Every finding on record at Shawnee Gardens Healthcare & Rehab Center

Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly by failing to ensure the lid of the dumpster was kept closed and failing to ensure the trash bags filled with dietary and nursing trash were kept in an enclosure. Findings included:- During an initial tour of the kitchen on 08/03/2026 at 07:42, the following concerns were identified: 1. One of two dumpsters had the cover open. There were random pieces of trash littering the ground around the dumpster. 2. On 08/05/2026 at 07:45 AM, two of the two dumpsters were empty. There were 14 bags of trash containing dietary and nursing trash stacked next to one of the empty dumpsters. On 08/05/2026 at 07:56 AM, Administrative Staff A stated the sanitation company had not picked up the garbage on 08/04/2026, as planned but had picked up the garbage in the early morning of 08/05/2026. Administrative Staff A confirmed the bags of garbage had not been placed into the empty dumpsters and were stacked on the ground next to the dumpster. The facility policy for Garbage and Rubbish Disposal, dated 2020, included: Garbage and rubbish will be disposed of to ensure a clean and sanitary kitchen that does not encourage insects or rodents. All outside dumpsters will be maintained in clean and sanitary condition.

Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions to the residents of the facility appropriately to prevent the potential for food borne bacteria in one of the kitchens. Findings included:- During an initial tour of the kitchen on 08/03/2026 at 07:42 AM, the following areas of concern were noted: 1. One three-tiered black plastic cart used for food preparation had two melted areas on the second tier. 2. A black wire rack in the refrigerator walk-in had a build-up of food debris. 3. A wire rack holding clean pots and pans had multiple areas of rust. 4. Thirty-five plastic trays, used for serving residents meals, were put away wet. 5. A large plastic container holding dry rice lacked a lid. 6. A plastic container of uncooked oatmeal was left uncovered. During an initial tour of two kitchenettes on 08/03/2026 at 08:00 AM, the following area of concern was noted: 1. The microwave in each location had a build-up of dried food on all inside surfaces of the microwaves. On 08/05/2026 at 07:56 AM, Dietary Staff BB confirmed the listed areas of concern. The facility policy, Sanitation of Dining and Food Service Areas, dated 2020, included: The Dining Services staff will uphold sanitation of the dining areas according to a thorough, written schedule.

Based on record review and interview, the facility failed to ensure the staff person designated as the Infection Preventionist (IP), who was responsible for the facility's Infection Prevention and Control Program (IPCP), was certified and had completed the specialized training in infection prevention and control Findings included:- On 08/04/2026 at 08:45 AM, Administrative Nurse D, upon request, was unable to provide evidence of certification for the facility's IP.On 08/04/2026 at 08:57 AM, Administrative Nurse D stated that she took over the IP position in December 2025 and that she had acquired her IP certification at another facility and did not have a copy of it. She stated that she had been unable to obtain it.The facility's policy Infection Preventionist, dated 07/07/2026, documented the facility would employ one or more qualified individuals with responsibility for implementing the facility's infection prevention and control program. The facility would designate a qualified individual as Infection Preventionist (IP) whose primary role was to coordinate and to be actively accountable for the facility's infection prevention and control program, including the antibiotic stewardship program. The IP must have obtained specialized IP certification beyond initial professional training or education prior to assuming the role and must provide evidence of training through a certificate of completion or equivalent documentation.

Based on observation, record review, and interviews, the facility failed to ensure an environment free from accident hazards when staff failed to secure disinfectant chemicals in a locked area and out of the reach of the 10 cognitively impaired, independently mobile residents. Findings included:- During the initial tour of the facility's Memory Unit on 08/03/2026 at 08:10 AM, an unlocked cabinet over the dining counter had an unmarked bottle with brown liquid, a bottle of rapid cleaner disinfectant, and two small bottles of peri care wash. On 08/03/2026 at 08:00 AM, Certified Medication Aide (CMA) stated chemicals should be locked, and it was every staff's responsibility to ensure chemicals were in a locked cabinet.On 08/03/2026 at 08:10 AM, Licensed Nurse (LN) G stated that chemicals should be locked in a cabinet, or placed in the dirty laundry room, which was locked.On 08/05/2026 at 12:33 PM, Administrative Nurse D stated chemicals should be in a locked cabinet, or behind a locked door. She stated all bottles should be labeled with contents.The facility's Accidents and Supervision policy documented the resident's environment would remain as free of accident hazards as possible. Each resident would receive adequate supervision and assistive devices to prevent accidents.

Based on record review, observation, and interviews, the facility failed to ensure a safe, clean, home-like environment in the facility extended recovery unit (ERU) lounge area. Findings include:- Observed on 08/03/2026 at 07:47 AM, the ERU lounge area, across the hall from the shower room and by the exit to the smoking area, had three paper towels on the floor next to the sink, and the faucet was turned on. There was an empty medicine cup on the floor. There was an empty cup, unfolded gait belt, and a clock that had a loose battery on it, sitting on the table that was under the television. There was food debris on the floor next to a recliner, no trash bag in the trash can, and a dirty cup laid upside down on the counter next to the sink, the ice machine had a visible substance on it, and there was brown debris on the drain tray. There were two plastic cups stacked together with a visibly dirty coffee cup sitting next to the ice machine on the counter. The counter, under the ice machine, was visibly dirty with white debris. There was an unfolded gait belt on the table under the television and a clock with the battery laying on it on the table. Observed on 08/03/2026 at 02:34 PM, the ERU lounge area had a dirty coffee cup and dirty plastic cup sitting next to the ice dispenser machine on the counter.Observed on 08/04/2026 at 07:55 AM, the ERU lounge area had an empty medicine cup on the floor in front of the sink next to the trash can along with a wrapper and a piece of paper towel sitting on the floor. There was a dirty cup sitting on the table under the television and the ice machine was visibly dirty and a dirty cup sat next to sink on the counter. On 08/05/2026 at 09:32 AM, Certified Nurse Aide (CNA) P stated that she did not know who was responsible for cleaning the ERU lounge area and ice machine. On 08/05/2026 at 09:36 AM, Licensed Nurse (LN) H stated that there was a third-party contractor that cleaned the ice machine in the ERU lounge area and staff were to pick up the trash and dishes.On 08/05/2026 12:36 PM, Administrative Nurse D stated that a third-party contractor came semiannually and cleaned the ice machine in the ERU lounge area. She stated that she had discussed with staff that they were to check the ERU lounge area for trash and debris.The facility policy Safe and Homelike Environment, dated 07/15/2026, documented in accordance with residents' rights, the facility would provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.

Based on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) for two residents: Resident (R)118, regarding discharge location, and R10, regarding the use of continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep). Findings included:- 1. R118's Electronic Medical Record (EMR) recorded an MDS dated [DATE], which recorded R118 discharged , with return anticipated, to Home/Community, on 07/13/2026.R118's EMR under the Prog Notes tab, 07/13/2026, documented R118 admitted to the hospital.2. R10's EMR recorded a Significant Change MDS dated 05/01/2026, which lacked documentation of the use of a CPAP during the observation period.R10's EMR under the Orders tab revealed the following physician orders: Non-invasive ventilator (NIV) settings: Intelligent Volume-Assured Pressure Support with Auto EPAP (iVAPS-AE), maximum 25 centimeter (cm), minimum EPAP 5 cm, maximum expiratory positive airway pressure (EPAP) 15 cm, minimum pressure support (PS) 5 cm, maximum PS 15 cm, Vt 500 milliliter (ml), rate-auto dated 03/06/2026.On 08/04/26 at 11:30 AM, Administrative Nurse E stated the MDS dated [DATE], for R118 was inaccurate as R118 discharged from the facility to the hospital and did not discharge to her Home or the Community. Administrative Nurse E stated it was the expectation for the MDS to be completed accurately. Administrative Nurse E stated R10's CPAP should have been marked yes related to his usage of the CPAP in the facility.The facility policy for MDS, revised 09/29/25, included: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary (ID) care plan.

Based on observation, interview, and record review, the facility failed to complete comprehensive Minimum Data Set Assessment (MDS) for two Residents (R)67, regarding discharge and R10, regarding nutrition. Findings included:- 1. R67's Electronic Medical Record (EMR) recorded a Significant Change Minimum Data Set (MDS), dated [DATE], with the Activity Care Area Assessment (CAA), dated 06/05/26, triggered but lacked an analysis of findings.2. R10's EMR recorded a Significant Change Minimum Data Set (MDS) dated 05/01/2026, with the Nutritional Status CAA dated 05/06/2026 triggered but lacked analysis of findings.On 08/05/26 at 11:15 AM, Administrative Nurse D confirmed the activity CAA on the significant change MDS for R67, triggered but lacked an analysis of findings.On 08/04/26 at 11:30 AM, Administrative Nurse E stated it was the expectation for triggered CAAs to include an analysis of findings. Administrative Nurse E confirmed the Nutritional Status CAA on Significant change MDS dated [DATE] lacked analysis.The facility policy for MDS, revised 09/29/25, included: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary (ID) care plan.

Based on observation, interview, and record review, the facility failed to provide the necessary activities of daily living (ADL) services for Resident (R)8, who did not receive adequate assistance with personal hygiene. Findings included:- Review of the Electronic Health Record (EHR) revealed R8's diagnoses included subarachnoid hemorrhage (bleeding in the space just outside of the brain), lack of coordination, contracture of muscle of multiple sites to lower body (abnormal permanent fixation of a joint or muscle), quadriplegia (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord), neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet), and dementia (a progressive mental disorder characterized by failing memory and confusion).R8's Annual Minimum Data Set (MDS), dated 10/13/2025, documented a Brief Interview for Mental Status (BIMS) score of eight indicating moderate cognitive impairment. He required a wheelchair for mobility; he required set-up/clean-up assistance for eating and was dependent on staff for bathing and all other ADLs.The Functional Abilities Care Area Assessment (CAA), dated 10/13/2025, documented R8 was dependent on staff for transfers to the shower and with personal hygiene.The Urinary Incontinence and Indwelling Catheter CAA, dated 10/13/2025, noted that R8 was dependent on staff for toileting hygiene and was incontinent of urine.R8's Quarterly MDS, dated 07/15/2026, documented a BIMS score of three indicating severe cognitive impairment. He required a wheelchair for mobility; he required set-up/clean-up assistance for eating and was dependent on staff for bathing and all other ADLs.R8's Care Plan dated 10/18/2023, instructed staff to provide substantial maximal assistance with oral hygiene, supervision with set-up assistance for eating, and he was dependent on staff for toileting hygiene, upper body dressing and to shower/bathe. Staff was instructed to provide R8, who was dependent on staff to shower and bathe, with washcloths and soapy water for sponge bathing if bathing was refused.R8's EHR, under the bathing Tasks showed R8 received bathing eight times between 07/06/2026 and 08/04/2026. There were three documented bathing refusals in July 2026. The task did not show if the task performed was a bath, a shower or a bed bath.R8's EHR lacked documentation that R8 had refused to have his hair washed, face cleaned or clothes changed during the survey and observation dates below.Observation on 08/03/2026 at 09:22 AM, revealed R8 sat in his wheelchair at a table in the dining room. R8's hair was disheveled and uncombed. The hair looked greasy and had various sized pieces of debris throughout his shoulder length hair. R8 had a beard and mustache from his upper lip to just below his chin that had small to medium pieces of debris throughout his beard and small crumbly material around his mouth and lips.Observation on 08/04/2026 at 07:51 AM, revealed R8 sat at a table in the dining room eating his breakfast. His shirt had dried food stains to the right sleeve of his shirt that were reddish in color. His hair had large pieces of white debris and flakes throughout his hair. His hair looked greasy, disheveled, and uncombed.Observation on 08/04/2026 at 01:20 PM, revealed R8 was in his room in a wheelchair receiving wound care from Licensed Nurse H. R8's pants were wet in the front groin-area. His hair looked unkempt, matted, uncombed, oily and greasy.Observation on 08/05/2026 at 08;23 AM, revealed R8 was in his bed watching television. A tray with his morning meal was on table at bedside. His hair looked unkempt, disheveled, oily, and he had small to medium white debris throughout his hair,On 08/04/2026 at 08:42 AM, R8 reported that he had only been allowed one shower since admission and was told by staff he would get a shower two weeks ago but never did. He stated that he had requested showers but did not get them and said he had to give himself bed baths.On 08/05/2026 at 10:43 AM, Certified Nurse Aide (CNA) O reported that R8 does not go into the shower. CNA O said staff gives R8 a bed bath, and during his bed bath staff used washcloths with some soap on them for his hair.On 08/05/2026 at 10:49 AM, Licensed Nurse (LN) H reported that he was unsure if staff cleaned R8's hair well when he was bathed. LN H reported R8 only received a shower 25% of the time and received a bed bath the other 75% of the time. LN H stated R8 was dependent on staff to transfer him to the shower with a mechanical lift which made it difficult when staff transferred him to the shower chair.On 08/05/2025 at 01:30 PM, Administrative Nurse D stated that R8 was dependent on staff and needed to be transferred using a mechanical lift. Administrative Nurse D stated it was her expectation that R8 received a bed bath, staff should use the available shower caps that were designed to wash/shampoo hair. Administrative Nurse D stated staff would be educated on how the shower caps were to be used and would use them going forward.The facility policy Activities of Daily Living dated 12/01/2025, documented that a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, record review and interview, the facility failed to provide an ongoing program of activities designed to meet the interests and well-being of Resident (R)11 and R67. Findings included:- 1. R11's Electronic Medical Record (EMR) documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion). R11's Significant Change Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed severe cognitive impairment. R11's preferences for activities included listening to music, being around animals such as pets, spending time outdoors, and participating in her favorite activities. She was dependent on staff for locomotion on the unit in her wheelchair. R11's Cognitive Loss/Dementia Care Area Assessment (CAA), dated 04/01/2026, documented staff should ask her yes/no questions. R11's Quarterly MDS, dated [DATE], documented the staff assessment for cognition revealed severe cognitive impairment. She was dependent on staff for locomotion on the unit in her wheelchair. R11's Care Plan for activities, revised 07/02/2026, instructed staff the resident enjoyed listening to music, watching movies, visiting with her family, and resting in her recliner. On 08/03/2026 at 08:37 AM, R11 sat in her specialized wheelchair at the dining table with peers. There was no activity or stimulation occurring at that time. On 08/04/2026 at 07:16 AM, R11 sat in her specialized wheelchair at the dining table with peers. There was no activity or stimulation occurring at that time. On 08/04/2026 at 09:59 AM, R11 sat in her specialized wheelchair at the dining table with peers. There was no activity or stimulation occurring at that time. R11 called out to several staff on several occasions with no response. On 08/04/2026 at 12:22 PM, Certified Nurse Aide (CNA) M stated the resident did not participate in activities because she had dementia. On 08/04/2026 at 12:24 PM, CNA N stated R11 could not participate in activities due to her cognition; the resident would sit and people watch. On 08/04/2026 at 01:12 PM, Activity Staff Z stated there were multiple activities for residents with cognitive loss to do while they sat at the dining room table. Activity Staff Z stated she would need to do education with staff to ensure the activities were brought out and used on a routine basis. On 08/05/2026 at 10:00 AM, Licensed Nurse (LN) I stated the resident rarely participated in activities due to her cognitive loss. 2. R67's EMR documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion). R67's Significant Change MDS dated 06/05/2026, documented the staff assessment for cognition revealed severe cognitive impairment. R67's preferences for activities included listening to music, being around animals such as pets, spending time outdoors, and participating in her favorite activities. She was dependent on staff for locomotion in her wheelchair. R67's Activity CAA dated 06/05/2026, triggered but lacked an analysis of findings. R67's Cognitive Loss/Dementia CAA, dated 06/05/2026, documented R67 had dementia. R67's Care Plan for activities, revised 06/18/2026, instructed staff it was important for her to have the opportunity to engage in daily routines and activities. She enjoyed visiting with her family, going outdoors, and looking out the window. On 08/03/2026 at 08:37 AM, R67 sat in her wheelchair at the dining table with her peers. There was no activity or stimulation occurring at that time. On 08/04/2026 at 07:16 AM, R67 sat in her wheelchair at the dining table with her peers. There was no activity or stimulation occurring at that time. On 08/04/2026 at 09:59 AM, R67 sat in her wheelchair at the dining table with her peers. There was no activity or stimulation occurring at that time. On 08/04/2026 at 12:22 PM, Certified Nurse Aide (CNA) M stated the resident did not participate in activities because she had dementia. On 08/04/2026 at 12:24 PM, CNA N stated R67 could not participate in activities due to her cognition. The resident would sit and people watch. On 08/04/2026 at 01:12 PM, Activity Staff Z stated there were multiple activities for residents with cognitive loss to do while they sat at the dining room table. Activity Staff Z stated she would need to do education with staff to ensure the activities were brought out and used on a routine basis. On 08/05/2026 at 10:00 AM, Licensed Nurse (LN) I stated the resident rarely participated in activities due to her cognitive loss. On 08/05/2026 at 12:33 PM, Administrative Nurse D stated it was the expectation for the residents with cognitive loss to have activities they enjoy. The facility policy for Activities, revised 01/07/26, included: It is the policy of the facility to provide an ongoing program to support residents in their choice of activities.

Based on observation, interview, and record review, the facility failed to ensure appropriate wheelchair positioning for Resident (R)11. Findings included:- R11's Electronic Medical Record (EMR) documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion). R11's Significant Change Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed severe cognitive impairment. She had limited range of motion (ROM) in her bilateral lower extremities (LE-legs). R11 was dependent on staff for locomotion in her wheelchair. R11's Activity of Daily Living (ADL) Care Area Assessment (CAA), dated 04/01/2026, did not trigger. R11's Quarterly MDS, dated [DATE], documented the staff assessment for cognition revealed severe cognitive impairment. She had limited ROM in her bilateral LEs and was dependent on staff for locomotion in her wheelchair. R11's Care Plan, revised 07/02/2026, instructed staff she was dependent on staff for locomotion in her wheelchair. On 08/03/2026 at 08:37 AM, R11 sat in her wheelchair at the dining room table. Her feet hovered several inches above the footrest of the wheelchair. On 08/04/2026 at 07:16 AM, R11 sat in her wheelchair at the dining room table. Her feet hovered several inches above the footrest of the wheelchair. On 08/04/2026 at 09:59 AM, R11 continued to sit in her wheelchair at the dining table with her feet hovering several inches above the footrest of the wheelchair. On 08/04/2026 at 12:22 PM, Certified Nurse Aide (CNA) M confirmed R11's feet did not reach the footrests of her wheelchair. On 08/04/2026 at 12:24 PM, CNA N stated R11's feet did not reach the footrests of the wheelchair. CNA N stated the footrest of the wheelchair needed to be adjusted to fit R11 better. On 08/05/2026 at 12:33 PM, Administrative Nurse D stated R11's footrest needed to be adjusted to better fit the resident and support her feet. The facility policy for Use of Assistive Devices, revised 01/27/2026, included: The use of assistive devices will be based on the resident's needs, as indicated.

Based on interviews, observation, and record review, the facility failed to ensure Resident (R) 10's continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) mask and oxygen tubing was stored in a sanitary manner to prevent contamination and respiratory infections. Findings included:- R10's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), dependent on dialysis (a procedure where impurities or wastes are removed from the blood), dependent on supplemental oxygen.The Significant Change Minimum Data Set (MDS) dated 05/01/2026 documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS lacked documentation R10 was provided with his CPAP during the observation period. R10's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA), dated 05/06/2026, documented staff would assist R10 with activities of daily living (ADLs) as needed and encourage his participation with ADLs.R10's Care Plan documented the following interventions:04/24/2026 - Staff would change oxygen tubing and rinse oxygen concentrator filter weekly. Staff would check oxygen saturation as ordered, see the treatment administration record. Staff would monitor changes in oxygenation status and keep the physician informed. Staff would administer R10's oxygen as ordered, see the treatment administration record. R10's EMR under the Orders tab revealed the following physician orders:Non-invasive ventilator (NIV) settings: Intelligent Volume-Assured Pressure Support with Auto EPAP (iVAPS-AE), maximum 25 centimeters (cm), minimum EPAP 5 cm, maximum expiratory positive airway pressure (EPAP) 15 cm, minimum pressure support (PS) 5 cm, maximum PS 15 cm, Vt 500 milliliter (ml), rate-auto dated 03/06/2026.Oxygen 3 liters per minute (LPM) continuous to keep oxygen saturation greater (>) than 90%, every shift for chronic respiratory failure dated 03/06/2026.Assist R10 with putting on NIV mask every night (Turn on machine, put mask on, and hit Start button on screen). Wake him to put on mask, even if he was already asleep. Make sure oxygen is set at 3LPM and connected to the NIV dated 03/06/2026.Assist R10 with taking the NIV mask off in AM (Take off mask and press and hold power button to turn off machine). Make sure to put oxygen on at 3LPM via nasal cannula, for obstructive sleep apnea (OSA) dated 03/06/2026.On 08/03/2026 at 09:45 AM, R10's NIV mask lay directly on the bedside table next to the machine, not in a container. On 08/04/2026 at 07:42 AM, R10 lay asleep on his bed with lights turned off. The head of his bed was elevated, and his oxygen was on. On 08/05/2026 at 10:26 AM, R10's oxygen tubing was wrapped together and placed under the handle of the oxygen concentrated machine, not in a container.On 08/05/2026 at 10:20 AM PM, Certified Nurse Aide (CNA) MM stated she would transfer the oxygen tubing from the concentrator to the portable oxygen tank after getting R10 up for the day. CNA MM stated she would then place the oxygen tubing inside the concentrator handle. On 08/05/2026 at 10:26 AM, Licensed Nurse (LN) I stated R10's CPAP mask and oxygen tubing should be stored in a bag when not in use.On 08/05/2016 at 12:30 PM, Administrative Nurse D stated she expected R10's respiratory equipment to be cleaned and changed as ordered. Administrative Nurse D stated she expected the respiratory equipment stored in the bag that was dated.The facility's Oxygen Administration policy dated 05/21/2026 documented oxygen was administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences.

