/her left instep. - Resident #3's annual (MDS) Minimum Data Set assessment, dated 6/22/14, indicated the resident was cognitively intact with a (BIMS) Brief Interview for Mental Status score of 15, independent with eating and locomotion, but required limited assist with all other (ADLs) Activities of Daily Living. The MDS indicated the resident did not walk, had (ROM) Range of Motion impairment in 1 upper extremity and both lower extremities, and was frequently incontinent of urine. The MDS indicated the resident weighed 224(#) pounds, had no swallowing or dental problems, was at risk for pressure ulcers and had 4, Stage 2, pressure ulcers, (3 present on admission).The MDS lacked measurements, indicated the ulcer had granulation tissue and treatments included pressure reduction devices to the resident ' s chair and bed, pressure ulcer care, and ointments. The quarterly MDS, dated [DATE], indicated the same except a BIMS of 14 (cognitively intact), weight 191#, three Stage 2 (open sore in the upper layer of skin) pressure ulcers, not present on admission. The MDS indicated the resident had one Stage 3 pressure ulcer, present on admission, which measured 7.9 (cm) centimeters by 2.5 cm, with granulation tissue. The quarterly MDS, dated [DATE], indicated the same except a BIMS of 15, weight 203# and the MDS indicated the resident had two Stage 2 pressure ulcers, three Stage 3 pressure ulcers, (1 present on admission), which measured 2.9 cm by 0.9 cm by 0.1 cm, with granulation. The MDS indicated the pressure ulcers that were not present at admission or were at a lesser stage included one Stage 2 and two Stage 3 pressure ulcers. The 6/22/14 (CAA) Care Area Assessment summary for pressure ulcers stated the resident had four Stage 2 pressure ulcers to his/her buttocks, excoriated skin to his/her upper posterior right thigh, daily treatment to his/her buttocks, pressure reducing mattress and pad in chair, weekly skin assessments, and skin observed with toileting, dressing and bathing. The CAA indicated the resident was cognitively intact and had a history of [REDACTED]. The CAA indicated the staff worked with the resident to find the best method of treatment to prevent or heal existing skin conditions and the resident had a trapeze (a triangular bar) above his/her bed to assist with repositioning him/herself in bed and to prevent shearing. The CAA summary for nutrition stated the resident weighed 224# and his/her target weight was 200#, the resident ate 34% of meals, had snacks in his/her room, received crackers and cheese each evening, and a fortified milkshake each afternoon. The undated care plan, reviewed 4/10, 6/26, 9/11 and 11/26/14, directed the nurses to assess the resident's skin weekly, and directed the staff to assist the resident with bed mobility at night on rounds and remind him/her to reposition as he/she allows. The care plan further directed the staff to report to the nurse any reddened skin site that does not resolve within 30 minutes, provide a pressure relief cushion to the resident's wheelchair, a fortified milkshake daily, a regular diet for meals, offer alternatives, administer Vitamin C juice with an iron supplement, monitor intake, and weigh and monitor the resident's weight weekly. The care plan directed the staff to provide a trapeze bar on the bed to assist the resident with bed mobility, apply skin treatments to his/her buttocks as ordered, a pressure reducing mattress to the bed, and reposition the resident off his/her buttocks 2-3 times/day. The 8/22/14 update directed the staff to provide daily ulcer washes with treatment, and powder to the toilet seat. The 9/3/14 update included a pressure pad to his/her ankle, and the 9/18/14 update included 2 calorie supplement, as ordered. The 1/30/14 laboratory blood work indicated the resident's total protein (Total protein measurements can reflect nutritional status) 5.7 (6.2-8.3), [MEDICATION NAME] (a blood test used to measure the amount of protein in the blood and is used in part to determine a person's nutritional status) 2.7 (3-3.5). Review of the medical record revealed no documentation of weekly skin assessments, by the facility, from 1/16/14 to 4/1/14, from 4/3/14 to 5/19/14, from 5/21/14 to 6/24/14, and from 10/09/14 to 11/18/14. The 1/1/14 EZ Graph Wound assessment revealed the wound on the resident's posterior left thigh, measured 3 cm by 2 cm, with a small amount of serosanguiness (clear, tinged with blood) drainage and the wound on the left buttock measured 5.5 by 3 cm with serosanguiness drainage. The 1/11/14 skin assessment stated the resident had "open areas" , with no further information. The 1/15/14 EZ Graph revealed the Stage 2 wound on the resident's left upper thigh had odor, and measured 13 cm by 9 cm. The 3/5/14 physician's orders [REDACTED]. The 3/17/14 facsimile to the physician indicated the resident had an open area to his/her left buttock with thick green drainage. The physician ordered Keflex (antibiotic), 500 (mg) milligrams, by mouth, 3 times daily, for 10 days. The 4/2/14 EZ Graph revealed the open area/wound on the left upper buttock, measured 4.5 cm by 2 cm, with odor and moderate, bloody green drainage. The 4/2/14 skin assessment revealed the wound on the resident's left upper thigh measured 13 cm by 13 cm, with a small amount of bloody, green drainage. The 5/20/14 to 6/18/14 weekly skin assessments revealed an old open area to the resident's left buttocks and upper thigh with no measurements or other information documented. The 5/20/14 nutrition assessment indicated the estimated daily nutritional needs for the resident included 2110 calories, 81-97 grams of protein, and 2700 cc fluids. The 6/25/14 to 8/6/14 weekly skin assessments indicated the resident had an open area to his/her left buttocks and upper thigh, without measurements or further information. The 7/8/14 physician's orders [REDACTED]. The 8/4/14 (RD) Registered Dietician note indicated the resident weighed 210 pounds, did not eat meals well, received a large milk shake with meals, still had skin issues and recommended the staff continue to offer supplements. The note contained no recommendations to improve the resident's nutritional intake and enhance wound healing. The 8/6/14 EZ wound graph revealed the Stage 2 wounds on the resident's left buttock, measured 2.5 cm x 1.5 cm, 2.6 cm x 0.9 cm and 2 cm x 0.3 cm. The Stage 2 wounds on the left posterior (back) thigh, had odor, slough (dead tissue, usually cream or yellow in color), and scant bloody drainage, from below the buttocks to 2-3 inches above the back of the knee. The 8/14/14 EZ wound graph revealed the Stage 2 wounds on the resident's right inner thigh, measured 2.5 cm x 2.5 cm, the Stage 2 wound on the left buttock measured 4 cm x 4.5 cm, and the left thigh wound measured 9 cm x 10 cm ( an increase in size), with bloody, green drainage. The 8/15/14 physician's orders [REDACTED]. The 8/15/14 facsimile to the physician indicated the staff gave the resident a 2 (cal) calorie nutrient drink, 90 (cc) cubic centimeters, and he/she drank it. The staff requested an order for [REDACTED]. (11 days after the dietitian recommendation) The 9/2/14 (RD) Registered Dietician note indicated the resident had recurrent wounds to his/her buttocks and coccyx. The note stated the resident just ate bites of food at meals, was lethargic (prolonged sleepiness, sluggishness, or serious drowsiness at times), and received a regular diet without swallowing difficulty. The note indicated the resident ate independently, refused some meals, was offered 2 cal protein supplement, and the resident received milkshakes at meals. The note contained no recommendations to improve nutritional intake and enhance wound healing. The 9/3/14 skin assessment revealed the resident developed a Stage 2 pressure ulcer on the left inner ankle, measuring 3.3 cm x 2.2 cm. The 9/10/14 EZ wound graph revealed the wound on the left inner ankle, measured 4.5 cm x 2 cm. The 9/16/14 physician note indicated the resident still does not spend any significant time in an easy chair but sat all day in his/her wheelchair, has purplish discoloration of the entire left posterior thigh from the buttock to the popliteal fossa (back of the knee), and no bleeding. The note indicated the resident had 2 shallow ulcers on the left buttock that are filled with xenoderm (ointment which increases blood flow to your wound, helps fight bacteria, helps reduce pain, and removes unhealthy tissue from the wound), clean, without odor, or drainage. The resident was alert and well oriented. The 10/8/14 EZ wound graph revealed the resident's left inner ankle had a Stage 2 wound with eschar (black scab)/slough (dead tissue, usually cream or yellow in color) as described by the nursing staff. According to www.webmed.com a stage 2 pressure ulcer is when the skin breaks open, and can look like a scrape (abrasion), blister, or a shallow crater in the skin. Sometimes this stage looks like a blister filled with clear fluid). The graph lacked measurement of the wound. The 10/16/14 RD note indicated the resident weighed 205 pounds, continued to have skin issues that are long standing, received milk shakes and crackers with cheese for added protein and 2 cal with meals. The note contained no recommendations to improve nutrition or enhance wound healing. The 11/19/14 EZ wound graph revealed the Stage 3 wound on the resident ' s left buttock, measured 2.9 cm x 0.9 cm, and the Stage 2 wounds measured 0.4 cm x 0.4 cm, and 0.6 cm x 0.4 cm. The graph revealed the Stage 2 posterior thigh wounds measured 2 cm x 3.2 cm, and 1 cm x 0.7 cm. The 11/24/14 dietary note indicated the resident