Based on observation, record review, and interviews, the facility failed to complete and document a post hemodialysis (a procedure where impurities or wastes are removed from the blood) assessment for Resident (R) 10. Findings included:- R10's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), dependent on dialysis (a procedure where impurities or wastes are removed from the blood), dependent on supplemental oxygen.The Significant Change Minimum Data Set (MDS) dated 05/01/2026 documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R10 had received dialysis during the observation period. R10's Nutritional Status Care Area Assessment (CAA), dated 05/06/2026 lacked analysis. R10's Care Plan, documented the following interventions: 02/26/2026 - Staff would encourage R10 to go to scheduled dialysis appointments.R10's dialysis days were on Monday, Wednesday, and Friday at 11:30 AM. Staff would send a snack meal with R10 if at dialysis during a meal. Staff would monitor his shunt site for signs and symptoms of infection, bleeding, or edema.Staff would not take blood pressure in the arm that has a shunt.Staff would obtain dry weights prior to dialysis treatment. Staff would weigh daily and notify physician if gain or loss (blank) in one day or (blank) gain or loss in a week. (Specify).TR10's EMR under the Orders tab revealed the following physician orders:Dialysis on Monday, Wednesday, and Friday. Have R10 ready by 10:30 AM for dialysis dated 03/18/2026. The physician order lacked location of the dialysis provider.Monitor arteriovenous (AV) fistula/graft site for signs or symptoms of infection, edema, and bleeding upon return from dialysis. Notify physician of any signs noted. If site has bleeding, apply pressure for 15 minutes and notify physician if bleeding does not stop every shift. Port site right upper chest dated 03/07/2026.Weigh every Monday, Wednesday, and Friday prior to dialysis for fluid management for dialysis dated 03/06/2026. Review of the Dialysis Communication Form provided by the facility from 05/01/2026 to 08/03/2026 revealed 41 dialysis communication sheets. No post dialysis documentation was completed on the following 25 dates 05/01/2026, 05/08/2026, 05/11/2026, 05/13/2026, 05/18/2026, 05/2026, 05/2026, 05/22/2026, 05/27/2027/2026, 05/29/2026, 06/01/2026, 06/2026, 06/2026, 06/15/2026, 06/17/2026, 07/01/2026, 07/03/2026, 07/06/2026, 07/17/2026, 07/20/2026, 07/22/25026, 07/24/2026, 07/27/2026, 07/31/2026, and 08/03/2026.On 08/04/2026 at 07:42 AM, R10 laid asleep on his bed with lights turned off. The head of his bed was elevated, and his oxygen was on. On 08/05/2026 at 10:20 AM, Certified Nurse Aide (CNA) MM stated she would assist R10 with dressing and obtain his vital signs and weight before leaving for dialysis.On 08/05/2026 at 10:26 AM, Licensed Nurse (LN) I stated he would obtain R10's vital signs prior to leaving for dialysis. LN I stated the dialysis communication book was sent along with R10 to dialysis. LN I stated R10 would be assessed upon his return from dialysis and it would be documented on the dialysis communication sheet.On 08/05/2016 at 12:30 PM, Administrative Nurse D stated she expected the charge nurse to complete an assessment for R10 post return from his dialysis appointment. Administrative Nurse D stated she expected the nurse to document the assessment on the dialysis communication sheet. The facility's Hemodialysis policy dated 11/25/2025 documented the facility would provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis.

Based on interviews, observation, and record review, the facility failed to ensure collaboration with the hospice provider for Resident (R) 2. Findings included:- R2's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), dementia (a progressive mental disorder characterized by failing memory and confusion), and myasthenia gravis (an abnormal condition that causes muscles to tire and weaken easily).The Quarterly Minimum Data Set (MDS) dated 05/27/2026 documented a Brief Interview of Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The MDS documented R2 had received hospice services during the observation R2's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA), dated 02/27/2026 documented staff would assist her with activities of daily living as needed. R2 would work with therapy services to assist in increasing her functional mobility.R2's Care Plan documented the following interventions: 02/16/2026- Staff would assess her pain, restlessness, agitation, constipation, and other symptoms of discomfort.Staff would administer medication as ordered and evaluate effectiveness.Staff would provide nonpharmacological approaches to aid in decreasing discomfort.Staff would notify hospice of significant changes, clinical complications needing plan of care change, need to transfer to emergency department or death. Staff would provide medications per hospice and physician orders, see medication administration record and treatment administration record. Staff would provide food and fluids as desired for physical and emotional comfort.The plan lacked the frequency of hospice staff visits and the care they would provide, as well as the medications and equipment to be provided by hospice.R2's EMR under the Orders tab revealed the following physician orders:Admit to hospice with a diagnosis of myasthenia gravis dated 02/13/2026.On 08/04/2026 at 07:45 AM, R2 sat in a wheelchair in her room and had self-propelled herself to the bathroom.On 08/05/2026 at 10:20 AM PM, Certified Nurse Aide (CNA) MM stated she was informed of which resident received hospice services from the nurse during report. CNA MM stated the information for the services provided by hospice was listed on the residents' personalized care plan. On 08/05/2026 at 10:26 AM, Licensed Nurse (LN) I stated he communicated with hospice staff when they came to the facility to provide care. LN I stated the information of what services are provided by hospice should be listed on the resident's care plan.On 08/05/2016 at 12:30 PM, Administrative Nurse D stated she expected there to be collaboration of care and services provided by hospice and that collaboration should be listed on the resident's care plan.The facility's Coordination of Hospice Services policy dated 12/02/2025 documented when a resident chose to receive hospice care and services, the facility would coordinate and provide care in cooperation with hospice staff in order to promote the resident's highest practicable physical, mental, and psychosocial well-being.

Based on record reviews and interviews, the facility failed to post the required staffing information when the posted nurse staffing sheet did not list the actual staff hours worked as required. Findings included:- Review of the posted staffing sheets from 02/02/2025 to 08/02/2026 revealed the facility was unable to provide the posted staffing documentation that contained all the actual hours worked. The sheets contained the number of staff and the scheduled hours but not the actual hours worked. On 08/05/2025 at 12:33 PM, Administrative Staff A stated the staff coordinator was the person who posted and filled out the forms daily. She stated Administrative Staff A created a posted staffing sheet specifically to ensure all required information was posted.On 08/05/2026 at 12:55 PM, Administrative Staff A stated he had designed a posted staffing sheet to ensure the sheet that was posted met all required criteria for the state. He stated he did have a lot of the actual staff hours worked, but they were not posted. Administrative Staff A stated on the log staff must sign their hours. He confirmed the log was in a binder in the lobby, but it was not posted.The facility's Nurse Staffing Posting Information Policy last revised on 02/02/2025 documented it was the policy of the facility to make nurse staffing information readily available in a readable format to residents and visitors at any given time. The information posted would be presented in a clear and readable format. The posted staffing would be placed in a prominent place readily accessible to residents, staff, and visitors.

The facility identified a census of 116 residents. The sample included three residents, with one resident reviewed for abuse. Based on observation, record review, and interviews, the facility failed to report an allegation of abuse from Resident (R) 1 towards R2 to the State Agency (SA). Findings included:- The facility's investigation narrative, dated 03/29/26, signed by Administrative Staff A, Administrative Nurse D, and Social Services X, documented on 03/29/26 at approximately 03:30 PM, Licensed Nurse (LN) G texted Administrative Staff A asking him to call her when he had a few minutes. Administrative Staff A contacted LN G and LN G stated to him that she received a call from a staff member with an allegation at the facility. Administrative Staff A merged the call with Administrative Nurse D then asked LN G to repeat the conversation. LN G stated she received a call from Certified Medication Aide (CMA) R related to an interaction the CMA happened upon between two [cognitively impaired] residents in the facility. Administrative Staff A asked Social Services X to report to the facility along with himself and Administrative Nurse D. Administrative Nurse D entered R2's room, where the resident laid in bed and did not appear to be in distress. Administrative Nurse D asked R2 if she had any concerns about any visitors coming into her room, and R2 said she did not. Administrative Nurse D asked R2 if an unwelcomed visitor entered her room, how she would react, and R2 stated she would tell them to get out of the room. R2 stated if the welcomed visitor made any advancements towards her, she would not be offended to have that interaction with them. Social Services X interviewed R1, who had no recollection of any interaction with R2. CMA R reported when she walked down the hallway to another resident's room, she witnessed R1 rolling himself down the hallway. CMA R stated she advised R1 to turn around and head back to his room then continued to the other resident's room, stopping too close to R2's door as she passed by. CMA R stated she entered R2's room and immediately separated R1 and R2 and R2 yelled and asked CMA R what she was doing. CMA R removed R1 from the room and provided him with snacks and took him to his room. According to the video surveillance, R1 entered R2's room and was in there for one minute and 40 seconds before CMA R entered. The investigation conclusion documented Social Services X assessed R1 and R2 for psychosocial well-being and determined neither resident was at risk from the allegation. As an intervention, the facility connected with R1 and R2's representatives to schedule a care conference related to their loved ones' interactions. The facility waited to hear back from representatives related to the care plan meetings. The facility reviewed R1 and R2's care plans. On 04/07/26 at 11:36 AM, CMA R was unavailable for interview. On 04/07/26 at 11:42 AM, LN G stated she received a call from CMA R on 03/29/26 stating she walked in on R1 in R2's room with his pants down. She stated she asked CMA R what R2 was doing during the incident, and CMA R stated R2 was just lying there. LN G stated she notified Administrative Nurse D first, who told her to call Administrative Staff A, which she did. LN G stated that following day, she went into work and had not seen any incidents created in Risk Management about the allegation. She stated the facility did not put any interventions into place to prevent inappropriate touching between R1 and R2. On 04/07/26 at 01:27 PM, Administrative Staff A stated he had received a text from LN G asking him to call her which he did promptly, and LN G reported an incident of inappropriate touching between R1 and R2. He stated he added Administrative Nurse D to the call to better ascertain the circumstances of the allegation. Administrative Staff A stated when the facility finished their investigation, they involved corporate as well. He stated R1 and R2's families were not very prompt with getting back to the facility about a care plan meeting and the facility was unable to corroborate that the allegation occurred. On 04/07/26 at 03:08 PM, Administrative Nurse D stated the biggest intervention the facility put into place after the allegation was the plan to involve the family in the care plan meeting to discuss the allegation, but the facility had not heard back from R2's family and R1's representative was in the hospital. Administrative Nurse D stated an incident was considered reportable to the SA if it was abuse, neglect, or exploitation with intent and the facility had two hours to report it. She stated the facility had worked through the investigation with corporate and decided not to report the incident. Administrative Nurse D stated any incident that was reportable to the SA would also involve the police and the facility sent in the completed investigation within five business days. On 04/07/26 at 03:30 PM, Administrative Staff A stated the reason the facility did not report this incident was because the facility determined the residents could make decisions on the interaction and the facility could not define if there was willful intent of abuse. He stated the facility reported to the SA on anything that fell under the guidance which included abuse, neglect, and misappropriation of funds. Administrative Staff A stated allegations should be reported if the initial investigation substantiated the allegation and the facility had two hours to report it. He stated the facility reported resident-to-resident altercations if there was unwanted contact made. Administrative Staff A stated the facility sent in the completed investigation within five working days. The facility's Resident Rights to Freedom from Abuse, Neglect, and Exploitation Policy and Procedure, dated 2025, directed in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility ensured all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, and misappropriation of resident property, were reported in the proper time frame pursuant to the policy. The policy directed the facility reported the results of the investigation to the SA within five working days.

The facility identified a census of 114 residents. The sample included eight residents, with seven residents reviewed for misappropriation of medications. Based on observations, record review, and interviews, the facility failed to ensure Resident (R) 1, R2, R3, R4, R5, R6, and R7 remained free from misappropriation of medications. This deficient practice had the risk of missed medications and further misappropriation of medications for the affected residents.Findings included:- R1's Electronic Medical Record (EMR) documented an order with a start date of 07/24/25 for morphine sulfate (narcotic pain medication) solution 20 milligrams (mg)/milliliters (mL) with instructions to give 0.5 mL by mouth every four hours as needed for shortness of breath (SOB) or pain.R2's EMR documented an order with a start date of 06/18/25 for morphine sulfate solution 20 mg/mL with instructions to give 0.25 mL by mouth every hour as needed for pain/SOB.R3's clinical record documented an order with a start date of 10/03/24 for morphine 20 mg/mL with instructions to give 0.25 mL orally every four hours as needed for pain/SOB.R4's EMR documented an order with a start date of 03/29/25 and a discontinued date of 04/06/25 for morphine solution 20 mg/mL with instructions to give 0.5 mL sublingually (under the tongue) every four hours as needed for pain/SOB.R5's EMR documented an order with a start date of 05/14/25 and a discontinued date of 07/22/25 for morphine sulfate solution 20 mg/mL with instructions to give 0.5 mL sublingually every four hours as needed for moderate pain. R5's EMR documented an order with a start date of 05/14/25 and a discontinued date of 07/22/25 for morphine sulfate solution 20 mg/mL with instructions to give 0.25 mL sublingually every four hours as needed for pain or SOB.R6's EMR documented an order with a start date of 09/30/24 for morphine sulfate solution 20 mg/mL with instructions to give 0.25 mL by mouth every four hours as needed for pain or SOB.R7's EMR documented an order with a start date of 04/22/25 and a discontinued date of 08/24/25 for morphine sulfate solution 20 mg/mL with instructions to give 0.25 mL orally every four hours as needed for pain/air hunger (a form of respiratory distress characterized by gasping and labored breathing).The facility's Investigation dated 08/27/25, documented on 08/20/25, Licensed Nurse (LN) G reported to Administrative Nurse D and Administrative Staff A a noted color discrepancy for several liquid narcotics. The facility immediately started investigating, and staff assessed residents on liquid narcotics for pain and gave medication as needed. The facility audited liquid narcotics with no other discrepancies noted. The facility notified the provider and affected residents' representatives. The facility reported the discrepancies to the police. The facility suspended LN I on 08/20/25 pending the investigation, as she worked on both units during the timeframe. The facility contacted the pharmacy, and Consultant GG went to the facility to investigate. Consultant GG discovered R1, R2, R3, R4, R5, R6, and R7 had liquid morphine that appeared to be different in color or smell. Consultant GG destroyed the tampered medications per protocol. The facility reviewed camera footage and was unable to identify any suspicious activity of diversion. The facility identified multiple staff members who had access to the medications in question and were unable to narrow down the exact date the medications may have been tampered with. The investigation included the Individual Resident's Controlled Substance Record sheets for the affected residents. The sheets revealed the following last doses of liquid morphine received for each affected resident: R1 on 08/20/25, R2 on 08/07/25, R3 on 03/01/25, R4 on 04/07/25, R5 on 07/22/25, R6 on 05/02/25, and R7 never received any doses.R5 passed away on 07/22/25.On 08/27/25 at 02:11 PM, R6 laid in bed with her eyes closed. R6 appeared comfortable and without signs of pain or discomfort.On 08/27/25 at 02:13 PM, R2 laid in bed with her eyes closed. R2 appeared comfortable and without signs of pain or discomfort.On 08/27/25 at 02:16 PM, R3 laid in bed on his left side facing the wall. R3 appeared comfortable and without signs of pain or discomfort.On 08/27/25 at 02:56 PM, R1 laid in her bed. R1 appeared comfortable and without signs of pain or discomfort.On 08/27/25 at 02:58 PM, R4 laid in bed. R4 appeared comfortable and without signs of pain or discomfort.On 08/27/25 at 03:00 PM, R7 sat in her wheelchair near the nurses' station and talked to staff. R7 appeared comfortable and without signs of pain or discomfort.On 08/27/25 at 03:34 PM, LN H stated she prevented misappropriation of narcotics by performing a count with the oncoming nurse or with the off-going nurse during shift change. She stated the nurses counted the number of cards and bottles and compared them to the narcotic log. LN H stated the off-going nurse read the count book and the oncoming nurse counted the amount in the cards/bottles. LN H stated the nurse verified the resident's name, medication name, and count number. She stated if the nurse received new medications or removed a medication, the card count was reflected on the log.On 08/27/25 at 04:01 PM, Administrative Nurse D stated on 08/20/25, LN G completed count at the beginning of her shift and noticed some of the bottles of morphine were questionable as far as color and consistency. LN G notified Administrative Nurse D of the problem, and the facility pulled out all of the morphine bottles to compare with the count sheets. Administrative Nurse D stated the facility started an investigation and immediately suspended the last nurse who worked the cart. She stated the facility had notified the police and the pharmacy. She stated Consultant GG went to the facility and completed an assessment, then talked to her boss, before giving the facility the findings. Administrative Nurse D stated she and Consultant GG destroyed the liquid narcotics together. She stated the facility had the pharmacy initially only refill R1's morphine as she was the only one actively using it. Administrative Nurse D stated the facility collected evidence and educated nurses on proper narcotic counts and being precise with dosages. She stated the facility pulled the schedules and suspected the upstairs nurse, but throughout the investigation, the facility could not officially put it on LN I. Administrative Nurse D stated the facility investigated every nurse that touched the narcotic carts, and after the investigation was unsubstantiated, the facility allowed LN I to return to work. She stated LN I never appeared altered under the influence, and the facility policy did not drug test unless the staff member appeared altered.On 08/27/25 at 04:31 PM, Administrative Nurse D stated that staff prevented misappropriation of narcotics by conducting a narcotic count. She stated the oncoming nurse counted the cards while the off-going nurse read the narcotic sheet in the book. Administrative Nurse D stated the nurses counted all the medications in total and made sure the total count was correct, then they went one-by-one and compared. She stated that when the nurse got to the liquid narcotics, they placed the bottle on a flat surface to read the amount and made sure the color looked appropriate. Administrative Nurse D stated she expected that even if the medication had not been given recently, the staff would remove it from the box and view it with their own eyes. She stated if staff found a discrepancy, she expected them to report to her immediately, and she expected staff not to take someone's medications.The facility's Abuse, Neglect, and Exploitation policy, not dated, directed the facility provided protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibited and prevented abuse, neglect, exploitation, and misappropriation of resident property.The facility's Controlled Substance Administration and Accountability policy, dated 01/01/20, directed two licensed nurses to account for all controlled substances and access keys at the end of each shift.The facility put the following corrective actions into place prior to the onsite visit with a compliance date of 08/20/25:The facility reported the liquid morphine discrepancies to the police on 08/20/25.The facility notified the liquid morphine discrepancies to the pharmacy on 08/20/25.Consultant GG inspected the seven bottles of morphine for signs of tampering and reported her findings to the facility.Administrative Nurse D and Consultant GG destroyed the tampered morphine bottles on 08/20/25.The facility replaced R1's morphine as she was the only one actively using it on 08/20/25.The pharmacy planned to bill the facility for the diverted morphine bottles that the residents paid for on 08/20/25.The facility conducted an Ad-Hoc Quality Assurance and Performance Improvement (QAPI) meeting on 08/20/25.The facility educated Licensed Nurses and Certified Medication Aides (CMA) on Controlled Substances and The Elder Justice Act on 08/20/25.This deficient practice was cited at past noncompliance. The scope and severity remain an E.