remained on 2 cal, 8 ounces milk with meals, fortified milkshake in the afternoon, cheese and crackers in the evening and weighed 203 pounds. The 11/25/14 physician note stated the resident had a fresh ulcer on his/her coccyx in the midline crease, without drainage, and the thigh pressure ulcers were doing well on the present regimen. The 12/2/14 RD note indicated the resident snacked on carbohydrates/sweets, and continued to have skin issues. The note indicated the resident weighed 205 pounds, and was not worried about diet or types of food recommended to him/her and prefers sweets. The note stated the resident received 2 cal, 90 cc, twice daily, for extra protein and dietary continued to work with preferred sources of protein. The note stated the resident needed 90-110 gram protein and recommended the staff continue to offer 2 cal and milk, but did not recommend further interventions for nutrition. The Braden scale (used to assess the risk for pressure ulcers or skin breakdown) revealed the resident score 17 on 4/8/14, 17 on 6/23/14, 16 on 9/8/14, and 17 on 11/21/14, indicating the resident was at mild risk for skin breakdown. The October, November and December treatment record included the physician's orders [REDACTED]. The record indicated the resident refused the majority of the time. The record indicated the resident was out of his/her wheelchair, in mid-afternoon, 8 days in October, 3 days in November, and no days from 12/1 through 12/17/14. The treatment record also indicated the resident refused to roll side to side most days. Review of the physician progress notes [REDACTED]. The notes revealed the physician had directed several interventions and stated the resident was not compliant most of the time. On 7/8/15 the physician indicated he/she spent 45 minutes discussing the resident's situation and management with him/her and the nursing staff. The 7/22/14 physician note indicated he/she had tried multiple consultants and multiple approaches to the wounds, but did not get a lot of compliance from the resident. On 8/5/14 the physician note indicated he/she rescheduled the resident at the wound clinic and the resident had been there many times before and they had dismissed him/her because of non-compliance. On 12/15/14 at 4:50 PM, observation revealed the resident sat in his/her wheelchair, (which had a thick cushion in the seat) putting together a jigsaw puzzle in his/her room. On 12/17/14 at 10:25 AM, observation revealed Nurse I measured the resident's left buttock wound, applied [MEDICATION NAME] (ointment) to all areas, and covered the largest wound with [MEDICATION NAME] non-stick dressing. The pressure ulcer on the resident's left buttock measured 3.2 cm by 2.5 cm, with 5 smaller open areas. On 12/17/14 at 9:55 AM, Nurse I stated the nurses assess the resident's wounds weekly or if a new skin issue is found. On 12/17/14 at 11:40 AM, Administrative Nurse B verified the nurse's notes lacked thorough documentation or description regarding the wounds. He/she stated if the resident's wound graphs were not found, and the documentation was not completed. On 12/17/14 at 9:40 AM, Administrative Staff A stated the resident would not wear incontinent products and then would have incontinence and he/she refused to lie down during the day or sit in the recliner. He/she stated the staff and the physician have discussed wound care and prevention with the resident and now the resident will wear underwear and will sit in a chair at times. Administrative Staff stated the resident had longstandin

The facility had a census of 33 residents. The sample included 22 residents. Based on record review and interview the facility failed to assess, promptly notify the physician of a change in condition and provide necessary care and services for 1 of 3 sampled residents (#39). This failure placed the resident in immediate jeopardy. Findings included: - Resident # 39's (MDS) Minimum Data Set 3.0 assessment, dated 7/15/12, indicated the resident had severely impaired vision. The MDS further indicated the resident had short term and long term memory problems, and moderate impairment with decision making skills. The MDS indicated the resident displayed daily rejection of care. The MDS further indicated the resident required 1 staff assistance for bed mobility, eating, toilet use and personal hygiene and 2 staff assistance for transfer and dressing. The MDS further indicated the resident had range of motion impairment affecting his/her upper and lower extremities on both sides. The MDS indicated the resident had no chronic disease to indicate the resident had less than a 6 month life expectancy. The 7/19/12 (CAAs) Care Area Assessment, stated the resident yelled and refused most everything offered to help him/her, including medication, food and staff encouragment regarding safety