The facility identified a census of 116 residents. The sample included five residents. Based on record review and interviews, the facility failed to obtain a physician-ordered urinalysis (UA- lab analysis of urine) and other laboratory tests ordered on 06/03/25. The facility further failed to notify the physician related to the delay in obtaining the ordered UA and laboratory tests for Resident (R) 2. R2 had fallen on 06/05/25 and 06/06/25, and R2 had a change in condition on 06/07/25. R2 went to the hospital where he was admitted to the Intensive Care Unit (ICU) for septic syndrome (a life-threatening condition that arises when the body ' s response to an infection injures its own tissues and organs), urinary infection (UTI) with urosepsis (a severe, life-threatening condition where a systemic infection originating in the urinary tract, spreads throughout the body), high fever, and unresponsiveness. Findings included: - R2's Electronic Medical Record (EMR) documented diagnoses of hypertensive chronic kidney disease (kidney damage caused by long-term high blood pressure), personal history of UTI, atrial fibrillation (rapid, irregular heartbeat), repeated falls, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). R2's Annual Minimum Data Set (MDS) dated 04/19/25, documented R2 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R2 had impairment on both sides of his lower extremities. R2 required setup or clean-up assistance with toileting hygiene, personal hygiene, and transfers. R2 was occasionally incontinent of urine and bowel movements. The Functional Abilities / Rehabilitation Potential Care Area Assessment (CAA) dated 04/28/25, documented R2 needed assistance with activities of daily living (ADL) related to chronic kidney disease, cardiac disease, hearing loss, unsteady gait and balance, dysphagia (difficulty swallowing), depression, and poor vision. R2's Care Plan, dated 04/10/23, documented R2 was occasionally incontinent of bowel and bladder and was at risk for complications. The plan directed staff to monitor and document signs and symptoms of UTI which included pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, chills, altered mental status, changes in behavior, and changes in eating patterns. R2's EMR revealed the following: An order on 06/03/25 for a UA, complete blood count (CBC- laboratory blood test), comprehensive metabolic panel (CMP- laboratory blood test), and magnesium (laboratory blood test) level. R2's EMR lacked documentation on signs and symptoms or the reason behind the diagnostic test orders. An eInteract SBAR [situation, background, assessment, and recommendation] Summary for Providers note on 06/05/25 at 03:51 PM documented R2 had a change in condition related to a fall. An eInteract Change in Condition Evaluation on 06/05/25 at 03:51 PM documented R2's signs and symptoms improved since the change in condition and the nurse selected No when asked if the facility notified the primary care clinician of the change in condition and notifications. An Orders- Administration Note on 06/06/25 at 02:31 PM documented R2 sat in his chair and did not feel well. R2 was uncooperative with wound care. The note lacked evidence staff notified the physician. A Nurse's Note on 06/06/25 at 04:13 PM documented staff called the nurse into R2's room after staff found him on the floor in his room. R2 stated he attempted to go from his wheelchair to his recliner and slipped. R2 denied hitting his head and was confused. The nurse did not note any trauma and staff assisted R2 into his recliner. The nurse took R2's vital signs and initiated neurological checks. R2's call light was within reach and staff educated the resident to call when he needed to transfer. An eInteract Change in Condition Follow-Up on 06/06/25 at 04:20 PM documented R2 had improved after the initial change in condition. A Nurse's Note on 06/07/25 at 07:45 PM documented R2 was confused and disoriented throughout the shift. R2 made several attempts to use the restroom but did not remove his pants. R2 became combative when the staff offered him assistance. The note documented Licensed Nurse (LN) I attempted to obtain a urine sample multiple times, but R2 refused and remained uncooperative. After lunch, R2 had a near fall on his way to the bathroom but did not sustain any injuries. Around 06:00 PM, R2 had a noticeable change in condition, staff could arouse him, but he was very drowsy and breathing loudly and heavily. LN I placed R2 on supplemental oxygen via a face mask when his oxygen saturation dropped to 85% (normal saturations are 95-100%). R2 removed the face mask, and staff switched him to a nasal cannula which he also removed several times. Due to R2's continued respiratory distress and altered mental status, LN I called for an ambulance to take R2 to the hospital. R2's medical record lacked evidence staff attempted to collect the UA as ordered by the resident's physician prior to 06/07/25. R2's medical record lacked evidence that he refused the UA or laboratory tests prior to 06/07/25. R2's medical record further lacked evidence staff notified R2's physician of any alleged refusals for the UA or the staff's inability to collect the samples for the UA and laboratory (labs) tests. R2's medical record lacked evidence the facility completed the UA or laboratory tests, ordered on 06/03/25. Upon request, the facility was unable to provide the UA results or laboratory results. A History and Physical Note from the hospital on [DATE] at 10:03 PM, documented R2 arrived at the emergency department from the nursing facility due to a high fever and unresponsiveness. R2 was unresponsive and had a temperature of 104.2 degrees Fahrenheit (F) (normal body temperature is 98.7 F). R2 was tachycardic (high heart rate), and tachypneic (rapid breathing), and was placed on bilevel positive airway pressure (BiPAP- treatment that uses mild air pressure to keep your airways open). The note documented R2 received intravenous (IV-administered directly into the bloodstream via a vein) fluids and antibiotics (medications used to treat infections) and was admitted to the ICU for septic syndrome, urinary infection with urosepsis, high fever, healthcare-associated pneumonia (facility-acquired lung infection), atrial fibrillation, acute hypoxic (inadequate oxygen supply) respiratory failure, and unresponsiveness. On 06/11/25 at 03:21 PM, Certified Medication Aide (CMA) R stated R2 was very confused and fell a couple of times. She stated he got combative because he was used to being independent. CMA R stated staff tried to get a UA on R2 and he refused. On 06/11/25 at 03:43 PM, Administrative Nurse D stated R2 refused cares, the UA, and ordered labs. She stated the provider rounded and put the resident's orders in. On 06/11/25 at 03:59 PM, Administrative Nurse D stated Consultant GG entered R2's UA and lab orders herself. She stated she was not sure why there was no note on the orders. On 06/11/25 at 04:37 PM, LN J stated if a resident had a change in condition, she notified the doctor, family, her supervisor, and hospice if applicable. She stated if a provider ordered labs, the facility notified the lab and put the labs into the portal to be drawn Monday through Friday. She stated a UA should have been completed within 24 hours after the order was received. If the resident refused, she notified the provider the resident refused and would see what else they could do. LN J stated she documented behaviors, notifications to family and doctors, refusals for UAs, and attempts at obtaining a UA in a nurse's note. LN J stated if a resident had confusion, staff did change in condition charting for 72 hours. She confirmed R2 had a delay in care if staff did not attempt to get a UA until 06/07/25 when it was ordered on 06/03/25. On 06/11/25 at 04:58 PM, Administrative Nurse D stated she did not see any documentation for R2's UA and lab refusals, staff attempts at obtaining R2's UA, or notification to the provider of R2's refusals of the UA and other labs. She stated Consultant GG ordered labs that R2 kept refusing and everybody told her R2 refused the UA and labs. Administrative Nurse D stated she expected the nurse to follow through with the UA order, document attempts at obtaining the UA, notification to physicians, and resident refusals. She stated she expected if staff noticed a significant change in a resident's condition, staff should immediately call the provider. She stated if they received an order and did not see an improvement within a couple of hours, she expected staff to call the physician again. Administrative Nurse D stated she noticed the nurse's note regarding R2 being confused all shift on 06/07/25 and she called the facility to ask the nurse what they did about it. She stated the nurse said they were watching R2 because everyone said it was his normal baseline. She stated she directed the nurse to call the physician. Administrative Nurse D stated if only viewing R2's medical record, it did appear he had a delay in care but if viewing in the building, it was not an intentional delay in care while they attempted to put steps into place. On 06/11/25 at 05:16 PM, Administrative Nurse E stated on 06/05/25, she was notified a resident was on the floor when R2 fell in the bathroom. She stated if the facility received an order for a UA, the facility obtained the UA and put it in the specimen refrigerator. She stated the lab order went into the EMR then the staff put the order into the lab portal. Administrative Nurse E stated staff tried to get the UA and R2 refused. She stated she expected staff to document when a resident refused a UA, when they notified the family and/or physician and attempted to get the UA. She stated if a resident refused to do the UA, she expected staff to continue to attempt to obtain the UA and notify the physician of the refusals. Administrative Nurse E stated she expected labs to be drawn the next day, and she did not believe there was a delay in inputting orders in the lab portal. She stated she expected the UA to be completed in the first two days and the physician should be notified about refusals or the inability to get the UA timely. On 06/12/25 at 02:42 PM, Administrative Staff A emailed additional documentation from the laboratory company, which included on 06/06/25 at 04:34 PM, R2's urinalysis with culture attempt was unsuccessful because the specimen was not collected. On 06/18/25 at 01:47 PM, LN I stated on 06/05/25, she went to lunch and received a text reporting a resident fell. She stated Administrative Nurse E took over until she returned and continued neurological checks on R2. LN I stated she notified Consultant HH and was instructed to continue with assessments and neurological checks with no change to his plan of care. She stated she did not know R2 very well or much about his baseline. LN I stated she saw R2 had an order for a UA and labs but nobody could obtain them. She stated she did not document the refusals for the UA and noted the facility used a book to communicate with the provider during rounds. Staff would write it in the book if they were unable to obtain the UA. LN I stated whoever notified the physician would document the notification. On 06/18/25 at 01:56 PM, Consultant GG stated on 06/03/25, she had a brief interaction with staff who mentioned R2 reported he had brain fog but otherwise seemed at baseline. She stated as she left the facility that day, she put in an order for a UA and labs to figure out why R2 did not feel great. Consultant GG stated she did not know if the facility completed the UA and labs as she went on vacation the next day and Consultant HH took over for her while she was gone. She stated the facility had a book to communicate to the provider during rounds for anything not emergent like medication refills or rashes. Consultant GG stated she expected staff to call with anything that needed immediate intervention and typically received calls when a resident refused a UA or labs. On 06/18/25 at 02:01 PM, Consultant HH was unavailable for an interview. On 06/18/25 at 02:03 PM, LN K stated on 06/07/25, R2 had a change in condition and was confused and not able to do things for himself like he normally did. She stated the facility was supposed to do a UA that day but was not able to obtain it. She stated sometimes R2 got up to the toilet, would sit there, and then go back to his chair. LN K stated when she did rounds in the afternoon, she and the CMA went into R2's room and found him having a hard time breathing. She stated she took his vital signs and placed an oxygen mask on him, but he removed the mask, so she placed a nasal cannula for supplemental oxygen. LN K stated R2 could hear but he would not open his eyes, so she called for an ambulance. She stated she was told that staff were unable to get the UA because he was confused and aggressive with refusing care. She stated she was not told whether the facility notified the physician about the refusals and behaviors. LN K stated normally, she notified the provider for refusals and documented the refusals and physician notification. She stated that R2's representative sounded very frustrated and told her he had been asking for prophylactic (preventative in nature) antibiotics for a UTI. On 06/18/25 at 02:12 PM, LN L stated on 06/06/25, she learned R2 had two previous falls prior to her taking care of him. She stated it was the first day she met him and did not know his baseline. She stated she did not remember his full report. LN L stated if a resident had an order for a UA, she tried to get the UA done but residents had the right to refuse, and she had to make sure medications were given correctly and timely before getting a UA. She stated she assessed R2 throughout the day, his vitals were okay, and he was oriented to himself. LN L stated nursing was a 24-hour job so if one shift did not obtain the UA then the next shift should have obtained it. She stated she usually notified the physician of refusals of UA and lab tests and documented the physician's notification and refusal in the resident's record. LN L stated the CNA reported to her that R2 needed help to the bathroom, and he became combative, but he did not appear combative when she went to help, just confused. The facility's Notification of Changes policy, last revised on 10/21/24, directed the facility to consult with the resident's physician when there was a change requiring such notification. Circumstances that required notification included a significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental, or psychosocial status; and circumstances that required a need to alter treatment such as a new treatment or discontinuation of current treatment due to adverse consequences, acute condition, or exacerbation of a chronic condition. The facility's Provision of Physician Ordered Services policy, dated 2025, directed the facility to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality.

The facility identified a census of 116. The sample included five residents, with one resident reviewed for visitation rights. Based on observations, record review, and interviews, the facility failed to ensure Resident (R) 1 was able to exercise her right to receive visitors of their choosing at the time of R1's choice. This deficient practice affected R1's psychosocial well-being and placed R1 at risk for impaired resident rights and social isolation. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) and dementia (a progressive mental disorder characterized by failing memory and confusion). R1's Annual Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of three, which indicated severe cognitive impairment. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated [DATE], documented R1 was alert and oriented to person and had a BIMS of three. R1's Care Plan dated, [DATE], documented R1 had impaired cognitive function/dementia or impaired through processes related to cerebral infarction. The plan directed staff to allow R1 to make daily decisions about clothing, daily care, meal alternatives, et cetera (etc.); staff kept R1's routine consistent and tried to provide consistent caregivers as much as possible in order to decrease confusion. The facility's Investigation, dated [DATE], documented on [DATE] at approximately 06:11 PM, Licensed Nurse (LN) G immediately reported to Administrative Staff A that R1's family was confrontational with staff and when R1 was upset and wanted it to stop, R1's family told R1 to shut up or she would slap her face. LN G asked R1's family to leave and when she refused, police were called and R1's family left the facility. LN G assessed R1 with no injuries noted. R1 was visibly upset and calmed down with staff support. The facility notified R1's representative, primary care provider, and police. R1's family returned to the facility and met with Social Services and Administrative Staff A. R1's family denied threatening R1 but admitted to stepping towards and cussing at staff. R1's family was unable to take responsibility for her behavior or work to create a safe plan for future visits and the facility issued a trespassing order and police escorted R1's family from the property. Upon request, the facility provided the Trespass Order for R1's family. The order, dated [DATE], stated R1's family was ordered to vacate the facility and not return, if she returned then she would be prosecuted for criminal trespass. The order expired in one year. On [DATE] at 01:38 PM, R1 sat in her wheelchair in the television room and conversed with the surveyor. She stated her family got kicked out and had not threatened to smack her. She stated she never felt unsafe around her family, and it made her feel terrible as her family was the only people who visited her. R1 stated all of a sudden now her family could not come in to see her and she wanted her family to be able to come in. R1 became visibly upset and started crying while stating her family was the only person she had. On [DATE] at 12:03 PM, R1's representative stated he had nothing to do with the decision to give R1's family a trespassing order. He stated sometimes the family member lost control of herself, but she never became violent. R1's representative stated he thought it was fine that R1's family went to visit R1 and that R1 was upset that she could not see her family. He stated R1 was very upset that her family got into trouble and the facility said there was nothing they could do about it right now. R1's representative stated that R1's family had issues controlling her anger, but she had never struck R1 but got verbally abusive to staff. In a witness statement on [DATE], Certified Nurse Aide (CNA) M stated she went in to change R1's roommate and pulled the curtain. R1's family told CNA M not to touch the curtain and CNA M told her it was for privacy. CNA M stated R1 told R1's family to stop and R1's family told R1 to shut up, or she would slap her. CNA M stated she immediately stopped care and got LN G who went to R1's room. She stated that R1's family started to yell and got in CNA M and LN G's faces. CNA M stated LN G asked R1 if she felt safe and R1 stated no. CNA M stated LN G asked R1's family to leave then called the police when she refused but R1's family left before the police arrived. On [DATE] at 11:39 AM, Administrative Staff A stated R1's family threatened to slap R1. She stated that R1's family admitted to getting up in the nurse ' s face but denied saying she would slap R1 in the face. Administrative Staff A stated R1's representative understood the situation and the facility notified him he could be present during the visit, but he did not want to be at the facility. She stated R1's family had threatened R1 but never put her hands on R1 and had gotten into staff's faces. Administrative Staff A stated that R1 wanted to see her family and the facility told R1's family her significant other could pick R1 up from the facility and take R1 for a visit outside the facility. On [DATE] at 01:43 PM, LN H stated she was in the facility sometimes when R1's family visited and had never seen her threaten or hit R1. She stated sometimes R1 called her family and seemed upset about R1's family not coming in to visit. On [DATE] at 05:23 PM, Administrative Staff A stated prior to the incident, R1's family had issues with staff and the facility talked to her significant other about the inappropriate behavior. She stated that R1's family upset R1 and threatened to slap her and confronted staff. The facility called the police and R1's family left before they arrived. Administrative Staff A stated when staff notified her of the threat, the facility filed a police report and reported it to the State Agency (SA). She stated the next time R1's family and her significant other came to the facility; she told them they needed to talk. She stated R1's family admitted to profanity and going up to staff. Administrative Staff A stated she notified R1's family that for the safety of residents and staff, she received a no-trespassing order which upset R1's family. She stated R1's family asked what they could do to drop the trespassing order but R1's family could not come up to the facility for visitation. Administrative Staff A stated she did not reach out to the Long-Term Care Ombudsman regarding the visitation restriction. She stated R1's family received the trespassing order for being combative towards staff after being warned. The facility's Resident Rights policy, last revised [DATE], directed the facility to inform the residents orally and in writing, in a language they understood, of their rights and all rules and regulations governing resident conduct and responsibilities during their stay in the facility. The policy included Resident Rights which documented the resident had a right to receive visitors of his or her choosing at the time of his or her choosing, subject to the resident's right to deny visitation when applicable, and in a manner that did not impose on the rights of another resident.

The facility identified a census of 117 residents. The sample included eight residents, with one resident reviewed for abuse and neglect. Based on observation, record review, and interview, the facility failed to prevent an episode of resident-to-resident sexual abuse for cognitively impaired Resident (R) 2. On 02/08/25, facility staff witnessed R1 groping R2's nipples, breast, and buttocks while both were seated at the dinner table on the locked unit for cognitively impaired residents. R2 voiced she did not consent to R1 touching her. This placed R2 in immediate jeopardy and at risk for ongoing and/or unidentified abuse and feelings of fear for R2, based on reasonable person concept. Findings Included: - The Medical Diagnosis section within R1's Electronic Medical Records (EMR) included diagnoses of chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and a history of sexual behaviors related to psychiatric illness. R1's Quarterly Minimum Data Set (MDS) completed 12/15/24 noted a Brief Interview for Mental Status (BIMS) score of 12 indicating mild cognitive impairment. The MDS noted he had verbal and physical aggression one to three days weekly. The MDS noted he had rejection of care behaviors one to three days weekly. The MDS noted he was independent with transfers, bed mobility, bathing, toileting, and walking. R1's MDS noted no sexual behaviors. R1's Cognitive Loss/Dementia Care Area Assessment (CAA) completed 06/11/24 noted he had impaired cognition related to his medical diagnoses. The CAA noted he required reorientation, reminders, and reassurance to make sense of things. The CAA noted a care plan was implemented with interventions and monitoring to reduce the risks. R1's Behavioral Symptoms CAA was not triggered. R1's Care Plan initiated on 10/25/23 noted he was admitted to the long-term care unit due to his medical diagnoses. The plan noted he exhibited sexually inappropriate behaviors related to his psychiatric illness (03/04/24). The plan instructed staff to explain and reinforce to R1 why his behaviors were inappropriate or unacceptable (03/04/24). The plan instructed staff to educate and collaborate with R1 to find successful coping and interaction strategies (03/04/24). The plan instructed staff to administer and monitor his medication's side effects and effectiveness (03/04/24). The plan revealed that R1 was moved to another unit due to exhibiting sexually inappropriate behaviors (related to a sexual behavioral episode with R2 on 02/08/24). R2's Care Plan initiated 06/15/24 revealed R2 had a deficit related to her severe cognitive impairment. The plan noted she had difficulty understanding others and making her needs known. The plan instructed staff to provide R2 with a calm and safe environment. The plan instructed staff to allow her to share her feelings and verbalize her feelings, perceptions, and fears. The plan noted she had a history of behavioral concerns related to other peers invading her personal space. The plan instructed staff to ensure other residents respected her personal space. The plan noted she exhibited wandering behaviors and had impaired safety awareness. R1's EMR under Assessments revealed a Social Service Assessment completed on 04/17/24 revealed he had a history of sexual behaviors, and a medication change was implemented for his Estradiol medication. R1's EMR under Progress Notes revealed a Nursing Note completed on 07/10/24. The note revealed direct care staff reported they observed R1 seated in the dining room next to R2. The note revealed that R1 and R2 were inappropriately touching each other. The note indicated R2 was immediately moved away from R1 and both residents were kept separated for the rest of the shift. R2's EMR under Progress Note revealed an Alert Note completed 02/08/25. The note documented that R2 was in the dining room attempting to stand up at the table. The note indicated that R1 grabbed R2's breast and buttocks. The note indicated both residents were immediately separated. The note revealed that R1 was moved off the unit due to his sexual behaviors towards female residents. (Refer to F610) A Facility Incident Report #3462 completed on 02/08/25 revealed that R1 was observed by staff touching R2's breast and buttocks during meal service. The report indicated that R1 was moved away from R2 and placed on one-on-one supervision. A Staff Witness Statement completed 02/08/25 revealed that R1 sat at the dining room table next to R2. The statement revealed staff witnessed R1 grope R2's nipples and pulled her breast downward. The statement indicated that R2 was visibly upset and reported to staff she felt like she was being held against her will. The statement indicated that R2 continued to verbalize she was scared. The statement indicated R1 was supervised for the remainder of the evening. On 02/19/25 at 11:10 AM, R2 sat in walked around the locked memory care unit. R2 was unable to recall the incident that occurred on 02/08/25. On 02/19/25 at 11:55 AM, R1 walked from his room to the 2nd-floor dining area without staff assistance or supervision. On 02/19/25 at 11:03 AM, Certified Nurse Aide (CNA) M stated cognitively impaired residents should be monitored closely due to the potential risk of injuries and abuse. CNA M stated residents with noted behaviors should be monitored closely around other residents and said male residents with sexual behaviors should not be left unsupervised around female residents. CNA M stated R1 should not be seated next to or be around female residents unsupervised. On 02/19/25 at 01:04 PM, Licensed Nurse (LN) G stated R1 was recently moved from the locked unit due to sexual behaviors towards females. LN G stated the direct care staff documented behavioral monitoring under the Tasks section of the EMR. LN G stated R1 recently moved to the unit, so he was not sure if the monitoring section was under Tasks for the resident. LN G stated staff were expected to keep an eye on R1 while he was out walking around. LN G stated all staff had access to the care plan and the care plans should reflect his repeated behaviors toward females, monitoring, coping strategies, and interventions to prevent his behaviors. LN G said suspected abuse allegations were reported immediately to the director of nursing and facility administrator. LN G stated staff would immediately separate the perpetrator from other residents and ensure everyone was safe. On 02/19/25 at 02:40 PM, Administrative Nurse D stated R1 was immediately separated from R2 and placed on one-on-one supervision. Administrative Nurse D stated R1 was moved to another hall. Administrative Nurse D said R1 had medication changes occurring and was not a risk to the females in the new hallway. Administrative Nurse D said she expected staff to monitor R1's behaviors and document them under the Psychotropic Medication Monitoring section of his MAR. She stated events should be documented there. She stated staff were expected to immediately separate the suspected perpetrator from all potential victims. The facility's Abuse, Neglect, and Exploitation policy revised 11/2017 indicated the facility will provide safety and dignity for all residents by implementing proper procedures for enforcing resident rights. The policy noted the facility will protect residents of suspected abuse and all potentially affected residents from incidents of abuse. The facility failed to ensure cognitively impaired R2 remained free from abuse when the facility failed to prevent an episode of resident-to-resident sexual abuse. This placed R2 at risk for ongoing and/or unidentified abuse and mistreatment based on the reasonable person concept, this deficient practice resulted in feelings of fear for R2 and placed R2 at risk for further psychosocial harm, intimidation, and neglect. The facility failed to identify and implement preventative interventions related to Resident (R)1's sexual behaviors upon moving him to a new unit. This deficient practice placed 19 female residents at risk for sexual abuse. On 02/19/25 at 03:31 PM, Administrative Staff A was provided a copy of the IJ template and notified of the facility's failure to prevent the sexual abuse of R2, the facility additionally placed 19 other female residents at risk for sexual abuse after moving R1 to another unit without addressing his sexual behaviors. The facility provided an acceptable plan for the removal of the immediacy on 02/19/25 at 04:30PM which included the following: 1. R1 was immediately placed on one-on-one supervision until psychiatric evaluation can be completed. 02/19/25 2. The facility identified all at-risk residents on the new unit. 02/19/25 3. Staff were provided in-service upon hire, annually, and post-allegation on abuse, neglect, and exploitation with comprehensive testing. 02/19/25 4. Safe survey conducted on female residents of new unit. 02/19/25 5. Psychiatric evaluation will be completed. The Surveyor verified the implementation of the IJ removal plan while onsite on 02/19/25 at 04:45 PM. The deficient practice remained at a G after removal of the immediacy based on reasonable person concept.

The facility identified a census of 117 residents, with eight residents sampled, including two residents reviewed for abuse. Based on observation, record review, and interviews, the facility failed to implement effective preventative interventions related to Resident (R)1's sexual behaviors to protect the female residents in the facility including R2 (See F600). This failure placed 19 female residents at risk. Findings Included: - The Medical Diagnosis section within R1's Electronic Medical Records (EMR) included diagnoses of chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and a history of sexual behaviors related to psychiatric illness. R1's Quarterly Minimum Data Set (MDS) completed 12/15/24 noted a Brief Interview for Mental Status (BIMS) score of 12 indicating mild cognitive impairment. The MDS noted he had verbal and physical aggression one to three days weekly. The MDS noted he had rejection of care behaviors one to three days weekly. The MDS noted he was independent with transfers, bed mobility, bathing, toileting, and walking. R1's MDS noted no sexual behaviors. R1's Cognitive Loss Care Area Assessment (CAA) completed 06/11/24 noted he had impaired cognition related to his medical diagnoses. The CAA noted he required reorientation, reminders, and reassurance to make sense of things. The CAA noted a care plan was implemented with interventions and monitoring to reduce the risks. R1's Behavioral Symptoms CAA was not triggered. R1's Care Plan initiated on 10/25/23 noted he was admitted to the long-term care unit due to his medical diagnoses. The plan noted he exhibited sexually inappropriate behaviors related to his psychiatric illness (03/04/24). The plan instructed staff to explain and reinforce to R1 why his behaviors were inappropriate or unacceptable (03/04/24). The plan instructed staff to educate and collaborate with R1 to find successful coping and interaction strategies (03/04/24). The plan instructed staff to administer and monitor his medication's side effects and effectiveness (03/04/24). The plan revealed that R1 was moved to another unit due to exhibiting sexually inappropriate behaviors (02/08/24). The plan lacked information related to his sexual behaviors towards female residents, required supervision around female residents, and required monitoring while out of his room on the unit. R1's Care Plan revealed a resolved intervention that noted R1 was separated from a female resident on 07/10/24 due to inappropriate touching. R1's EMR under Physician Orders revealed an order (started 03/04/24) for him to receive one milligram of Estrace (Estradiol- lowers hormonal imbalances) every morning by mouth for sexual behaviors. No changes to this order have been documented since its start date. R1's EMR under Progress Notes revealed a Nursing Note completed on 03/04/24. The note revealed direct care staff observed R1 as he sat on a female resident's rollator walker seat. The note revealed that R1 had his head between the female resident's breasts as she pushed him down the hallway for lunch. The note indicated staff separated the residents and asked them to sit away from the female residents during meals. The note revealed that R1 was to be supervised at all times while outside of his room and around other residents. R1's EMR under Assessments revealed a Social Service Assessment completed on 04/17/24 revealed he had a history of sexual behaviors, and a medication change was implemented for his Estradiol medication. R1's EMR under Progress Notes revealed a Nursing Note completed on 07/10/24. The note revealed direct care reported they observed R1 seated in the dining room next to R2 (severely cognitively impaired resident). The note revealed that R1 and R2 were inappropriately touching each other. The note indicated R2 was immediately moved away from R1 and both residents were kept separated for the rest of the shift. R1's EMR under Progress Notes revealed a Nursing Note completed on 07/14/24. The note revealed that R1 walked up to a female resident and began patting her on the shoulder. The note revealed the resident became distressed and attempted to push his hand away from her. The note revealed staff had to ask R1 to leave the female resident alone. R1's EMR under Progress Notes revealed a Nursing Note completed on 12/07/24. The note revealed that R1 punched a female residents' hand as she attempted to throw food at him. The note revealed she was moved to another table. R1's EMR under Progress Notes revealed a Nursing Note completed on 02/02/25. The note revealed staff observed R1 approach a female resident while she lay in the common area recliner. The note revealed that R1 began touching the female residents outer arm. The note revealed the female resident attempted to push his arm away and R1 resisted. The note revealed that R1 pushed the female residents arm downward and continued touching her arm. The note revealed staff immediately separated both residents. The note indicated staff sat with the female resident during meal service due to concerns for her safety. A Facility Incident Report #3462 completed on 02/08/25 revealed that R1 was observed by staff touching R2's breast and buttocks during meal service. The report indicated that R1 was moved away from R2 and placed on one-on-one supervision. A Staff Witness Statement completed 02/08/25 revealed that R1 sat at the dining room table next to R2. The statement revealed staff witnessed R1 groped R2's nipples and pulled her breast downward. The statement indicated that R2 was visibly upset and reported to staff she felt like she was being held against her will. The statement indicated that R2 continued to verbalize she was scared. The statement indicated that R1 was supervised for the remainder of the evening. R1's EMR under Progress Notes revealed a Nursing Note completed on 02/08/25. The note revealed R1 was moved off the secured unit and moved to the Sunflower Hall. No information related to R1's sexual behavior episode on 02/08/25 was completed in his progress notes. R1's EMR under Tasks revealed no entries related to behavioral monitoring. R1's EMR under Treatment Administration Report (TAR) revealed no monitoring related to his sexual behaviors or noting of his previous sexual behavioral episodes. R1's EMR under Medication Administration Report (MAR) revealed psychotropic medication monitoring for behaviors but lacked monitoring related to his sexual behaviors or noting of his previous sexual behavioral episodes. On 02/19/25 at 11:20 AM, inspection of the Sunflower Hall revealed 19 female residents within the secured floor. On 02/19/25 at 11:55 AM, R1 walked from his room to the 2nd-floor dining area without staff assistance or supervision. On 02/19/25 at 11:03 AM, Certified Nurse Aide (CNA) M stated R1 was independently mobile and could ambulate without staff assistance. She stated he sometimes used a wheelchair or cane. She stated she was aware of his history of touching females and staff were to monitor his behaviors and document them under the Tasks section of the EMR. She stated care plan should note he was not to be left alone around females or attempt to enter their rooms. She stated she was expected to report all potential behaviors to the nurse. She stated potential abuse should be reported immediately to the nurse, director of nursing, and facility administrator. She stated staff were expected to immediately separate the suspected abuser from the victim and keep everyone safe. On 02/19/25 at 01:04 PM, Licensed Nurse (LN) G stated that R1 was recently moved from the locked unit due to sexual behaviors towards females. He stated behavioral monitoring was documented by the direct care staff under the Tasks section of the EMR. He stated that R1 recently moved to the unit, so he was not sure if the monitoring section was under Tasks for him. He stated staff were expected to keep an eye on him while he was out walking around. He stated all staff had access to the care plan. He stated the care plans should reflect his repeated behaviors toward females, monitoring, coping strategies, and interventions to prevent his behaviors. He reported suspected abuse allegations were to be reported immediately to the director of nursing and facility administrator. He stated staff would immediately separate the perpetrator from other residents and ensure everyone was safe. On 02/19/25 at 02:40 PM, Administrative Nurse D stated R1 was immediately separated from R2 and placed on one-on-one supervision. She stated that R1 was moved to the Sunflower Hall. She stated that R1 had medication changes occurring and was not a risk to the females in the new hallway. She stated staff were expected to monitor R1's behaviors and document them under the Psychotropic Medication Monitoring section of his MAR. She stated events should be documented there. She stated staff were expected to immediately separate the suspected perpetrator from all potential victims. The facility's Abuse, Neglect, and Exploitation policy revised 11/2017 indicated the facility would provide safety and dignity for all residents by implementing proper procedures for enforcing resident rights. The policy noted the facility would protect residents of suspected abuse and all potentially affected residents from incidents of abuse. The facility failed to implement effective preventative interventions related to Resident (R)1's sexual behaviors to protect the female residents of the facility. This deficient practice placed R2 (See F600) and 19 female residents at risk.

The facility identified a census of 120 residents. The sample included three residents reviewed for falls. Based on record review and interviews, the facility failed to identify and implement appropriate, resident-centered interventions to prevent falls for Resident (R) 1, who was cognitively impaired. The facility further failed to ensure R1 received post-fall care including neurological evaluations and nursing assessments following an unwitnessed fall that resulted in obvious head trauma on 04/27/24 at 03:28 AM. R1 was later sent out to the hospital on 04/27/24 at 08:45 AM where he was found to have nasal bone fractures and multiple rib fractures. This also placed R1 at risk for increased pain and other complications. Findings included: - R1 admitted to the facility on [DATE] and discharged to the hospital 04/27/24. The Diagnoses tab of R1's Electronic Medical Record (EMR) documented diagnoses of generalized muscle weakness, difficulty in walking, altered mental status, and vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain). The Admission Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of zero, which indicated severe cognitive impairment. R1 had two or more non-injury falls since admission. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 04/15/24, documented R1 had a diagnosis of vascular dementia and had a BIMS score of zero. The Falls CAA dated 04/15/24, documented R1 required staff assistance for activities of daily living (ADLs) completion. R1 was a high risk for falls. R1's Care Plan dated 04/02/24, documented R1 was at risk for falls related to impaired mobility, confusion, gait/balance problems, and unawareness of safety needs. The plan documented interventions for staff to anticipate and meet R1's needs. Staff were to make sure R1's call light was within reach and encourage him to use it for assistance as needed. The plan directed staff to educate R1 about safety reminders and what to do if a fall occurred; staff followed facility fall protocol. R1's Care Plan documented the following interventions added after actual falls: An intervention, dated 04/02/24, for staff education to orientate R1 to new surroundings and the use of the call light with ADL help. An intervention, dated 04/08/23, instructed staff to put a sign in R1's room directing R1 to ask for assistance before walking on his own. An intervention, dated 04/10/24, documented pharmacy would do a medication review. An intervention, dated 04/13/24, documented staff received education to provide R1 with an activity while he was awake. An intervention, dated 04/16/24, directed staff to make sure R1's wheelchair was locked and placed next to his bed while he was in bed. An intervention, dated 04/22/24, documented R1 would be added to the restorative (care provided to maintain a person's highest level of physical, mental, and psychosocial function to prevent declines that impact quality of life) nursing program for mobility, strength, and balance. An intervention, dated 04/24/24, documented that R1 had the right to fall, and he continued to fall with interventions in place. The Orders tab of R1's EMR documented an order with a start date of 04/02/24 for apixaban (anticoagulant medication- medication used to prevent blood from thickening or clotting), five milligrams (mg) two times a day for anticoagulant. The facility provided the following root cause analysis and intervention documentation upon request: The fall on 04/03/24 at 01:30 AM recorded the root cause of the fall as R1 was in a new environment and was not using the call light or asking for assistance with ADL. The intervention documented staff received education to help orientate R1 to his new surroundings and use the call light for assistance. The fall on 04/07/24 at 07:15 PM recorded the root cause of the fall as R1 had memory issues and was in a new environment. The intervention documented that staff placed a sign in R1's room to call for assistance. The fall on 04/10/24 at 05:30 AM recorded the root cause of the fall as R1 had an increase in falls with no identifiable cause at that time with possible medication side effects. The intervention documented the consultant pharmacist would conduct a medication review. The fall on 04/13/24 at 05:30 AM recorded the root cause of the fall as R1 was awake and appeared to be curious about the phone jack. The intervention documented staff were educated to provide R1 with an activity while he was awake. The fall on 04/17/24 at 05:00 AM recorded the root cause of the fall as R1 did not remember to check that his brakes were locked on his wheelchair before initiating a transfer. The intervention documented staff received education to make sure R1's wheelchair was placed next to his bed with the brakes locked while he was in the bed. The fall on 04/22/24 at 08:45 PM recorded the root cause of the fall as R1 continued to not use his call light for assistance with getting in and out of his bed, and it appeared he was unable to remember to lock his wheelchair brakes. The intervention documented R1 would be placed on a restorative program. The fall on 04/23/24 at 11:30 PM recorded the root cause of the fall as R1 did not have the ability to recall education or known physical limitations. The intervention directed R1 had the right to fall, and he continued to fall with interventions in place. The fall on 04/24/24 recorded the root cause of the fall as R1 did not have the ability to be educated regarding his imitations secondary to his cognitive problems. The intervention documented R1 continued to fall with interventions in place. R1's EMR, under the Notes tab, documented an Incident Note, on 04/22/24 at 11:20 PM, which recorded staff observed R1 sitting on the floor near his bed and R1 was unable to communicate how the fall occurred. R1 denied pain or discomfort and had a skin tear on his left elbow which was cleaned and had Steri-strips (adhesive wound closures) applied. The nursing staff lifted R1 off the floor and onto the bed. An Incident Note, on 04/23/24 at 11:59 PM, documented R1 sat in his wheelchair in the dining room and continuously attempted to stand up without assistance. R1's wheelchair slipped out from under him during one of his attempts to stand and he landed on his buttocks. Two staff members witnessed the fall. An Incident Note, on 04/24/24 at 04:14 AM, documented R1 laid on the floor beside his bed with his head near the foot of the bed. R1 had his covers under his head, and he had pulled his dry incontinence brief off. R1 did not voice any complaints of pain or discomfort and he moved his extremities independently without any indications of pain. Staff assisted R1 to his wheelchair and brought him to the dining area for supervision. Staff initiated neurological checks. An Incident Note, on 04/24/24 at 06:39 AM, documented staff left a message with R1's provider's answering service regarding R1's two non-injury falls. R1 slept approximately two hours during the night and was very difficult to redirect. He refused snacks and drinks when offered and was checked and changed as required. An Interdisciplinary Team (IDT) Note, on 04/25/24 at 10:53 AM, documented R1 had a balance problem and needed assistance for support during transfers. No wandering behavior had been reported. R1 had eight falls in the last monthmonth, and he received staff support for transfers and safety needs. R1 was care planned for a right to fall and he continued to work with therapy, but he was forgetful at times. Staff continued to monitor for any changes. In an Incident Note on 04/27/24 at 04:53 AM, Licensed Nurse (LN) G documented R1 was found in another resident's room on the floor. R1 was lying prone (face down) with a head injury. R1 was unable to recall how he fell and what he was doing before the fall. R1 had two small skin tears along the nose and a hematoma (a collection of blood trapped in the tissues of the skin or an organ, resulting from trauma) between his eyebrows. Vitals signs and neurological checks were performed and R1's wounds were cleaned and dressed. Ice was applied to the swelling between his eyebrows. R1's physician and family were notified. The Assessments tab revealed Neuro Checks- 15 minutes for an hour on 04/27/24 were completed at 03:30 AM, 03:45 AM, 04:00 AM, and 04:15 AM. R1's clinical record lacked evidence that neurological checks were completed after 04:15 AM on 04/27/24. In an Incident Note on 04/27/24 at 08:44 AM, LN H documented R1's family called the unit to follow up on R1's fall incident. LN H assessed R1 and consulted with Administrative Nurse D and the Nurse Practitioner (NP). R1 was sent to the hospital to rule out any possible complications at 08:45 AM. A Trauma History and Physical on 04/27/24 at 03:50 PM documented R1 admitted to trauma services after sustaining a fall. R1's catalog of injuries included bilateral nasal bone fractures and fractures of his right fifth through seventh ribs and his left sixth rib. The facility's undated investigative report documented that on 04/27/24 at approximately 03:28 AM, R1 was found in another resident's room lying prone on the floor with a head injury. R1 was unable to recall how he fell or what he was doing before the fall. Vital signs and neurological checks were completed and the skin tears on R1's face were cleaned and dressed. Staff noted a hematoma between R1's eyes and applied an ice pack to assist with swelling prevention. Staff notified the family, on-call management, and physician and received an order to send R1 out for evaluation and treatment at the hospital. The hospital notes indicated R1 had nasal fractures as well as bilateral rib fractures. On 05/01/24 at 12:22 PM, Administrative Staff A stated neurological checks were completed under the Assessments tab and if there were only 15-minute checks in R1's EMR from 04/27/24, then that was all they had. On 05/01/24 at 12:59 PM, LN I stated if there was an unwitnessed fall when in doubt, send the resident to the hospital. She stated if the resident had a visible injury, she checked vital signs, performed neurological checks, and then called 911 immediately, especially if the resident was on anticoagulant medications. LN I stated if the resident did not go to the hospital, neurological checks were completed every 15 minutes for an hour, every 30 minutes for an hour, every hour for four hours, and every four hours. She stated when a resident had a fall, a risk management was completed which populated the neurological checks in the computer for the nurse to complete. On 05/01/24 at 01:25 PM, Administrative Nurse D stated if a resident had an unwitnessed fall, staff were expected to assess for injuries, make sure the resident was safe, and notify her, management, the provider, and the family. She stated the nurse completed the risk management and the assessments that populated, which included pain, fall assessment, neurological checks, and change in condition. Administrative Nurse D stated if a resident fell and had injuries on their head, she expected the nurse to call the provider and receive orders to send out or any other orders the provider gave. She stated neurological checks were completed every 15 minutes times four, every 30 minutes times four, every hour times four, every four hours times four, and maybe daily for four times. Administrative Nurse D stated if a resident was on neurological checks, she expected the nurse to pass that on in the report so that the checks were continued. She stated neurological checks were continued past an hour after a fall. She stated on 04/27/24, she was not notified that night of R1's fall but LN H called her to inform her R1 had a fall that night and was acting a little different and informed her the previous nurse did not send him out. Administrative Nurse D stated she told LN H to notify the provider of what happened and then notify the family. She stated she expected if a resident was on anticoagulant medications, the nurse assessed the resident and called the on-call provider for orders. Administrative Nurse D stated she educated LN G to always check a resident's diagnosis and orders to see what medications they were on and even if the nurse did not see any bleeding, the nurse was to tell the doctor the resident was on an anticoagulant medication. On 05/01/24 at 05:26 PM, LN H stated on 04/27/24, she arrived at the unit around 08:00 AM after she was pulled from another unit when LN G's relief did not show up. She stated LN G was already gone and she received a written report. LN H stated R1 had a dressing on his forehead between his eyebrows onto his nose and did not appear to be bleeding through the dressing. She stated R1's family called as soon as she had arrived at the unit and asked about his fall. LN H asked R1's family to give her a few minutes to find out what happened. She stated she read a note in R1's chart that said he was found in another resident's room. LN H stated she called Administrative Nurse D, who did not know about the fall and called the on-call provider. She stated she told the provider R1 had clear airways, his vitals were within normal limits, and he was on an anticoagulant medication. She received an order to send R1 to the hospital for evaluation. LN H stated the written report she received said R1 was found in another resident's room and had a skin tear on his nose. She did not recall if the written report mentioned neurological checks for R1. On 05/02/24 at 03:40 PM, LN G stated on 04/27/24, he returned from break and the aides told him R1 was found on the floor in the room next to his. He stated when he entered the room, R1's face was bleeding. LN G stated he cleaned the wound, took R1's vital signs which were good, and did a quick neurological assessment which revealed his pupils were reactive. He stated R1 did not complain of any pain or a headache and he denied any dizziness. LN G stated they helped R1 off of the floor and brought him to the nurse's station. He continued to check R1's vital signs and pupils every 15 minutes, applied a dressing to R1's nose, and applied an ice pack to his nose which seemed to help. LN G stated he called R1's representative and notified her of his fall then let her talk to R1. He then notified the on-call service for the provider and was told the provider would call him back, but he did not receive a call back before the end of his shift. LN G stated neurological checks were completed every 15 minutes times four, every 30 minutes times four-, and every hour times four after a fall. He stated he had called on-call provider service before 04:00 AM and his shift ended at 07:00 AM. LN G stated he did not try to call the on-call provider again before his shift ended since R1 was stable and had the same cognition as he usually had. LN G stated he did not check to see if R1 was on an anticoagulant medication but if he had and had seen he was on an anticoagulant, he would have sent R1 to the hospital. On 05/07/24 at 10:21 AM, Certified Nurse Aide (CNA) M stated on 04/27/24, R1 kept getting out of his recliner and walking around. She stated she redirected him back to his wheelchair or his recliner. CNA M stated she went to break and when she returned, the nurse went to break, and she began her rounds. She stated a female resident came into the hallway, which was strange. CNA M went into her room and found R1 on the floor. She stated R1's fall interventions were redirecting him back to his room and completing frequent rounds every hour. She stated he did not have a fall mat and he was checked and changed every two hours for incontinence. The facility's Accidents and Supervision policy, not dated, directed the resident's environment remained as free from accident hazards as possible and each resident received adequate supervision and assistive devices to prevent accidents which included identifying hazards and risks, evaluating, and analyzing hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. The facility's Nursing Services and Sufficient Staff policy, not dated, directed the facility provided sufficient staff with appropriate competencies and skill sets to assure resident safety. The policy directed the facility ensured licensed nurses had the specific competencies and skill sets necessary to care for resident's needs as identified through resident assessments and described in the plan of care. The policy directed providing care included but was not limited to, assessing, evaluating, planning, and implementing resident care plans and responding to resident's needs. The facility's Head Injury policy, revised on 10/16/23, directed the facility reported head injuries to the physician and implement interventions to prevent further injury. The policy directed the facility notified the physician and followed orders for care; performed neurological checks as indicated or as specified by the physician; continued monitoring for 72 hours following the incident; and notified the family and documented all assessments, actions, and notifications. The facility failed to identify and implement appropriate, resident-centered interventions to prevent falls for R1 and failed to ensure R1 received post-fall care including neurological evaluations and nursing assessments following an unwitnessed fall. R1 sustained nasal bone fractures and multiple rib fractures. This also placed R1 at risk for increased pain and other complications.

The facility identified a census of 110 residents The sample included three residents reviewed for accidents. Based on record review, interview, and observation, the facility failed to ensure staff possessed the appropriate knowledge, skills, and training to provide resident care in a safe manner when uncertified Nurse Aide Student (NAS) M transferred Resident (R)1 without a facility staff member or her nursing instructor present. NAS M could not complete the transfer with R1, which resulted in an assisted fall and R1 subsequently diagnosed with a left distal (away from the farthest point of origin or attachment) femur (thigh bone) fracture. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab listed diagnoses of cerebral palsy (progressive disorder of movement, muscle tone or posture caused by injury or abnormal development in the immature brain, most often before birth), lack of coordination, abnormal posture, pain in left upper arm, and muscle weakness. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 was dependent on staff for bed to chair transfers, toilet transfers, and sitting to standing. R1 was dependent on staff for lower body dressing and applying or removing footwear. The Falls Care Area Assessment (CAA) dated 05/02/23 documented R1 as at risk for falls related to her chronic health conditions. The Activities of Daily Living (ADL) CAA dated 05/02/23 documented R1 required extensive assistance with daily care related to her chronic health conditions. The Quarterly MDS dated [DATE] lacked a BIMS assessment. The MDS also lacked an ADL assessment. R1's ADL Care Plan initiated 06/23/22 documented R1 required minimal assistance of one staff member for transfers. The facility's Fall Incident dated 12/04/23 at 01:40 PM documented R1 reported her bed was too high and her feet could not touch the ground while sitting up, prior to her transfer. Review of NAS M's notarized Witness Statement dated 12/04/23 documented NAS M lowered R1's bed as low as it would go. NAS M placed a gait belt on R1 and lifted R1 into a sitting position and moved R1's legs so they hung off of the bed. NAS M then placed R1's wheelchair beside the bed with the brakes on and started to lift R1. NAS M tried to guide R1 into her wheelchair, but reported it seemed like R1's legs gave out. R1 stated her legs hurt. NAS M realized that R1 could not be lifted high enough to get into her wheelchair. NAS M revealed she lowered R1 to the ground and asked NAS N to get a nurse. Review of NAS N's notarized Witness Statement dated12/04/23 documented NAS N saw R1 falling down and NAS M holding R1 up with the gait belt. NAS N stated she grabbed R1 from the back of the belt and tried placing R1 down slowly. R1 complained of pain while NAS M lowered her, so NAS N went to get a nurse. NAS N revealed R1 complained she needed a new bed and stated her bed was not able to go low enough. On 12/11/23 at 11:24 AM R1 laid in her bed with the bed in the lowest position. R1 stated when NAS M attempted to transfer her from the bed into her wheelchair, NAS M dropped her. R1 revealed that NAS M was alone when NAS M attempted to perform the transfer. R1 further revealed her leg broke and she had to go out to the hospital and have surgery. On 12/11/23 at 11:29 AM Certified Medication Aide (CMA) R stated prior to the fall R1, required one person to transfer and further stated R1 could stand and pivot easily with one staff member. CMA R revealed NAS M was with R1 without a facility staff member when the incident happened. CMA R stated students were not supposed to transfer a resident alone and were required to have a staff member with them. On 12/11/23 at 11:31 AM Licensed Nurse (LN) G stated all students were supposed to have a staff member with them when transferring a resident so the level of care needed for the residents was known, and the residents were kept safe. On 12/11/23 at 11:33 AM LN H stated the students had different levels of training. The care the students were allowed to give depended on where they were in the program. LN H revealed the students' instructor was present on the unit. LN H said they did not understand what NAS M was doing alone, because students were supposed to always have a staff member with them. On 12/11/23 at 12:08 PM Administrative Nurse D stated the facility relied on the instructor to know how the students were doing and the students' ability to transfer residents safely or not. Administrative Nurse D revealed the students were never told they could not do cares without staff present. Administrative Nurse D further revealed she expected R1's feet to touch the floor prior to starting a transfer. Administrative Nurse D confirmed the facility was uncertain if R1 had footwear on as it was not documented in any of the statements. On 12/11/23 at 01:03 PM R1 reported the day she fell , she did not have any footwear on because she had just gotten up from sleeping and was not dressed yet. R1 confirmed that her bed was not lowered all the way and her feet did not touch the ground. On 12/11/23 at 03:06 PM Administrative Staff A stated she expected a facility staff member to be present when the students transferred a resident. On 12/11/23 at 03:35 PM Consultant GG stated he felt that R1 had a spontaneous fracture that resulted in her fall. Consultant GG further stated that for R1 to break her femur, it would have needed to be a big fall. The Facility's Nursing Services and Sufficient Staff revised October 22 documented the facility would provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. The facility failure to ensure trained staff with the appropriate skills and knowledge necessary were present during a transfer. As a result, R1 had an assisted fall which resulted in a left distal femur fracture.