for him/her. The CAAs indicated the resident's health had declined and he/she was eating very little, an average of 4% and fluid intake was also poor. The resident required total assistance with all (ADL's), Activities of Daily Living. The 7/6/12 care plan instructed the staff to check the resident's blood glucose daily and as needed. The care plan further instructed the staff to administer the insulin as ordered. The care plan stated the resident often would refuse his/her insulin. The care plan further instructed the staff to provide a limited concentrated sweets diet to the resident. The care plan stated the staff the resident would often only request fruit and often refused meals. The care plan further instructed the staff to encourage fluids to the resident. Review of the 7/6/12 physician's orders [REDACTED]. - Blood glucose monitoring before meals and before bed call if <60 or >350 - [MEDICATION NAME], 15 units, a blood glucose medication, subcutaneous twice daily - Humalog, 8 units, a blood glucose medication, subcutaneous before meals Review of the 7/18/12 treatment administration record for the resident revealed the following: - At 6:00 AM, a blood glucose level of 69. - At 8:00 AM, administered [MEDICATION NAME], 15 units subcutaneous, and Humalog, 8 units, subcutaneous. Review of the 7/18/12 nurses notes for the resident revealed the following: - 11:03 AM The resident had a blood glucose reading of 42. Physician notified and ordered to hold the noon insulin dose and to go ahead and feed the resident lunch. - 12:00 PM Certified Medication Assistant had called the charge nurse to the resident's room. The resident was unresponsive to name being called, shaking and sternal rub. Skin was cool and dry to touch. - 12:15 PM The resident's right pupil was fixed and his/her blood glucose level read "lo". - 12:30 PM The staff administered glucose gel to the resident's [MEDICATION NAME] area and the resident remained unresponsive. - 12:57 PM The nurse attempted to stimulate the resident. The resident did not respond to stimulation. The nurse paged the physician. - The clinical record lacked evidence the physician responded to the call, nor did the staff follow up on the call. - 2:12 PM The physician's office called regarding the resident's status and directed the nurse to send the resident to the emergency department. Blood glucose checked multiple times, meter status continued to read "lo". (approximately 1 hour and 45 minutes after the nurse administered the glucose gel and the resident remained unresponsive) Review of the 7/18/12 physician's orders [REDACTED]. - 12:40 PM for glucose gel stat. - 2:04 PM to transfer the resident to the emergency department. Review of the dietary intake record for 7/18/12 revealed the resident did not eat or drink during breakfast, snack or lunch. On 9/12/12 at 2:00 PM, Nurse F verified the nursing staff did not follow standards of practice with documenting, reassessing and notifying of the physician. Nurse F further verified the facility did not have a [DIAGNOSES REDACTED] protocol in place. On 9/13/12 at 10:36 AM, Direct Care J verified he/she went to attempt to assist the resident with the lunch meal around noon on 7/18/12 and the resident was unresponsive. He/she then notified the nurse. (The staff went to provide the resident his/her lunch approximately 57 minutes after the physician directed the staff to feed the resident) On 9/13/12 at 2:30 PM, Physician K verified he/she expected for the facility to feed the resident immediately after the order was received by the facility. Physician K further verified he/she expected for the facility to notify him/her if the resident was not going to eat. Physician K further verified after the order was given for the glucose gel he/she would have expected a phone call right away if the resident's blood glucose and level of consciousness did not improve. Physician K also verified he/she expected the facility to use a hypoglycemic protocol for diabetic residents. The facility failed to adequately assess, provide treatment and notify the physician for staff to follow physican's orders for Resident # 39 who became unresponsive after a low blood sugar. This failure placed the resident in immediate jeopardy. The immediate jeopardy was abated on September 13, 2012, when the facility implemented a Hypoglycemic Protocol and inserviced their licensed nursing staff on 9/13/12 at 4:30 PM regarding the Hypoglycemic Protocol, the signs and symptoms of [DIAGNOSES REDACTED] and when to notify the physician for changes in residents' conditions. The facility inserviced their direct care staff on 9/13/12 at 4:30 PM regarding the signs and symptoms of [DIAGNOSES REDACTED] and when to notify the nurse for changes in residents' condition. The deficient practice remains at a scope and severity of a G.