The facility reported a census of 122 residents and the sample was 24. Based on observation, record review, and interview the facility failed to provide supervision and prevent a cognitively impaired resident (#167) from leaving the facility unsupervised, and failed to investigate falls for 1 (#136) of 4 residents investigated for accidents. Findings included: - Resident #167's closed record revealed the [DIAGNOSES REDACTED]. The resident's 14 day Minimum Data Set (MDS) 3.0 dated 8/18/13 recorded the resident with a Brief Interview for Mental Status (BIMS) score of 4 which indicated the resident was severely cognitively impaired. The MDS recorded the resident required limited assistance with bed mobility, transfers, dressing, toilet use, and required supervision with eating. The MDS recorded the resident wandered 4-6 days of the seven day observation period. The Care Area Assessment (CAA) dated 8/18/13 for cognition recorded the resident tended to wander thru the hallways and would ask for direction and time of events. The resident required redirection, cueing and reminders to stay on task. The CAA dated 8/18/13 for falls stated the resident was at risk for falls secondary to impaired mobility and poor safety awareness. The resident was ambulatory with a walker and had fallen last Easter and had fractured his/her right shoulder. A wandering assessment completed on admission on 8/5/13 at 4:30 P.M. documented the resident was at high risk due to the routine and sporadic confusion and the staff were prompted to implement a prevention plan. The record lacked an assessment risk assessment. The initial care plan dated 8/5/13 identified a behavior of the resident walking without a walker and the intervention was to redirect the resident as needed, and to keep the environment calm and relaxed. The care plan also identified falls/safety risk/elopement with interventions to keep the call light within reach, encourage/instruct use of call light, instruct the resident on safety measures and repeat as needed to remind to use walker, and assess the resident's footwear for proper fit and non skid shoes. An update on 8/22/13, after the elopement, indicated for the staff to escort the resident while outside of the facility at all times. The care plan lacked interventions for wandering. An untimed nurse's note dated 8/6/13 documented the resident wandered into other resident's room and was a fall risk. The resident wandered around unit and did not ask for help. A nurse's note dated 8/7/13 at 2:00 A.M. documented the resident was observed pacing up and down the hallway and tried to find his/her room, when shown room would forget and would start to walk up and down the halls again. A nurse's note dated 8/10/13 at 3:30 P.M. documented the resident was confused and very impulsive. A nurse's note dated 8/11/13 at 5:00 P.M. documented the resident did not know where he/she was and ambulated with his/her walker up and down the hallway. An untimed nurse's note dated 8/14/13 documented the resident was alert with confusion and wandered into other residents' rooms. A nurse's note dated 8/20/13 at 7 A.M. to 7 P.M. documented the resident wandered off the unit to the front door two times today. A nurse's note dated 8/22/13 at 7 A.M. to 7 P.M. documented the resident was alert and oriented to his/herself and ambulated with walker independently on the unit. The resident had wandered to the lobby and was redirected back to the unit. A nurse's note dated 8/22/13 at 3:10 P.M. documented the resident was taken out to the courtyard by a direct care staff and was seen several minutes later walking outside the fenced area. The facility investigation dated 8/27/13 documented, on 8/22/13 the resident was escorted out into the courtyard at 3:00 P.M. The resident sat down in a chair and was told by direct care staff how to get back into the facility and he/she would come back and check on the resident in about 20 minutes. At 3:13 P.M. direct care staff was leaving the facility and recognized the resident walking down the street, the staff stopped and escorted the resident back into the facility. The road on which the resident was found had a speed limit of 25 miles per hour (mph) and was .25 miles away from a major 4 lane highway with a speed limit of 45 mph. The outside temperature on 8/22/13 at 2:54 P.M. was 92 degrees Fahrenheit according to wunderground Weather resources. An interview with licensed staff L on 10/15/13 at 9:35 A.M. stated the resident would go out to the courtyard in the afternoon with either the staff or family. On some occasions the staff would let the resident sit outside alone and then would have the resident knock on the door when he/she wanted to come in. All the staff assumed the gate around the corner was locked. The resident did wander and would often leave the unit and the person at the front desk would call staff to come get him/her. An interview with administrative licensed staff A on 10/15/13 at 11:35 A.M. stated the intervention for this elopement was to add another latch to the gate. An interview with administrative licensed staff D on 10/15/13 at 1:45 P.M. stated our interventions were to have the staff put a second latch on the gate and the staff were then inserviced on that. We implemented a new program of identifying cognitively impaired residents so that when these residents would ask to go outside, someone would supervise them. The staff also received inserviced on the new program. A facility policy dated 5/9/08 documented the facility will identify external environmental hazards as internal hazards that pose foreseeable danger to residents who wander or have exit seeking behavior and implement interventions to minimize these risks. The facility failed to provide supervision for this cognitively impaired independently ambulatory resident at risk for falls and elopement which placed him/her in immediate jeopardy when he/she left from the facility through an unlocked gate, unsupervised and was found on a street not far from a busy 4 lane road. The facility abated the immediate jeopardy when the facility provided: 1. Training to all staff on the latch of the courtyard gate. 2. Reassessed all residents for cognition. 3. Identification on the care plans, care cards, and door frames of the resident's rooms who were cognitively impaired. 4. Developed a book with cognitively impaired residents' pictures in it. 5. Elopement and interventions brought to the Quality Assurance and committee. 6. Staff educated on the new assessment and identification of cognitively impaired resident and the system that cognitively impaired residents were required to have supervision when outside. Based on the above interventions and record review the deficient practice was identified as past non-compliance which was corrected on 9/23/13. - The quarterly Minimum Data Set 3.0 ((MDS) dated [DATE] for resident #136 revealed a Brief Interview for Mental Status score of 4, indicating severe cognitive impairment. The resident required extensive assistance from 1 person for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, personal hygiene, and bathing. He/she was not steady and only able to stabilize with assistance when moving from seated to standing, moving on and off the toilet, and surface-to-surface transfers. The resident had no falls since the prior assessment. The quarterly MDS dated [DATE] revealed the resident had 2 or more non injury falls and 1 major injury fall since the prior assessment. The 2/12/13 Care Area Assessment (CAA) for falls revealed the resident was at risk for falls and had sustained a hip fracture due to a fall. He/she required total assistance with all transfers, mobility, and activities of daily living (ADLs). The resident had a high/low (hi/lo) bed and a low air loss mattress. The Care Plan regarding falls with a revision date of 9/17/13 revealed the resident had a history of [REDACTED]. The resident used a highback wheelchair, fall pads by the bed, hi/lo bed, was not to be left alone in his/her room while in the wheelchair, and was encouraged to participate in activities. The care plan documented the resident sustained [REDACTED]. The care plan lacked evidence of side rail use for the resident. The device and physical restraint assessment dated [DATE] revealed the resident was on hospice services but did not identify the use of side rails for this resident. The device and physical restraint assessment dated [DATE] revealed the resident had an indication for use of a cushion to reduce the risk of sliding out of the wheelchair but did not identify the use of side rails for this resident. The nurse's note dated 4/17/13 at 1:10 A.M. revealed the resident was observed by staff sitting on the floor in the doorway to his/her room with his/her back facing the bed at 1:00 A.M. 2 half side rails were up and in the locked position. The clinical record lacked evidence the facility investigated for the causative factors for the fall on 4/17/13. Observation on 10/14/13 at 2:17 P.M. revealed the resident rested quietly in bed with his/her eyes closed. Two half side rails were raised, the bed was in low position, a fall mat was next to the bed, and the call light was within reach. Interview on 10/15/13 at 11:04 A.M. with administrative staff A revealed staff investigated all falls. Interview on 10/15/13 at 12:05 P.M. with administrative staff A revealed the facility was unable to locate the fall investigation for this resident's fall on 4/17/13. Interview on 10/16/13 at 10:28 A.M. with licensed nursing staff K revealed the resident did have side rails in use. Staff K stated staff completed an assessment for side rail use on residents with side rails. Staff K reviewed the resident's chart and acknowledged the use of side rails was not addressed for this resident. He/she also reported staff should complete a fall investigation for each fall. Interview on 10/16/13 at 12:11 P.M. with administrative nursing staff E revealed if a resident used side rails staff address it on the device and physical restraint assessment and documented this on the care plan. Staff E expected staff to complete an investigation with each fall. The policy provided by the facility regarding incident and accident management with a revision date of 10/1/2010 revealed the facility investigated and reported them as required by law. The policy provided by the facility regarding fall prevention with a revision date of 11/05 revealed the facility assessed residents for risk of falls, followed up, evaluated falls of residents in order to assess the resident's condition, identified the reason for the fall, and prepared a plan of care to reduce the potential for future falls. The facility failed to investigate a fall and failed to thoroughly assess the use of side rails for this resident with severe cognitive impairment.

The facility identified a census of 122 residents. The sample included 24 residents. Based on , interview and record review the facility failed to implement interventions to prevent significant weight loss in a timely manner for 1 of 3 residents reviewed for nutrition. (#15) Findings included: - Resident #15's admission Minimum Data Set 3.0 Assessment ((MDS) dated [DATE] documented the resident's Brief Interview for Mental Status score (BIMS) was 13, which indicated the resident was cognitively intact. The resident required extensive assistance with activities of daily living (ADLs) for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. The MDS documented the resident's weight at 175 pounds (lbs) and did not have weight loss or gain. The Nutrition Care Area Assessment (CAA) dated 6-7-13 documented the resident received a regular diet, weighed 175 lbs, had left sided [MEDICAL CONDITION] (muscular weakness of one half of the body) and was able to feed his/herself with set up assistance. The resident received speech therapy for dysphagia (difficulty in swallowing). The Cognition CAA dated 6-7-13 documented the resident had dementia (a progressive mental disorder characterized by failing memory and confusion) and [MEDICAL CONDITION] (an anxiety disorder characterized by recurrent and persistent thoughts, ideas and feelings of obsessions sufficiently severe to cause marked distress, consume considerable time or significantly interfere with the patient's occupational, social or interpersonal functioning). The resident was able to state his/her needs, enjoyed TV but had difficulty with reality versus (vs) TV and mixed TV events with his/her own daily routine. The resident's history included a large hemispheric right [MEDICAL CONDITIONS] (the sudden death of brain cells due to lack of oxygen when the blood flow to the brain was impaired by blockage or rupture of an artery to the brain). The resident required a consistent routine to avoid confusion, required cueing/encouragement to stay on task and take part in activities, and became agitated. The ADL CAA dated 6-7-13 documented the resident with a left hand contracture (an abnormal permanent fixation of a joint), wore a hand splint, had hyperesthesia (an abnormal increase in sensitivity to stimuli) of extremities and had a right sided tremor. The resident complained of pain in his/her left foot and hand when touched. The resident required extensive assistance with mobility and cares. On 5-31-13 the care plan documented the resident received Hi Cal (a high-calorie oral supplement fortified with vitamins and minerals) 120 milliliters (ml) twice daily (BID) and staff recorded the % taken. On 6-3-13 staff discontinued the Hi Cal. The 5-31-13 Nutritional Assessment documented the resident had his/her own teeth, required set up assistance with meals, received Hi Cal 120 ml BID and re-admitted to the facility on [DATE] following hospitalization . Staff monitored the resident for weight loss and the resident's weight was stable. The resident remained on Hi Cal 120 ml BID and his/her current weight was 174.9 lbs. On 6-5-13 the dietary note referred to the 5-31-13 Dietary Assessment. Review of the August 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 7-12-13 the physician progress notes [REDACTED]. The record recorded the following weights for the resident: 7-1-13 - 178.4 pounds 7-8-13 - 162.8 pounds 7-11-13 documented re weigh the resident, but record lacked a weight. 7-15-13 - 167 pounds 7-22-13 - 163.2 pounds 7-29-13 - 159.2 pounds Consisting of a 19.2 pound or 10.76 percent weight loss in less than 1 month. On 7-17-13 the registered dietician's note documented the resident with significant weight loss, on 7-1-13 the resident weighed 178.4 lbs. On 7-8-13 the resident weighed 162.8 lbs. On 7-15-13 the resident weighed 167 lbs. Interventions were deferred at this time since the resident's weight appeared to go up, but staff may need to resume the Hi Cal if he/she had further weight loss. On 7-29-13 the dietary manager documented on 7-22-13 the resident weighed 167 and no longer received Hi Cal. The resident lost 15.7 lbs since 7-1-13, his/her meal intake was 50-100%, did not have a current [MEDICATION NAME] level (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) and recommended a consultation with the registered dietician. On 7-30-13 the resident's [MEDICATION NAME] level was within normal limits. The resident's total protein was low at 5.8 grams/deciliter (g/dl). The normal range was from 6.4 - 8.9 g/dl. The resident's iron level was low at 24 microgram/deciliter (ug/dl). The normal range was 50-212 ug/dl. On 7-20-13 at 8:30 P.M. the NN documented the resident had weight loss and fluctuating weights. The meal intake log documented the resident consumed 75-100% of meals and consumed all fluids offered. The family brought in chips, chocolate pudding and other high calorie snacks. On 7-30-13 at 2:45 P.M. the NN documented the resident with an 11% weight loss in 30 days, was not eating, and had ongoing confusion. On 7-30-13 at 8:00 P.M. the NN documented the resident re-started the Hi Cal supplement BID due to weight loss. Review of the July 2013 weights revealed a 19.2 lb or 10.76 percent (%) from 7-1-13 through 7-29-13 with no interventions attempted. On 10-15-13 at 1:15 P.M. dietary consultant II stated the resident showed significant weight loss from July 1st through the 8th and was not receiving a supplement. On 7-15-13 the resident's weight was up at 167 and he/she deferred any interventions because the resident's weight increased. Dietary staff II stated his/her recommendation was if the resident lost more weight, then implement the Hi Cal and the dietary manager did that on 7-29-13. He/she stated he/she was not made aware of the weight loss sooner. On 10-16-13 at 8:27 A.M. administrative nurse E stated the registered dietician saw the resident on 7-17-13 and addressed the weight, but deferred any interventions unless the resident's weight continued to decrease. The certified dietary manager saw the resident on 7-29-13 and recommended the registered dietician see the resident and started him/her on Hi Cal. The fortified food plan was implemented on 7-30-13. On 10-16-13 at 10:40 A.M. administrative nurse D stated the facility implemented weekly weights for all residents. The nurses contacted the registered dietician with weight loss concerns. He/she stated staff initiated a fortified food plan as the first plan of action, then provided Hi Cal or another type of high calorie supplement. He/she stated the unit managers reviewed the weekly weights and contacted the dietician as needed. The 4/04 facility provided Resident Weight and Vital Sign Monitoring Policy and Procedure documented facility monitored, documented, and responded to variances in monthly weight and vital signs. The facility failed to implement interventions in a timely manner for this resident who had 10% weight loss in 28 days.

The facility identified a census of 126 residents with 5 residents in the sample. Based on observation, interview, and record review, the facility failed to develop and implement timely and effective interventions and supervision, to prevent falls for 3 of 5 residents sampled for accidents (#2, #3, #4), who experienced falls and sustained fractures or serious injury. Findings included: - According to the resident's face sheet, the facility admitted resident #2 on 3/18/10 with a readmission on 5/14/13. Review of the resident's physician order [REDACTED]. Review of the annual Minimum Data Set 3.0 assessment dated [DATE] recorded the resident with a Brief Interview for Mental Status (BIMS) score 2 (severe cognitive impairment), required extensive assistance from staff for all activities of daily living (ADL), and had 2 or more non-injury falls since the previous assessment. Review of the Care Area assessment dated [DATE], recorded the resident with a slow progress of dementia, remained alert for the most part with an orientation of 1 or 2. The resident's prior BIMS score of 9 (indicated moderate cognitive impairment), current BIMS of 2, severe cognitive impairment, required extensive assistance for bed motility, transfers, dressing, locomotion on the unit, and bathing. The resident's balance was unsteady and the resident was only able to stabilize with staff assistance. The resident was at risk for falls due to dementia, generalized weakness, debility, osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), and had impulsive behaviors with poor safety awareness. The resident did not always ask for help, required cueing/encouragement to use the call light, and had a history of [REDACTED]. Staff planned to develop a care plan to promote safety/help and to prevent injury. Review of the monthly nursing Resident (MDS) data set [DATE], recorded the resident had a non-injury fall on 12/10/12. The resident attempted to take him/herself to the bathroom. Staff educated the resident about using the call light. The resident understood how the call light worked, but did not want to bother anyone. The staff assured the resident that we (the staff) expected him/her to call and ask for help. Review of the monthly nursing Resident (MDS) data set [DATE], recorded staff observed the resident on the floor next to his/her bed with a non-injury fall. The resident reported to staff that he/she was on the way back to bed. Review of the nursing notes dated 1/7/13 at 4:10 P.M., revealed staff found the resident on his/her back, on the floor next to his/her bed. Review of the monthly nursing Resident Data Set, dated 3/4/13, recorded the resident was alert, easily distracted, had slow movements, moderately impaired decision-making skills, and usually understood. The resident required limited assistance from one staff for transfers, bed mobility, toileting, and gait/balance was unsteady with a fall risk assessment score of 15 (identified a total score of 10 or greater at high risk for falls). Nursing notes, dated 3/12/13 at 1:50 P.M., the resident's roommate came out of their room and stated, (resident) was on the floor. The resident was previously at the nurses' station taking his/her pills at approximately 8:50 A.M. Upon entering the room, staff observed the resident laying supine next to his/her bed, between the wheelchair and the bed on the floor, with no injury noted. Documentation revealed an intervention to not leave the resident unattended in his/her room while in the wheelchair. Review of the monthly nursing Resident Data Set, dated 4/22/13, blank (not done). Review of the resident's comprehensive plan of care, dated 3/14/13, documented the resident with a potential for injury/falls related to impaired mobility and poor safety awareness. This plan of care directed staff to: - Monitor vital signs PRN (as needed) and notify the physician if not within baseline for resident. - Observe for changes in gait, balance, and mobility. Report to the physician if changes exist. - Therapy referrals PRN after fall and PRN change of status or as ordered by physician. - Anticipate ADL needs and keep routine as consistent as possible. - Remind resident to use call light for assistance. - Remind resident not to get up independently without assistance if unable to transfer or ambulate by self. - Evaluate medications PRN for possible reduction/adjustment in dosages. - Assure the resident's toileting needs are met. - Keep room, hallways free of clutter. - Reposition the resident every 2 hours and PRN or cue the resident if they were independent with bed mobility. - Frequent visual checks when walking by resident rooms. - Encourage the resident to be involved in facility activities/events. - Therapy referral on 3/15/13 for occupational, physical and speech therapy. Nursing notes, dated 4/5/13 at 3 A.M., documented to discontinue occupational therapy services following treatment on 4/5/13. Nursing notes, dated 5/4/13 at 9:45 A.M., stated "The resident has been exhibiting an increase in confusion today. Wanted to make pancakes this morning and was worried that his/her (child) did not know where he/she was. (The resident) has been a little difficult to redirect, called physician extender, and received a new order. Urinalysis with culture and sensitivity (if indicated) today, 5/4/13. TSH (thyroid stimulating hormone) (test) on Monday 5/6/13. Urinalysis collected at 9:40 A.M., and (laboratory) contacted to be picked up. (Responsible party) notified. Will monitor for changes." Nursing notes, dated 5/4/13 at 5:45 P.M. recorded " At approximately 4:20 P.M., patient's roommate came to nurse to notify that patient was on the floor in his/her room. Nurse then went to check on him/her. (The resident) was on the floor in his/her room facing the floor right beside his/her bed with walker next to him/her. Had laceration to right eye that was bleeding along with his/her nose. Vital signs: temperature 97.9 degrees, pulse 76, respirations 20, blood pressure 190/97, and oxygen saturation of 97 percent on room air. Placed in wheelchair after ROM (range of motion) for completion of evaluation. Complaining of headache and right eye was swollen, making it difficult to assess neuros (an assessment made by a medical professional on someone with a head injury to determine the extent of the injury). Call placed to physician extender with order to send to (acute care hospital emergency room ) for further evaluation and treatment. Patient was transferred to (acute care hospital) by 911 ambulance at 4:30 PM. (Responsible party) notified and meeting him/her there." Review of the facility provided Report of Alleged Incident/Accident, dated 5/4/13 and timed 4:20 P.M., recorded staff last transferred the resident at 1:30 P.M. This same investigation recorded the resident had a laceration above the right eye and three peri-orbital fractures to the right eye. Review of the follow up investigation recorded an intervention of low bed and final disposition of the resident, "Sent 911 to ER (emergency room ). Has bruising on the brain with swelling, 3 peri-orbital fractures on right side." Review of the hospital discharge report, dated 5/14/13, recorded the resident with a fall that resulted in a small orbital fracture, tiny frontal contusion (bruise on the front portion of the brain), and small subdural cerebral spinal fluid hygroma (traumatic accumulation of cerebrospinal fluid in the subdural space after a head injury). Observation, on 7/17/13 at 9:41 A.M., revealed the sleeping resident lay in a low bed, with two ? rails in the up position at the head of the bed, positioned slightly to the left side, with a call light attached to the linen. This observation revealed no fall mat at bedside. On 7/17/13 at 12:45 P.M., the resident laid in a low bed with the head slightly elevated, a fall mat next to the right side of the bed, call light attached to the linen within reach of the resident. The resident was able to say okay but was unable to hold a conversation. On 7/18/13 at 11:30 A.M., direct care staff M, raised the bed height, put the resident's shoes on, applied a gait belt, and then lifted the resident from a supine to sitting position on the side of the bed. The resident reached around for the staff ' s arm, and groaned. Staff then lowered the height of the bed slightly so the resident ' s feet touched the floor. When direct care staff M asked the resident if he/she felt dizzy, the resident replied, "Yes". Staff waited to let the resident obtain his/her balance. Then holding onto the gait belt, staff used extensive assistance to stand the resident. The resident grimaced and took tiny shuffling steps to pivot into the wheelchair, resting his/her weight on direct care staff M. The care plan revealed the intervention to place a fall mat next to the bed with the initiation date of 7/171/3. On 7/17/13 at 10:30 A.M., administrative staff B reported this resident experienced an unwitnessed fall with injury and staff transferred the resident to the emergency room for treatment. On 7/17/13 at 1:00 P.M., licensed nursing staff D reported staff had to anticipate the resident's needs and the resident was at risk for falls. The resident did not use his/her call light and at times, his/her roommate would call help for him/her. Licensed nursing staff D confirmed the resident experienced a recent fall and prior to that fall, the resident self-propelled in his/her wheelchair. On 7/17/13 at 2:25 P.M., administrative staff A confirmed the resident received treatment in the emergency room for a head injury after a fall in the facility. On 7/18/13 at 9:25 A.M., direct care staff P revealed the resident needed 1 staff for transfers, could bear weight, and pivot. Direct care staff P reported the resident was a fall risk, had a low bed, fall mat, and experienced a recent fall. Direct care staff P revealed how often staff performed frequent visual checks, depended on the resident and how often the charge nurse directed staff to do them. Direct care staff P reported some frequent checks were every 15 to 30 minutes and some were every 2 hours. The 15 to 30 minute checks usually had paper documentation for times, initial, and number of days. Review of the clinical record lacked evidence of any documentation of frequent visual checks of the resident. On 7/18/13 at 9:45 A.M., licensed nursing staff N reported that when completing an investigation, staff tried to find an appropriate intervention and sometimes updated the resident's plan of care. On 7/18/13 at 11:30 A.M., direct care staff M reported the resident recently fell , which was why staff kept the wheelchair and walker out of the resident's sight in his/her room. Staff tried to anticipate the residents' needs and looked in on the residents as staff passed by their rooms. On 7/18/13 at 2:50 P.M., therapy staff Q revealed the resident received therapy after the 5/14/13 readmission with the frontal contusion, was discharged from therapy because of lack of progress, and did not return to the prior level of functioning. On 7/18/13 at 2:50 P.M., therapy staff R reported the resident was groggy, difficult to engage in therapy participation, and never got back to baseline activity level. The facility failed to provide supervision and implement effective interventions for this cognitively impaired resident, with a history of falls with fractures, who experienced 4 documented falls between 12/10/12 and 5/4/13. The fall on 5/4/13 resulted in a peri-orbital fracture, frontal contusion, and a subdural cerebral spinal fluid hygroma. - According to the clinical face sheet, the facility admitted resident #3 on 11/14/05, with a readmission on 7/8/12. Review of the physician's orders [REDACTED]. Review of the significant change Minimum Data Set Assessment Care Area Summary dated 11/4/12 and recorded fall risk factors as dementia with psychosis. The resident ambulated with the arm of a caregiver, but tended to wander at times, required extensive assist to safely complete transfers, toileting, bed mobility, and had an admission to hospice on 11/14/12. Review of the quarterly Minimum Data Set 3.0 Assessment, dated 2/13/13, recorded the resident with short and long-term memory problems, moderately impaired decision-making skills, signs of delirium (sudden severe confusion, disorientation, and restlessness), required extensive staff assistance with transfers, dressing, and personal hygiene. The resident's balance was not steady with walking, turning, moving on/off toilet, surface to surface transfers, and he/she was only able to stabilize with staff assistance. This same Minimum Data Set documented the resident with two or more injury falls (without fracture) since the prior assessment. Review of the plan of care, dated 1/23/13, documented with an injury potential from falls related to psychotropic medication use, osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), [DIAGNOSES REDACTED] (condition characterized by decreased activity of the thyroid gland), and [DIAGNOSES REDACTED]. This plan of care directed staff to: - Monitor vital signs PRN (as needed) and staff to notify the physician if not within baseline for resident. - Observe for changes in gait, balance, and mobility. Report to physician if changes exist. Broda chair (specialized wheelchair with the ability to tilt and recline) for instability. - Anticipate all ADL (activities of daily living) needs and keep routine as consistent as possible. - Evaluate medications PRN for possible reduction/adjustment in dosages. - Assure resident toileting needs were met. - Keep room, hallways, free of clutter. - Reposition resident every 2 hours and PRN or cue resident if they were independent with bed mobility. - Personal injury devices as ordered: anti-skid socks, put resident to bed following dinner meal; fall mat next to bed. - Frequent visual checks when walking by resident rooms. - Encourage resident to be involved in facility activities/events. A new intervention placed on 4/11/13 after he/she suffered a laceration from a fall; staff to assist with proper positioning in wheelchair. Review of the monthly nursing Resident (MDS) data set [DATE], documented a fall risk score of 15, unsteady gait/balance, revealed a fall risk score of 10 or greater placed the resident at high risk for falls. Review of the monthly nursing Resident (MDS) data set [DATE], documented the resident required extensive assistance of two staff for bed mobility, transfers, toileting and at risk for wandering related to dementia. Staff failed to complete a fall risk assessment. The facility provided fall tracking log recorded the resident suffered a laceration on 4/11/13 from a fall from a Broda chair which required sutures in an emergency room . Review of the physician telephone orders dated 4/11/13 at 2:05 P.M., directed staff to transfer the resident to a hospital emergency department for evaluation and treatment. Physician telephone orders dated 4/11/13 and timed 4:45 P.M., directed staff to cleanse upper eye sutures with wound cleanser, pat dry, cover until healed, and check each shift. Review of the nursing notes dated 4/11/13 at 2:22 P.M., documented the resident went to a hospital emergency department to receive evaluation and treatment for [REDACTED]. Nursing notes dated 4/11/13 at 4:45 P.M., recorded the resident returned to the facility from the emergency room by way of the family car with 5 stitches to the laceration on upper right eye and he/she had a purple bruise above the left eye. Review of the facility provided investigation dated 4/11/13 and timed 1:55 P.M., recorded the resident sat in a Broda chair in the dining room. Staff heard a loud noise, got up, and found the resident lying on the floor, with a laceration above the right eye. The resident was unable to state what happened. Review of the annual history and physical dated 5/1/13, recorded the resident was wheelchair bound with poor insight and poor judgment. Observation on 7/17/13 at 3:53 P.M. revealed the resident sat in a Broda chair slightly tilted back with the foot rest in place, in the dining room, talking (mumbling, yea) On 7/18/13 at 10:00 A.M., observation revealed the resident in the upright position, in the Broda chair; the resident leaned forward in a manner that required direct care staff L to place a hand to stabilize the resident. On 7/18/13 at 12:49 P.M., direct care staff H and L applied a gait belt to the resident who sat in a Broda chair, lowered the footrest, stood the resident, bearing most of the resident's weight, and transferred the resident to the bed. The resident's feet/toes were pointed, not flat-footed, and he/she was unable to bear weight. The resident did not attempt to assist or turn, just softly said " yea " during cares. On 7/17/13 at 12:10 P.M., direct care staff F reported the ADL book had exercise, range of motion, meal intake, as well as the care plan in the charts to direct resident cares. Staff asked the charge nurse or assistant director of nursing if they had any questions about cares. Direct care staff F reported the resident sat in a Broda chair to prevent falls and required a lot of supervision to keep a watch on him/her. Direct care staff F revealed staff just showered the resident (on the day of the fall) and the leg and footrest were flat, which allowed the resident to slip down and get out of the chair. The resident was brought into the dining room by staff who were not familiar with the resident. The staff kept the leg rest up to keep the resident from falling. The resident rarely tried to get up but tried every 6 months or so. Direct care staff F stated the resident was in the Broda chair for a while and was unsteady with walking. On 7/17/13 at 2:10 P.M., administrative nursing staff J reported the resident just came back from the beauty shop, his /her foot rest was not up, and staff did not catch it. On 7/17/13 at 3:47 P.M., direct care staff K revealed the resident was confused, did not talk much, and required full assistance with care and transfers. Two staff transferred the resident to the Broda chair. Direct care staff K reported the resident was not a fall risk and was unaware of any special precautions about positioning of the resident in the Broda chair. On 7/17/13 at 2:00 P.M., direct care staff G reported the resident leaned forward and got out of his/her chair. Staff positioned the Broda chair back and kept the feet rest up. Direct care staff G reported that every several months the resident attempted to get out of the chair (and walk). On 7/18/13 at 6:50 A.M., direct care staff S reported the resident required two staff to assist with transfers to the Broda chair. Direct care staff S said the chair moved in multiple positions and a slightly tipped back was a comfortable position for the resident. During an interview on 7/18/13 at 9:25 A.M., licensed nursing staff I reported staff kept the resident's Broda chair tilted back and completed a restraint assessment. The resident's (child) bought this chair. The resident could get out of the chair. Licensed nursing staff I reported he/she did not see, but heard the resident fall, and found the resident flat on his/her face on the dining room floor. The resident just returned from the beauty shop with the chair in an upright position. The resident could get out of the chair. The resident apparently just decided he/she could take a step and started walking. Licensed nursing staff I reported nursing informed the direct care staff of interventions, but there was a PRN staff working that day. Licensed nursing staff I said now staff took the resident to and brought him/her back from the beauty shop, that way we were assured the Broda chair was in correct position. On 7/18/13 1:00 P.M., direct care staff H reported the resident was able to roll him/herself in bed, and the resident seemed to think they could walk. Direct care staff H reported frequent checks could be every 30 minutes, one hour, or every 2 hours, depending on what the nurse told staff to do and what to check. On 7/18/13 at 2:45 P.M., licensed nursing staff I reported the resident was on every 10 minute checks after his/her fall. On 7/18/13 at 2:50 P.M., therapy staff Q revealed the resident received services briefly (from 5/1/13 to 5/10/13) after discontinuation of hospice services, the resident wanted to do some exercises and therapy, and had a good change in status. The resident received a new Broda chair that nursing services ordered the day before he/she experienced the fall. On 7/18/13 at 2:50 P.M., therapy staff T confirmed the resident just received a new Broda chair. On 7/18/13 at 3:30 P.M., administrative staff B reported the standard intervention on the care plan, frequent checks, did not have a standard of time and was not an appropriate intervention. The facility failed to ensure adequate supervision and implementation of effective interventions for this cognitively impaired, totally dependent resident with a history of falls, who experienced a fall that resulted in a facial laceration that required an intervention of 5 stitches by an emergency department. - According to the clinical face sheet, the facility admitted resident #4 on 6/20/13. Review of the admission physician orders [REDACTED]. glucose, there's not enough insulin made or the body can't respond to the insulin), congestive heart failure (a condition when the heart output was low and the body became congested with fluid). These same physician orders [REDACTED]. Review of the nursing admission Resident Data Set assessment, dated 6/20/13 and timed 2:15 P.M., recorded the resident's admission to the facility. This data set documented the resident was alert, independent, ambulatory, incontinent of bladder, unsteady with gait/balance problems, and required limited assistance of staff for bed mobility, transfers, and toileting. The fall risk assessment documented a total score of 16 (indicated a total score of 10 or greater placed the resident at a high risk for falls), and recorded the resident had 1 to 2 falls in the past 3 months. Review of the resident's initial admission plan of care dated 6/20/13 recorded the resident was at risk for falls and directed staff: - Keep call bell in reach. - Encourage/instruct use of call light. - NA (nurse aide) to assess resident every 30 to 60 minutes - Instruct resident on safety measure, repeat PRN (as needed). - Physical therapy referral PRN. - Mobility alarm. Review of the initial plan of care for Bowel/Bladder Incontinence directed staff to: - Toileting every 2 hours - Use moisture barriers with each incontinence episode. - Keep call light in easy reach - Briefs, depends, or pantiliners when out of bed Review of the admission nursing note dated 6/20/13 timed 4:35 P.M., the resident was alert and oriented before the hospital admission, ambulated independently, according to spouse, and experienced a fall while in the hospital. The resident required continuous supplemental oxygen of 2 liters by nasal cannula. Review of the occupational therapy evaluation, dated 6/20/13, recorded the resident with a new onset of reduced ability to safely ambulate, decreased ADL (activities of daily living) performance, reduced balance, decrease in functional mobility, increased need for assistance from others, and decrease in strength. This occupational therapy evaluation recorded precautions for fall risk and resident oxygen saturation fluctuations. The residents' standing balance during ADLs was fair, required contact guard assist in standing with unilateral upper extremity support without loss of balance, and he/she was unable to weight shift. Nursing notes dated 6/21/13 (untimed) documented the resident was alert and oriented times 2, and required assistance of 1 with transfers. He/she was wheelchair/bound and received oxygen therapy 2 liters per nasal cannula. The staff noted no shortness of breath. The physician ordered Tylenol 650 milligrams PRN for pain. Review of the skilled nursing notes dated 6/21/13 (untimed), recorded the resident required limited assistance from staff with bed mobility, transfer, and toileting during days, received extensive assistance from staff on nights, and both shifts documented the resident as a fall risk. Nursing notes dated 6/22/13 (untimed), recorded the resident was alert and oriented...experienced a fall at 2 A.M., without injury or trauma. The staff recorded an oxygen saturation of 90 percent (%) on room air and 93% on 2 liters of supplemental oxygen. Review of the facility provided partial incident accident investigation included a brief non-witness statement that documented a non-injury fall in the resident's bedroom. On 7/18/13 at 6:45 A.M., direct care staff O revealed on 6/22/13 at approximately 2:00 A.M., he/she heard the resident moaning, found the resident on the floor next to his/her bed. Direct care staff O reported that he/she summoned licensed nursing staff to perform an assessment and care for the resident. On 7/17/13 at 3:16 P.M., administrative nursing staff E confirmed direct care staff member O found the resident on 6/22/13 at 2:00 A.M. On 7/18/13 at 9:45 A.M., licensed nursing staff N reported the resident told staff that he/she was coming from the bathroom when staff found him/her on the floor at 2:00 A.M. Staff tried to orient the resident to the fact that he/she could not walk safely. Staff provided him/her a urinal to keep him/her from getting up and going to the toilet and advised him/her to use the call light. The facility did not use alarms (bed or otherwise). On 7/18/13 at 3:00 P.M., administrative nursing staff E acknowledged the facility did not use alarms. Review of the resident's initial care plan lacked evidence of any additional intervention to prevent further falls for this resident. Review of the medication administration record, documented on 6/22/13 at 9:15 P.M., the resident received from staff, Ambien (hypnotic sleep agent) 5 milligrams daily at bedtime PRN for sleep insomnia. Nursing notes dated 6/23/13 {sic 6/22/13} (untimed) documented, the resident was alert and oriented and able to make needs known to staff. The resident requested assistance with bed mobility, transfers, and toileting. Resident fell at about 10:15 P.M., which resulted in a hematoma of about 7 centimeters by 7 centimeters in diameter. The resident was conscious and sent to the hospital for further evaluation. The hospital admitted the resident for continuous evaluation. evaluation. Review of the physician's telephone orders dated 6/22/13 at 10:30 P.M., documented the resident fell and developed a hematoma on his/her left side forehead. The physician gave an order to transfer the resident to the hospital for further evaluation. The facility provided investigation dated 6/22/13 and timed 10:15 P.M., recorded the resident had a fall with hematoma and staff sent him/her to the emergency room for treatment. This investigation documented, the resident stated he/she tripped on his/her pants as he/she was urinating. On 7/17/13 at 2:20 P.M., administrative nursing staff A confirmed staff sent the resident out to the hospital and he/she did not return. On 7/17/13 at 2:45 P.M. administrative staff B reported staff was working on an improvement plan to investigate, analyze, and prevent resident falls. On 7/18/13 at 9:45 A.M., licensed nursing staff N revealed as he/she entered the resident's room on 6/22/13 at approximately 10:15 P.M., the resident was between the wall and bed, with his/her head down. Licensed nursing staff N stated the resident stumbled and he/she heard the resident's head bounce on the floor when he/she fell . Licensed nursing staff N said the resident stated he/she was urinating. There was a urinal with some urine in it and on the floor. Licensed nursing staff reported the resident had not used the call light. On 7/18/13 at 8:00 A.M., administrative staff B reported staff failed to follow the facility policy regarding investigations and follow up for fall prevention. On 7/18/13 at 2:50 P.M., therapy staff Q reported therapy evaluations for physical and occupational therapy on 6/20/13 and 6/21/13 revealed the resident experienced decreased oxygenation during ambulation to 86 percent (%). Therapy staff checked the resident's oxygen level prior to and with walking, and revealed the resident's oxygen saturation fluctuations. Therapy goals included strength, standing, independence with transfers without signs or symptoms of hypoxemia for reduced fall risk, bed mobility tasks, and gait distance with use of a roller walker. On 7/18/13 at 2:50 P.M., therapy staff V revealed therapy evaluated the resident on Friday and by Monday, the resident discharged to the hospital. The resident was very weak from pneumonia and required oxygen during the evaluation. On 7/17/13 at 3:06 P.M., hospital social service staff U reported the resident discharged to a private resident with home health care on 6/30/13. The facility failed to provide supervision for this newly admitted resident with a history of falls and who experienced a fall in the facility. The facility further failed to implement effective new interventions to prevent further falls. The resident experienced a second fall approximately 8 hours later, which resulted in a hematoma and hospitalization .

The facility had a census of 125 residents. The sample included 7 residents. Based upon observation, record review and interviews the facility failed to ensure that 1 (#5) of 1 residents sampled for nutritional status did not experience a significant weight loss. Findings included: - Review of resident #5's Physician order [REDACTED]. Hi-Cal (a nutritional supplement) three times a day for weight loss since 4/5/13. The resident's quarterly Minimum Data Set (MDS) 3.0 dated 4/19/13 identified the resident scored 3 (severely impaired cognition) on the Brief Interview for Mental Status, required extensive staff assistance with bed mobility, transfers, locomotion on/off the unit, dressing, toilet use, and personal hygiene, did not walk in the room/corridor, and required staff supervision with eating and set up. The MDS recorded the resident weighed 106 pounds, had experienced a weight loss and was not on a physician prescribed weight loss regimen. The MDS coded the resident was at risk for the development of a pressure ulcer, and did not have a Stage 1 or higher pressure ulcer. The resident's Nutritional Status Care Area assessment dated [DATE] included the resident received a regular diet, experienced a weight loss and the facility placed the resident on a fortified food plan (FFP) in December of 2012, the resident required staff set up at meals, staff monitored the resident's weight on a weekly basis.The resident weighed 121 pounds (#). In June 2012 and September of 2012, and weighed 115 pounds in January of 2013. The resident's care plan with a review date of 4/11/13 included the resident had a potential for nutritional impairment related to poor intake, staff served the resident the diet as the physician ordered, offered the resident foods he/she liked, and offered substitutes as needed if the resident did not like the food served and when the resident consumed 50% or less of the meal. The care plan included the facility consulted a dietician as needed for the resident's weight loss. An entry dated 4/5/13 included the facility started the resident on 90 cubic centimeters (cc's) of Hi Cal (nutritional supplement) three times a day between meals. An entry dated 6-4-13 included the facility started the resident on [MEDICATION NAME] ( a medication used to stimulate the appetite) for 30 days, staff provided verbal cueing during meals, and snacks were always available on the unit. A Nutritional History/Assessment completed by a registered dietician on 3/16/13 documented the resident had variable intake of the FFP diet and had minimal depletion visceral protein stores. The resident's weight had significantly decreased in the last year and the dietician recommended health shakes three times a day in a further attempt to increase oral nutritional intake for healing and promotion of nutritional status. The dietician encouraged food intake greater than 50 percent (%) at all meals, and especially of increased protein foods and supplements. Review of the resident's clinical record did not support the facility followed up on the dietician's recommendation regarding the resident receiving health shakes three times a day until 4/5/13 (19 days after the recommendation). A laboratory report (date unknown) documented the resident's protein level at 4.9 grams/deciliter (gm/dl) (normal reference range 6.4-8.9 gm/dl) and the resident's [MEDICATION NAME] at 3.4 gm/dl (normal reference range 3.5-5.7 g/dl). Review of the resident's weights revealed the following weights: 1/7/13: 119#'s 1/14/13: 113#'s (a decrease of 6#'s and/or 5.04 percent (%) of his/her body weight in 1 week) 2/18/13: 110#'s 3/11/13: 108#'s 4/1/13: 106#'s (a decrease of 13#'s and/or 10.2% of his/her body weight in 3 months) 5/20/13: 104#'s 5/27/13: 103#'s (a decrease of 16 pounds and/or 13.45% of his/her body weight in 4 months) The above represented the resident experienced a significant weight loss and during that time the resident developed 2 facility acquired pressure ulcers on his/her right heel. Review of the resident's April 2013, May 2013, and June 2013 (6/1/13 to 6/9/13) Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the resident's clinical record lacked evidence the facility offered the resident another supplement when the resident did not consume the supplement. The resident's clinical record did not support the facility attempted and/or implemented another nutritional supplement. Review of the resident's nutritional intake log for 6/2013 revealed the resident refused the breakfast meal served on 6/1/13 ,6/2/13, 6/3/13, 6/4/13 and 6/7/13, refused the lunch meal on 6/1/13, 6/4/13, and the dinner meal on 6/6/13. The resident's nutritional intake log documented the resident consumed 25% of meals 6 times from 6/1/13 to 6/7/13. The resident's clinical record did not support the facility offered the resident an alternative. Review of the resident's night time snack log documented the resident refused all of the snacks (no documentation for 6/8/13) from 6/1/13 to 6/10/13. The resident's clinical record did not support the facility offered the resident an alternative snack. On 6/11/13 at 7:40 A.M. the resident sat at a dining table, the resident's breakfast meal which consisted of a strip of bacon, scrambled eggs, toast juice and water sat in front of the resident. Observation revealed the resident had not eaten any of the meal and staff did not assist the resident. At 7:45 A.M. the resident attempted to open the jelly package, the resident could not open the package, and the resident placed the unopened jelly package on the table. Observation revealed the resident had not consumed any of the meal, and staff did not assist or cue the resident to eat. At 7:50 A.M. and 8:02 A.M. the resident had not consumed any of the meal and staff did not assist or cue the resident. At 8:12 A.M., a certified nurse aide opened the jelly package but did not place the jelly on the resident's toast. At 8:16 A.M. licensed nurse K placed the spoon in the resident's hand, asked the resident to eat the scrambled eggs, the resident placed the spoon in the eggs and ate a bite of the eggs. Licensed nurse K placed the jelly on the resident's toast.The resident picked up the toast and then ate 1/2 of the toast. At 8:22 A.M., 8:30 A.M., and 8:40 A.M. the resident continued to sit at the table,with the meal in front of the resident, the resident only consumed the food as listed above, and staff did not assist or cue the resident to eat. At 8:43 A.M. direct care staff Q wheeled the resident from the dining room to his/her room. On 6/11/13 at 11:40 A.M. the resident sat at a dining room table, with the resident's lunch meal in front of him/her which consisted of a turkey and cheese sandwich (cut in half), a bowl of potato soup, water, juice and a glass of wine. Observation revealed the resident held 1/2 of the turkey and cheese sandwich in his/her hand and was eating the sandwich. At 11:45 A/M. the resident continued to eat the sandwich. At 11:50 A.M. 11:55 A.M., 12:00 P.M. and 12:15 P.M. the resident had consumed 1/4 of the sandwich and all of the wine, the remainder of the sandwich sat on the resident's plate and staff did not assist or cue the resident to eat. On 6/11/13 at 4:50 P.M. staff delivered the resident his/her dinner meal which consisted of a bowl of fruit, barbeque beef on a bun, and french fries. At 4:52, 4:53 P.M., and 4:54 P.M. the food sat in front of the resident, the resident did not attempt to eat the food, and no staff assisted or cued the resident to eat. At 4:55 P.M., the resident removed the top bun off of the sandwich (the sandwich was not cut in half) and ate the bun. At 5:00 P.M. the resident continued to eat the bun, staff did not assist or encourage the resident to eat. At 5:10 P.M. the resident had consumed 100% of the top bun and none of the other food. Observation revealed the resident sat in the wheelchair at the table, and staff did not assist or cue the resident to eat. At 5:25 P.M. the resident had not consumed any of the other foods and staff did not assist or cue the resident to eat. On 6/12/13 at approximately 8:30 A.M. direct care staff R stated the resident did not like the taste of the nutritional supplement; therefore the resident did not always drink the nutritional supplement. Direct care staff R stated the facility usually offered one flavor of the supplement which contributed to residents refusing the supplement. On 6/12/13 at approximately 11:00 A.M. nursing administrative staff D stated the resident had experienced a weight loss, the facility started the resident on a fortified food plan in 12/2012, the resident required set up during meals and at times required staff assistance and cueing during meals. Nursing administrative staff D stated the facility started the resident on a nutritional supplement per the dietician's recommendation. The resident did not like the supplement and often times did not consume the supplement. On 6/12/13 at approximately 3:00 P.M., direct care staff Q stated the resident required set up assistance with meals, and at times required staff assistance and cueing with meals. Direct care staff Q stated if staff placed a eating utensil in the resident's hand, the resident could eat the meal without staff assistance. On 6/12/13 at approximately 3:05 P.M., direct care staff O stated the resident required set up assistance during meals and depending on the day, the resident required staff assistance and cueing with the meal. On 6/12/13 at approximately 3:15 P.M., licensed nurse L stated at times the resident required staff assistance and cueing with meals. On 6/13/13 at approximately 2:00 P.M. dietary consultant Y stated he/she was not the dietician that assessed the resident in March of 2013. Dietary consultant Y stated he/she had not assessed the resident's nutritional status since 3/13. Dietary consultant Y stated the facility should follow up on the dietician's recommendation within 1 week. The facility's nutrition protocols for weight loss dated 4/04 included the dietician would assess residents with an intended weight loss. Interventions in increments may include vitamins/mineral, if needed, and fortified meals according to the fortified meal plan foods, and if additional calories were needed, add the facility's supplement of choice, if the above interventions were not adequate, add 2 cal/cc med pass product in 4 ounce increments. The facility failed to assist this cognitively impaired resident with meals, and failed to follow up on the refusao of the nutritional supplements, and failed to implement the dietician's recommendation regarding the nutritional supplement in a timely manner, and failed to offer substitutes if the resident refused the meal and/or consumed less than 50% of the meal as care planned for this resident that experienced a significant weight loss.

The facility had a census of 125 residents. The sample included 7 residents, of which 3 were sampled for pressure ulcers. Based upon observation, record review and interviews the facility failed to ensure that 1 (#2) resident's pressure ulcer did not worsen and also failed to provide treatment and services to prevent the development of pressure ulcers and promote healing for 1 (#5) resident. Findings included: - Resident #2's (a closed record) with an admission date of [DATE] revealed an admission Minimum Data Set (MDS) 3.0 dated 5/3/13 identified the resident had severely impaired cognition, was totally dependent upon staff with bed mobility, transfers, locomotion on/off the unit, dressing, eating, toilet use, personal hygiene, and bathing, and did not walk in the room/corridor. The MDS recorded the resident was always incontinent of urine, was at risk for the development of pressure ulcers, had (1) Stage 3 pressure ulcer that was present upon admission/reentry, the pressure ulcer measured 0.8 centimeters (cm) by 2.2 cm with a depth of 0.4 and identified the tissue type as slough (non-viable tissue). The MDS coded the resident had a pressure relieving device for his/her bed and chair, and was on a turning/repositioning program. The resident's discharge MDS dated [DATE] recorded the resident had (1) Stage 3 pressure ulcer that worsened since the prior MDS and the pressure ulcer measured 7 cm by 5.8 cm with a depth of 0.5 cm. The MDS did not record the tissue type of the pressure ulcer. The resident's nutritional status Care Area Assessment (CAA) dated 5/3/13 documented the resident was unable to receive oral intake, received a continuous tube feeding of Promote with Fiber. The resident's pressure ulcer CAA dated 5/3/13 documented the resident was admitted to the facility with a Stage 3 pressure ulcer with areas of slough and scant serosanguinous drainage. The CAA included the resident had a surgical incision on his/her right chest area from the placement of a recent pacemaker. The resident's admission care plan dated 4/20/13 included the resident was incontinent of bowel and bladder, staff toileted the resident every 2 hours, and as needed, and the resident had a pressure sore. The treatment for [REDACTED]. The resident was on a low air loss mattress for positioning and comfort, and the resident received Glucerna 1.2 at 70 centimeters (cc) per hour. The resident's care plan dated 5/10/13 included the resident was admitted to the facility with a coccyx wound, staff turned and repositioned the resident every 2 hours, the resident wore heel protectors, and staff assessed the skin weekly. The care plan included the resident's pacemaker was located in the resident's right upper chest, and staff placed the immobilizer every shift to the resident's right upper extremity secondary to the pacemaker. The care plan included the resident received Promote at 70 cubic centimeters (cc's) per hour and the facility could use Glucerna until the Promote arrived. A physician examination progress note dated 4/22/13 included the resident had a Stage 2 pressure ulcer on his/her coccyx The resident's admission orders [REDACTED]. A physician's orders [REDACTED].M. included a clarification order that read as of 4/28/13 use Glucerna 1.2 cal at 60 cc/hour continuous for enteral nutrition until Promote arrives then run at 70 cc/hr. A nurse's note dated 5/16/13 (time unknown) documented the facility did not have the Promote nutritional supplement, the facility telephoned the resident's physician and received an order to give the resident Glucerna 1.2 Cal until the Promote Fiber arrived. A physician's orders [REDACTED]. A physician's orders [REDACTED].M. included to use Iodaform gauze to pack the resident's coccyx wound. According to the manufacturer's information Promote with Fiber was a complete, balanced, very-high-protein, and fiber-fortified formula for residents that needed a higher proportion of calories from protein. It is ideal for residents with low caloric and/or wound-healing needs and those at risk for protein-energy [MEDICAL CONDITION] or pressure ulcers. The resident's laboratory report dated 4/22/13 recorded the resident's [MEDICATION NAME] at 2.5 grams/deciliter (gm/dl) (normal reference range 3.5-5.7 g/dl), total serum protein at 6.1 gm/dl (normal reference range 6.4-8.9 gm/dl), and [MEDICATION NAME] at 12 gm/dl (normal reference range 17-34 gm/dl). A Nutritional assessment dated and signed by a Registered Dietician on 4/25/13 included the resident received Promote with fiber at 70 cc's per hour, the resident had a wound on his/her sacrum, the resident's [MEDICATION NAME] was at 12 which indicated the resident had depleting visceral protein stores. The dietician recommended to add a multivitamin with minerals each day to promote wound healing. A physician's orders [REDACTED]. A physician's orders [REDACTED].M. included for the resident to wear the immobilizer for the next 3 weeks. A physician's orders [REDACTED].M. included for staff to check the skin integrity of the resident's shoulder every shift secondary to immobilization, and for the resident to wear heel float boots at all times. The resident's May 2013 Treatment Administration Record (TAR) from 5/1/13 to 5/20/13 included staff released the resident's right immobilizer, and checked the resident's skin integrity each shift. The TAR also included the resident wore heel float boots at all times and staff checked the integrity of the resident's skin each shift. Review of the TAR revealed staff released the immobilizer each shift, the resident wore heel float boots at all times and staff checked the resident's skin integrity as mentioned above. However, review of the resident's clinical record did not support the facility documented the results of the skin integrity check. The above represents the facility did not discontinue the immobilizer as physician order [REDACTED]. The resident's May 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further review revealed the resident received the Promote Fiber at 70 cc's per hour from 5/1/13 to 5/12/13. The MAR indicated [REDACTED]. The resident's weekly pressure ulcer assessment dated [DATE] documented the resident had a Stage 3 pressure ulcer on his/her coccyx that measured 0.8 cm by 2.2 cm with a depth of 0.4 cm, the wound base was red and yellow in color, the wound base contained slough and granulation tissue, a small amount of serous (colorless) drainage, and healthy surrounding skin. The assessment included the current treatment was Santyl (ointment used to remove dead/non-viable tissue) and [MEDICATION NAME]. Review of the resident's clinical record lacked evidence to support the facility performed an assessment of the resident's Stage 3 coccyx pressure ulcer from 4/20/13 until 5/2/13 (duration of 11 days). The resident's weekly pressure ulcer assessment dated [DATE] documented the Stage 3 pressure ulcer on the resident's coccyx measured 4.2 cm by 2.2 cm with a depth of 0.4 cm (a increase in the size of the pressure ulcer), the wound base was red in color, the wound base contained slough and granulation tissue, a small amount of serous drainage, and inflamed healthy tissue. The assessment included the current treatment was Santyl and [MEDICATION NAME]. An additional narrative note on the 5/2/13 pressure ulcer assessment included the resident transferred out to the hospital. Review of the resident's clinical record revealed on 4/29/13 the facility transferred the resident to a local emergency room for evaluation of the pacemaker site, and the resident returned to the facility after an x-ray of the site was performed on 4/29/13. The clinical record did not support the resident was out of the facility for an extended amount of time. The resident's weekly pressure ulcer assessment dated [DATE] documented the Stage 3 on the resident's coccyx measured 4.2 cm by 2.2 cm and no depth recorded. The assessment included the wound bed was red and yellow, contained slough and granulation tissue, the wound edges were not healing, had a small amount of serosanguinous drainage, and the surrounding skin was inflamed. The assessment included the current treatment was Santyl with [MEDICATION NAME] with no change in the response to the treatment. The resident's weekly pressure ulcer assessment dated [DATE] documented the wound bed of the Stage 3 pressure ulcer on the resident's coccyx was red and yellow in color, contained slough and granulation tissue, had a small amount of sanguineous drainage, the wound edges were non-healing and the wound and the surrounding skin was healthy. The assessment included the current treatment was Santyl with [MEDICATION NAME] with no change in response to the treatment. The assessment did not include the measurement of the Stage 3 pressure ulcer. The resident's weekly pressure ulcer assessment dated [DATE] documented the Stage 3 on the resident's coccyx measured 7 cm by 5.8 cm with a depth of .5 cm. The assessment included the wound base was gray and black, contained necrotic tissue (dead tissue), and a small amount of serous drainage.The wound edges were not healing, and the surround tissue was inflamed. The assessment included the current treatment was Santyl/[MEDICATION NAME], and the pressure ulcer deteriorated in response to treatment. The additional narrative notes included the new [DIAGNOSES REDACTED]. A nurse's note dated dated 5/3/13 and timed 4:00 P.M. included the facility ordered the resident a low air loss mattress, and the facility would receive the mattress sometime on 5/4/13. A nurse's note dated 5/14/13 and timed 8:00 P.M. documented the resident's coccyx area had an abrasive area to the right side, the area was open above with white edges.Staff continued to turn the resident every 2 hours when in bed, and staff also encouraged this severely cognitively impaired resident to lay down between meals. Review of the resident's clinical record lacked evidence the facility re-evaluated the pressure ulcer treatment, the resident's condition or the resident's care plan after the resident's coccyx pressure ulcer did not heal and got worse. An Administrative Information Form/Communication sheet dated 5/21/13 (time unknown) included the facility transferred the resident to a local hospital. A hospital's emergency room 's documentation dated 5/21/13 (time unknown) included the resident's chief complaint per the nursing facility was the resident was diaphoretic and ashy with shortness of air and increasing pain to his/her coccyx wound. The reason for the resident's visit to the hospital included resident had [MEDICAL CONDITION] of unclear source, fever, ARF (acute [MEDICAL CONDITION]), [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. A hospital's history and physical (H&P) signed and dated by a physician on 5/21/13 at 4:02 P.M. included the resident resided in a nursing facility, was found to be more diaphoretic, and no documentation of fever at the nursing facility; however, on arrival to the hospital the resident had a temperature of 102 degrees Fahrenheit (F). The H&P included the resident did not talk, moaned on examination, and had boots on his/her bilateral lower extremities. The H&P included the resident had a stage 3 to stage 4 pressure ulcer, the pressure ulcer was foul smelling with serosanguinous drainage and the resident's skin was clammy. The H&P included the resident was admitted to the hospital with [REDACTED]. A hospital wound care consultation progress note dated 5/22/13 and timed 5:23 P.M. documented the resident had a necrotic non-stageable pressure ulcer on his/her coccyx that measured 6.0 cm by 5.0 cm by 1.5 cm with 1.5 cm underminning at 12:00, odorous with gray necrotic tissue in the wound base and outer wound edges, and the pressure ulcer was present upon admission (poa). The note included upon admission the resident had a shallow stage 3 pressure ulcer on his/her left axilla area that measured 3 cm by 5 cm with no measurable depth, and with a small amount of [MEDICATION NAME]. The note included the resident wore PRAFO splints on his/her heels, upon admission the resident's left heel had a deep tissue injury, mushy purple tissue, that measured 1 cm by 2.0 cm. A consultation report dated 5/23/13 documented the resident's diagnostic impression included the resident had a necrotic sacral decubitus ulcer, the resident was too medically unstable for operative interventions at that time, and if the resident's medical condition stabilized the physician would consider surgical debridement. On 6/11/13 at approximately 2:20 P.M. nursing administrative staff E stated a licensed nurse assessed the resident's skin on a weekly basis and documented the appearance of any skin issues but did not stage or measure pressure sores. Nursing administrative staff E stated he/she staged and measured pressure sore on a weekly basis. Nursing administrative staff E stated the resident's pressure ulcer treatment from admission until transfer to the hospital on [DATE] included staff applied Santyl to the resident's coccyx pressure ulcer, and then covered the pressure ulcer with [MEDICATION NAME]. Nursing administrative staff E stated other than receiving an order for [REDACTED]. On 6/11/13 at approximately 2:30 P.M. nursing administrative staff D stated the resident was admitted with a Stage 3 coccyx pressure ulcer and wore an immobilizer on his/her right shoulder due to placement of a recent pacemaker. Nursing administrative staff D stated the immobilizer went under the resident's arms and was secured in place with Velcro. Nursing administrative staff D stated the immobilizer was in place when the facility transferred the resident to the emergency room . Nursing administrative staff D stated the resident's health declined, the pressure ulcer worsened and the facility obtained a physician's orders [REDACTED]. Nursing administrative staff D stated the facility was unable to reach the resident's family regarding the hospice consult, therefore, the facility transferred the resident to a local emergency room for evaluation. Nursing administrative staff D stated a day or so after the resident was admitted to the hospital, hospital staff contacted the facility with concerns regarding the pressure ulcer on the resident's left axilla upon admission to the hospital. Nursing administrative staff D stated the resident did not have a pressure ulcer on his/her left axilla when the facility transferred the resident to the hospital. On 6/11/13 at approximately 2:45 P.M. licensed nurse H stated upon admission to the facility the resident resided on a different unit, the facility transferred the resident to his/her unit sometimes after the first of May, 2013. Licensed nurse H stated when the resident arrived to his/her unit the resident had a pressure ulcer on his/her coccyx and the pressure ulcer measured less than 1 cm. Licensed nurse H stated on/or around 5/21/13 the pressure ulcer worsened, due to the rapid deterioration of the pressure ulcer, the facility received a telephone physician's orders [REDACTED]. Licensed nurse H stated the immobilizer was in place at the time the resident was transferred to the hospital. Licensed nurse H stated the resident did not have a pressure ulcer on his/her left axilla at the time of the transfer. Licensed nurse H stated the Promote with Fiber was not an item the facility routinely stocked, the facility had to special order the Promote with Fiber and there were several days the facility substituted Glucerna for the Promote. On 6/12/13 at approximately 9:00 A.M. licensed nurse I stated the resident was admitted to the facility with a small pressure ulcer on his/her coccyx. Licensed nurse I stated upon admission to the facility the resident had a pressure relieving mattress and approximately 2 weeks after the resident's admission, the facility placed the resident on a low air loss mattress. According to the Pressure Ulcer Prevention & Treatment clinical Practice Guideline developed by the National Pressure Ulcer Advisory Panel and the European Pressure Advisory Panel: if progress was not seen toward pressure ulcer healing within 2 weeks, the individual, the pressure ulcer and the plan of care should be re-evaluated; offer vitamin and mineral supplements when dietary intake is poor or deficiencies are confirmed or suspected. Support surfaces with additional features (e.g. low air loss...) may be needed with full thickness ulcers (Stage 3, 4 and unstageable). Turning schedules should be individualized based on tissue tolerance, resident's rights, and specific surface being used. Position the individual off of the area if the individual had a Stage 3, 4 and unstageable pressure ulcer. The facility's undated pressure ulcer policy and procedure included a program of preventions, care and treatment of [REDACTED]. If the pressure ulcer did not respond to treatment, the facility discussed with the resident's physician a change in treatment. For residents with a Stage 3 pressure ulcer the facility obtained a dietary consultant for dietary interventions. For residents with a Stage 2 pressure ulcer, the facility started obtained a physician's orders [REDACTED]. The facility failed to reevaluate the resident's care plan, and treatment in a timely manner after the resident's coccyx pressure ulcer did not show signs of healing, failed to timely implement the registered dietician's recommendation for this resident admitted to the facility with a pressure ulcer and the pressure ulcer worsened. - Review of resident #5's Physician order [REDACTED]. of HiCal a nutritional supplement three times a day for weight loss since 4/5/13, wore a Prevalon boot (pressure relieving device) boot on his/her left foot when in bed from 3/9/11 to 5/15/13; on 5/15/13 the resident wore a Prevalon boot on both feet, staff painted the resident's right heel with [MEDICATION NAME] and covered it with a foam dressing,and secured in place with Kerlix and tape.The dressing was changed twice a day and as needed since 5/15/13. The resident's quarterly Minimum Data Set (MDS)3.0 dated 4/19/13 identified the resident scored 3 (severely impaired cognition) on the Brief Interview for Mental Status, required extensive staff assistance with bed mobility, transfers, locomotion on/off the unit, dressing, toilet use, and personal hygiene, did not walk in the room/corridor, and required staff supervision with eating and set up. The MDS recorded the resident was always incontinent of urine and bowel, weighed 106 pounds, experienced a weight loss and was not on a physician prescribed weight loss regimen. The MDS coded the resident at risk for the development of a pressure ulcer, did not have a Stage 1 or higher pressure ulcers, had a pressure relief device on his/her chair and bed, and was on a turning/repositioning program. The resident's Pressure Ulcer Care Area assessment dated [DATE] included the resident was at risk for skin breakdown related to general debility and incontinence, wore a Prevalon boot on his/her left foot when in bed, and the resident required extensive to total staff assistance with activities of daily living, and repositioning, and had pommel cushion on his/herchair. The resident's care plan with a review date of 4/11/13 included the resident required maximum staff assistance of 2 staff at times, and wore a Prevalon boot on his/her left foot when in bed. The care plan included the resident experienced a weight loss an on 4/5/13. The facility started the resident on 90 cubic centimeters (cc's) of Hi Cal (nutritional supplement) three times a day between meals. The care plan included the resident an alteration in his/her skin integrity related to decreased mobility, staff turned and repositioned the resident every 2 hours to prevent pressure to the area. An entry dated 5/5/13 included the resident had an unstageable fluid filled blister on his/her right heel that was an unstageable pressure ulcer, and the facility placed foam boots on the resident's feet as the resident allowed. A Nutritional History/Assessment completed by a registered dietician on 3/16/13 documented the resident had variable intake of the FFP diet and had minimal depletion visceral protein stores. The resident's weight had significantly decreased in the last year and the dietician recommended health shakes three times a day in a further attempt to increase oral nutritional intake for healing and promotion of nutritional status. The dietician encouraged food intake greater than 50 percent (%) at all meals especially of increase protein foods and supplements. Review of the resident's clinical record did not support the facility followed up on the dietician's recommendation regarding the resident receiving health shakes three times a day until 4/5/13 (19 days after the recommendation). A laboratory report (date unknown) documented the resident's protein level at 4.9 grams/deciliter (gm/dl) (normal reference range 6.4-8.9 gm/dl) and the resident's [MEDICATION NAME] at 3.4 gm/dl (normal reference range 3.5-5.7 g/dl). A physician's orders [REDACTED]. Review of the resident's weights revealed the resident lost 16 pounds or 11.76 percent of his/her body weight from 1/17/13 to 5/13/13 and 16 pounds or 13.45% of his/her body weight from 1/7/13 to 5/27/13 and during that time the resident developed 2 facility acquired pressure ulcers on his/her right heel. The facility's weekly pressure ulcer tracking log dated 6/6/13 documented on 5/15/13 staff observed the resident had a fluid filled blister on the medial aspect of his/her right heel and on 6/6/13 the area was unstageable and measured 2.5 centimeters (cm) by 4.5 cm. Documentation revealed the pressure area was facility acquired. The facility's weekly pressure ulcer tracking log dated 6/6/13 documented on 5/29/13 staff observed the resident had a fluid filled blister on the lateral aspect of his/her right heel and on 6/6/13 the area was unstageable and measured 2.5 centimeters (cm) by 3.8 cm. Documentation revealed the pressure area was facility acquired. On 6/10/13 at 2:45 P.M. observation revealed the resident laid in bed on his/her back, and a pressure relieving device was on the resident's bed and in the resident's wheelchair. On 6/11/13 at 8:45 A.M., 9:00 A.M., 9:15 A.M., 9:30 A.M. 9:45 A.M., 10:00 A.M., 10:15 A.M., 10:30 A.M., 10:45 A.M., 10:55 A.M., and 11:00 A.M. the resident laid in his/her bed on his/her back ( a duration of 2 hours and 15 minutes). with no change in position. On 6/11/13 at 4:15 P.M. the resident laid in bed on his/her back. Direct care staff O removed the covers from the resident and observation revealed the resident's right foot was in a heel boot and no heel boot on the resident's left foot. Direct care staff O removed the heel boot from the resident's right foot, and transferred the resident from the bed to the wheelchair and placed an extended foot pedal under the resident's left foot. Direct care staff O propelled the resident from his/her room to the dining room, and the resident's right foot was in direct contact with floor. During interview with direct care O during that time, he/she stated the resident only wore a heel boot on his/her right foot. On 6/12/13 at 6:40 A.M. licensed nurse J stated the resident wore a heel boot on his/her left foot prior to the development of the pressure ulcer on his/her right heel, and after the development of the pressure ulcer on the resident's right heel, the facility discontinued the heel boot on the resident's left foot and now the resident wore a heel boot on his/her right foot. Licensed nurse J stated night shift staff dressed the resident and the day shift staff got the resident up. Licensed nurse J entered the resident's room, the resident laid in bed on his/her back, and observation revealed a heel boot in the resident's chair. Licensed nurse J removed the covers from the resident, and observation revealed the resident did not have heel boots on his/her left or right foot. Licensed nurse J stated night shift staff removed the heel boot when he/she dressed the resident. Further observation revealed the resident's left foot directly on top of the resident's right foot, no device between the resident's legs to prevent skin to skin contact, the right foot was covered with gauze, and no open areas on the resident left heel noted, a pillow was under the resident's legs but not positioned correctly to float the resident's heels, and the resident's right foot was in direct contact with the bed linens. On 6/12/13 at 6:54 A.M. direct care staff P stated he/she dressed the resident at approximately 5:30 A.M., and he/she removed the heel boot from the resident's right foot at that time. Observation revealed the resident's left foot directly on top of the resident's right foot, no device between the resident's legs to prevent skin to skin contact, the resident's right foot was covered with gauze, and the resident's right foot in direct contact with the linens. During interview with direct are staff P at that time, he/she stated the resident wore a heel boot on his/her right foot when in bed. On 6/12/13 at approximately 7:25 A.M., direct care staff Q entered the resident's room. Observation revealed the resident laid in bed on his/her back, without heel boots. On 6/12/13 at 3:30 P.M. licensed nurse K removed the dressing from the resident's right foot. Observation revealed the resident had an unstageable pressure ulcer on the lateral and medial aspect of his/her right heel that measured approximately 2.5 cm by 3.0 cm, respectively. Licensed nurse K cleansed the pressure ulcers, after cleansing the eshar on the lateral aspect of the resident's right heel, the eschar came off and there was not an open area under the eschar. The eshar on the resident's medial aspect of the resident's right heel remained. On 6/12/13 at approximately 3:50 P.M., administrative nursing staff D stated the unstageable pressure ulcers on the resident's right heel were facility acquired. Administrative nursing staff D prior to the development of the pressure ulcers on the resident's right heel, the resident wore a heel boot on his/her left foot, but not on his/her right foot. Administrative nursing staff D stated after the resident developed the facility acquired pressure ulcer on the medial aspect of his/her right heel, the facility obtained a physician's orders [REDACTED]. The facility's undated pressure ulcer policy and procedure included a program of preventions, care and treatment of [REDACTED]. If the pressure ulcer did not respond to treatment, the facility discussed with the resident's physician a change in treatment. For residents with a Stage 3 pressure ulcer the facility obtained a dietary consultant for dietary interventions. For residents with a Stage 2 pressure ulcer, the facility started obtained a physician's orders [REDACTED]. The facility failed to implement interventions in a timely manner regarding this resident at risk for the development of pressure ulcers, failed to timely implement the dietician recommendations, failed to ensure the resident wore the heel boots per physician order [REDACTED].

The facility had a census of 128 residents. The sample included 7 residents. Based upon observation, record review, staff, resident, and family interviews the facility failed to ensure that a resident did not develop a pressure ulcer, failed to promote the development of additional pressure ulcers and failed to promote the healing of pressure ulcers for 2 (#130, #160) of 2 residents sampled for pressure ulcers. Findings included: - The physician's orders [REDACTED]. The 6/9/11 telephone order revealed an added [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/27/11 revealed in a Brief Interview for Mental Status (BIMS) Staff Assessment that the resident had long/short term memory problems with moderately impaired cognitive skills for daily decision making; the resident required extensive assistance with one person physically assisting with bed mobility, transfer, walk in room/corridor, locomotion on/off unit, dressing and toilet use; limited assist with one person physical assist with eating; required physical help in part of bathing activity with one person physical assist; balance was not steady but able to stabilize without human assist for moving from surface to standing position, walking, moving on/off the toilet, and surface to surface transfers; had no impairment to the upper/lower extremities; did not use a mobility device; was on a urinary toilet program and had bowel and bladder incontinence; the skin assessment noted the resident was not at risk for developing a pressure ulcer; had no pressure ulcer prior to assessment; had no other ulcers, wounds or skin problems; skin and ulcer treatment consisted of pressure reducing devices for the chair and bed and application of ointments/medications other than to the feet. The Incontinence assessment dated [DATE] revealed the resident was cognitively impaired with arthritis and dementia and that during bladder urge was unable to control loss of urine. The quarterly Resident Risk for Pressure Ulcers dated 4/15/11 revealed a score of 15 indicating the resident was at risk, and there was no redness to the coccyx area. The quarterly Resident Risk for Pressure Ulcers dated 5/19/11 revealed a score of 18 indicating the resident was not at risk, and there was a red area on the coccyx, and the skin condition was warm and dry. The revised care plan dated 4/28/11 for Risk of Skin Impairment recorded the staff performed weekly skin assessments; provided pressure relieving devices; provided incontinent care as needed following incontinence; applied moisture barrier cream for prevention; encouraged adequate fluids and nutrition; provided showers biweekly and as needed (PRN); notified the doctor and family of any change in resident status; performed a pressure ulcer risk assessment quarterly; and monitored for yeast in the groin area and treated as ordered. The Skin Impairment care plan lacked documentation of what pressure relieving devices the facility used for this resident. The revised care plan dated 4/28/11 for Care Deficit revealed that the staff checked the resident approximately every 2 hours during rounds; assisted the resident with dressing, transfers, hygiene, oral care, and toileting/pericare; monitored skin for breakdown such as redness, warmth, rash, bruising, skin tears, and decubitus ulcers during the Activity of Daily Living (ADL) cares, and reported to the doctor, charge nurse, and wound nurse. The routine Treatment Administration Record (TAR) for May 2011 lacked documentation of the resident's weekly skin assessments for 3 out of the 4 weeks of 5/4/11, 5/11/11, and 5/24/11. Observation on 6/7/11 at 2:57 P.M. showed the resident laid in bed on his/her left side. There was an anti-static mattress on the bed. The resident did not use a wheelchair and had no other pressure relieving devices. Observation on 6/7/11 at 3:14 P.M. showed the resident walked in the hallway unassisted holding up sweat pants and wearing non-skid socks. Observation on 6/7/11 at 3:15 P.M. showed the resident received a shower by Direct Care Staff A. The resident verbalized discomfort during the shower when staff washed and dried the coccyx area. When the resident stood up, this writer noted that the coccyx area was red with 3-4 open areas approximately the size of a pea. Staff applied periguard ointment and after dressing the resident, assisted him/her to an upright chair in the lounge area. Direct care staff A stated he/she saw the open areas in the coccyx and said they were not present when he/she gave the resident a bath several days before. The Bath Aide Skin Integrity Sheet dated 6/7/11 lacked documentation of open areas on the coccyx that this writer observed during the resident's shower on 6/7/11. The 3/15/11 Nurses Notes revealed the skin assessment noted the reddened peri area, and staff received a new order to apply a moisture barrier cream every shift and as needed for each incontinence episode. During an observation on 6/8/11 at 9:19 A.M. the resident ambulated into the bathroom with Direct Care Staff B who provided post toileting pericare, applied periguard to the coccyx area, and assisted the resident into bed to lay on the right side. Staff interview on 6/7/11 with Licensed Nursing Staff A at 4:16 P.M. who stated the staff checked on the resident every 2 hours for toileting and for dryness. Staff A also stated he/she did not know why the care plan referred to pressure relieving devices as the resident did not use any and could turn him/herself. Staff A said the clinical director and the unit manager were responsible for updating the care plans. Staff interview on 6/7/11 at 4:42 P.M. with Direct Care Staff A who stated that he/she checked the ADL book for information on the care of the residents assigned to him/her; and that Licensed Nursing Staff B updated the ADL book. Staff A stated if he/she noted any change in the resident, he/she informed the charge nurse. Staff interview on 6/8/11 at 7:06 A.M. with Direct Care Staff C who stated that they checked the resident at 11:00 P.M., 1:00 A.M. and 3:00 A.M. during night shift. At that time staff C checked and changed the resident as needed, and that they received a report on the resident care/needs from the charge nurse. Staff interview on 6/8/11 at 10:00 A.M. with Licensed Nursing Staff D who stated he/she was not aware the resident had open areas on the coccyx, that they did not receive a report from Direct Care Staff A concerning open areas observed during the resident ' s shower on 6/7/11. Staff interview on 6/8/11 at 2:00 P.M. with Licensed Nursing Staff D who stated they looked at the resident ' s coccyx area, saw some small openings and called the physician for an order for [REDACTED]. Staff interview on 6/8/11 at 2:00 P.M. with Licensed Nursing Staff B who stated that he/she did not have documentation for tracking repositioning/every 2 hour check of the residents, that he/she used the Nursing Rehabilitative Restorative Care Program sheet to monitor resident checks. Licensed staff B said the direct care staff providing the resident ' s shower should provide the nurse with a 'Bath Aide Skin Integrity Sheet' if he/she noted a skin problem. Staff B said the nurses initialed the TAR when they performed the weekly skin assessment. The nurse documented the skin findings/lack of findings on the Resident Skin Assessment form. The undated facility's policy and procedure for Pressure Ulcers revealed that the nursing assistants would complete a body check on shower days and report findings to the charge nurse; that a licensed nurse assessed each resident's skin condition weekly and documented on the Resident Skin Assessment form. The facility failed to monitor and assess this resident ' s skin who had open areas on the coccyx. - Review of resident #160's May 2011 Physician order [REDACTED]. The resident's quarterly Minimum Data Set 3.0 with an assessment reference date of 5/12/11 identified the resident scored 10 on the Brief Interview for Mental Status (a score of 10 identified the resident had mildly impaired cognition), did not exhibit behaviors, totally dependent upon staff for bed mobility, transferring, walking in the room and corridor, toilet use and locomotion on and off the unit. The assessment recorded the resident required extensive staff assistance with dressing and personal hygiene, frequently incontinent of bladder and occasionally incontinent of bowel, at risk for the development of pressure ulcers, did not have any pressure ulcers, utilized a pressure relieving device for the wheelchair and bed and on a turning/repositioning program. The resident's care plan dated 5/11 documented the resident required staff assistance with the completion of activities of daily living secondary to dementia, staff monitored the resident for skin breakdown and "decubitus ulcer" during activities of daily living (ADLs) cares, the resident at risk for skin impairment related to decreased bed mobility, required extensive staff assistance and utilized a pressure relieving device in the wheelchair and bed. The care plan documented the resident had a Stage II pressure ulcer to his/her to coccyx, staff applied [MEDICATION NAME] ointment and turned and repositioned the resident on rounds at least every 2-3 hours, and checked and changed the resident every 2 hours. The resident's Resident Assessment Protocol for Pressure (RAP) Ulcer Worksheet dated 9/3/10 included interventions/programs as pressure relieving devices for the chair/bed and turning/repositioning. The documentation included the resident required extensive staff assistance with bed mobility and able to assist staff by holding to the side rails of the bed. A risk for pressure ulcers assessment completed May of 2011 (no date or time) identified the resident scored a 15 and according to the legend a total score of 16 or below deemed the resident at risk for pressure ulcers and the facility should implement a plan of care). An entry on the assessment documented the resident had a wound on the top of his/her gluteal fold, slightly shallow with the top layer missing, the interior was flat, shiny and pink. Review of the resident's wound progress note documented on 5/11/11 staff observed the resident had a Stage II on his/her coccyx that measured 0.6 centimeters (cm) by 1 centimeter (cm) by 0 cm. Other measurements on the wound progress notes are as follows: 5/17/11: Stage II coccyx pressure ulcer that measured 0.4 centimeters (cm) by 0.6 cm by 0 cm 5/24/11: Stage II coccyx pressure ulcer that measured 0.6 cm by 0.8 cm by 0.1 cm 5/31/11 Stage II coccyx pressure ulcer that measured 0.7 by 0.8 by 0.1 cm with 10 percent slough and 90 percent granulation tissue 6/9/11 Stage II coccyx pressure ulcer that measured 0.7 cm by 0.4 cm by 0.1 cm and a macerated peri-wound (maceration is caused by moisture). Review of the resident's monthly weights and vital signs documented the resident's weights as follows: 4/25/11: 205 pounds 5/02/11: 202 pounds 5/10/11: 193 pounds 5/16/11: 194 pounds 5/31/11: 190 pounds 6/6/11: 189 pounds The above represented the resident lost 16 pounds or 7.80 percent in less than 3 months (a significant weight loss). During this time frame the resident developed a Stage II pressure ulcer on his/her coccyx. Review of the facility's pressure ulcer log identified the Stage II pressure ulcer as facility acquired and treatment/change included staff would frequently change the resident's seating from the wheelchair to recliner to the bed. On 6/8/11 at 7:15 A.M. direct care staff J transferred the resident from the wheelchair to the toilet via a mechanical lift. Observation revealed the resident had a white area on his/her coccyx that measured approximately 1 cm by .5 cm. On 6/8/11 at 7:30 A.M. direct care staff J transferred the resident from the toilet to the wheelchair and wheeled the resident to breakfast. On 6/8/11 at 7:45 A.M. the resident sat in the wheelchair eating the breakfast meal at the dining room table. Observation revealed the resident sat in the wheelchair in the dining room at 8:00 A.M., 8:15 A.M., 8:30 A.M. and 8:40 A.M. On 6/8/11 observation revealed the resident sat in the wheelchair in his/her room at 8:45 A.M., 9:00 A.M., 9:05 A.M., 9:10 A.M. and 9:15 A.M. On 6/8/11 at 9:20 A.M. staff wheeled the resident upstairs to the therapy room. At 9:30 A.M., 9:45 A.M., 10:00 A.M., 10:15 A.M. the resident sat in the wheelchair in the therapy room. At 10:30 A.M. therapy staff A wheeled the resident from the therapy room to a cooking class on the 1st floor. The resident sat in the wheelchair in the cooking class at 10:45 A.M. and at 10:50 A.M. staff wheeled the resident from the cooking class to his/her room. During interview with therapy staff A on 6/8/11 at 10:30 A.M. the staff reported that he/she repositioned the resident prior to therapy if the resident was not sitting straight in the wheelchair. The staff further reported that he/she did not reposition the resident prior to therapy on 6/8/11. On 6/8/11 the resident sat in the wheelchair in his/her room at 11:00 A.M. and 11:15 A.M. On 6/8/11 at 12 noon and 12:10 P.M. revealed the resident sat in the wheelchair at the dining room table. During interview with direct care staff J on 6/8/11 at 11:10 A.M. the staff reported the resident not on a turning/repositioning program. The staff also reported that he/she had not repositioned the resident since placing the resident in the wheelchair at 7:30 A.M. The staff reported the resident activated the call light when he/she needed to go to the bathroom. During interview with the resident on 6/8/11 at 11:15 A.M. the resident reported that he/she did not reposition himself/herself and most of the time just sat in the wheelchair. During interview with a family member on 6/8/11 at 2:30 P.M. the individual reported the resident sat in the wheelchair all day and that he/she asked the facility to allow the resident to sit in the recliner when not attending activities but the facility continued to allow the resident to sit in the wheelchair all day. During interview with licensed staff B on 6/8/11 at 2:50 P.M. regarding the resident's turning/repositioning program the staff reported the resident activated the call light every 2 to 3 hours to go to the bathroom and that was considered a turning/repositioning program. The facility failed to implement a turning/repositioning program for this resident at risk for pressure ulcer development as care planned.

The facility recorded a census of 134 residents. The sample included 3 residents. The facility identified 9 residents as having pressure sores of which the sample included 1 resident. Based on observation, interview and record review the facility failed to implement the treatments as ordered by the physician for 1 resident (#1). Findings included: - Resident #1 ' s Physician order [REDACTED]. The admission Minimum Data Set 2.0 (MDS) assessment dated [DATE], documented the resident had short and long term memory problems, moderately impaired decision making skills. The resident ' s mood patterns consisted of persistent anger up to 5 days per week that included repetitive anxious complaints, sad appearance and withdrawn from activities of interest daily that was not easily altered. The resident ' s behavior consisted of resisting care that was not easily altered 1-3 days in the last 7 days. The resident requires extensive assist on 2 staff with bed mobility, transfers, toilet use, extensive assist on 1 staff with dressing and personal hygiene, and totally dependent on 1 staff with eating. The resident was incontinent of bowel and had a Foley catheter. The resident had moderate pain less than daily. The MDS further documented the resident with an end stage disease and feeding tube. The section for pressure ulcers lacked documentation related to the resident ' s pressure ulcers. The Resident Assessment Protocols (RAPs) dated 6/28/10, documented that the resident was at risk for pressure ulcers due to the resident requiring extensive assist with bed mobility. The resident spends most of his/her time in bed, has a terminal prognosis, and frequently incontinent of bowels. The admission care plan dated 6/15/10 documented the resident had a pressure sore and the following interventions were in place: treatment of [REDACTED]. The preventative measures included hospice care, an air mattress, a wound nurse and the staff should report to charge nurse any redness or skin breakdown immediately. The care plan dated 6/27/10 documented the resident at risk for skin impairment related to a medial back wound, areas on both heels reddened, a terminal prognosis, decreased mobility, and incontinence. The following interventions were in place: a weekly skin assessments; pressure relief devices that included a wheelchair (w/c) cushion/foam boots/ low or alternating pressure air mattress, to turn and reposition the resident on rounds (at least every 2-3 hours), incontinent care as needed following episodes of incontinence, moisture barrier ointment for preventative skin care, encourage the resident to have adequate nutritional and fluids, biweekly showers and as needed, notify the physician of any changes in resident status, notify the resident ' s family of any changes in resident ' s status, document the pressure risk assessment quarterly, and notify hospice of any changes. The resident was admitted to hospice services for the [DIAGNOSES REDACTED]. Review of the resident ' s medical record contained the hospital ' s discharge records. In the hospitals discharge records a progress note dated 6/8/10 by the wound team revealed the following documentation: Patient was seen regarding two pressure wounds at mid-spine. The proximal (nearest) wound is a healing Stage II pressure wound measuring 0.3 cm (centimeters) by 0.3 cm by 0.1 cm. The wound base is light pink with 10% yellow [MEDICATION NAME]. The periwound (surrounding area) intact with minimal amount of exudates (drainage) of serosanguineous (contains both serum and blood). The distal (farthest) wound is a Stage IV pressure wound measuring 1.5 cm by 1.0 cm by 0.7 cm with undermining of 6.0 cm. The visible wound base is medium red and moist with moderate amount serosanguineous exudates noted on the removed dressing and not odor noted. The periwound had blanchable [DIAGNOSES REDACTED] (redness) extending 4.0 cm. The recommendation was to continue with [MEDICATION NAME] Gel (medication effective against a broad spectrum of bacteria and fungi) to both wound bases and the distal wound is to be gently packed with a plain packing strip, follow with a foam dressing. The entire dressing is to be changed daily by staff. The hospital ' s wound team progress note dated 6/15/10 documented that the proximal wound is healed and all tissue is intact. The distal wound remains a Stage IV pressure wound measuring 1.0 cm by 1.0 cm and 0.5 cm with undermining at the 12:00 site measuring 7.0 cm. The visible wound base is red and moist. The periwound is intact with moderate amount of serosanguineous exudates noted on the removed dressing with no odor noted. The recommendation was to continue the [MEDICATION NAME] Gel to the wound base, followed by gentle packed plain packing strip, the cover with foam dressing and secure with tape. The dressing is to be changed daily and as needed due to saturation. Review of the facility medical record revealed an undated, unsigned hand written report note taken from a nurse at the hospital where the resident was being discharged from. This hand written note documented that the resident had a Stage IV pressure ulcer on the upper back. The treatment included to use packing tape, [MEDICATION NAME] and cover with spongy tape. Licensed nursing staff B acknowledged on 9/14/10 at 2:45 P.M. that the hand written report was written prior to admission on 6/15/10 and that the report did document that the resident had packing in his/her wound. The resident was admitted to this facility on 6/15/10 with orders for hospice care. The nurses notes dated 6/15/10 documented the resident admitted with a stage 4 wound on the mid back with dressing intact. The resident also had a stage II bed sore to both Achilles and heels and wearing foam boots. Review of the facility ' s treatment administration record (TAR) dated 6/15/10 an order for [REDACTED]. Review of the hospice interdisciplinary progress notes dated 6/15/10 documented that the Stage II and Stage IV wounds on the resident ' s back were not visualized by the hospice nurse due to the resident not wanting the dressing removed since it was just replaced at the hospital. The hospice skin assessment form dated 6/15/10 documented the distal pressure ulcer a Stage IV wound that measured 1.0 cm by 1.5 cm with 4.5 cm tunneling. The distal wound dressing included to pack with one inch packing strip moistened with [MEDICATION NAME], cover with foam and tape in place. The nurse ' s notes dated 6/16/10 at 6:30 P.M. documented that the hospice wound nurse to evaluate all of the resident ' s wounds. The hospice interdisciplinary progress note dated 6/17/10 documented a wound at mid back along the spine area with open area measuring 1.5 cm by 1 cm by 0.2 cm. The hospice nurse noted pale tan slough tissue at the wound base with a large amount serosanguineous drainage coming from the wound. The periwound wound was angry red and warm to touch. The redness extends 16 cm circular around the wound. This area was tender to touch. The physician telephone order dated 6/17/10, written by the hospice wound nurse, revealed an order for [REDACTED]. and/or as needed. No documentation related to the packing in the resident ' s wound. The resident ' s Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. and to finish June 27th at 12:00 noon. The MAR indicated [REDACTED]. The Resident Data Set (monthly charting) dated 7/18/10 documented the resident remains on hospice for palliative care for terminal prognoses of the head/[MEDICAL CONDITION]. The resident refused to get out of his/her bed. The resident requires assistance with all bed mobility, requires extensive assist of 1 with all activities of daily living (ADLs). The resident continues to have a draining Stage II wound to mid spine with little changes and continues to see the hospice wound nurse for management of the wound. Review of the physician orders [REDACTED]. The laboratory results of the wound culture dated 7/23/10 revealed a growth of [MEDICAL CONDITION] (MRSA). The physician ' s telephone order dated 7/23/10 at 1:45 P.M. revealed an order for [REDACTED]. Review of the July 2010 MAR indicated [REDACTED]. The medication [MEDICATION NAME] started on 7/26/10 and only 3 doses of the medication were given. No further follow up on the wound culture was documented. Review of the wound progress report documented by licensed nursing staff C revealed that the pressure ulcer measured 1.2 cm by 1.0 cm by 0.1 cm with moderate drainage on 7/21/10. On 7/26/10 and 8/4/10 the documentation revealed no changes in the size of the wound and continued to have moderate serosanguineous drainage. On 9/15/10 at 10:50 A.M. licensed nursing staff A revealed that this facility does not do a repeat culture of wounds after antibiotic therapy is finished. On 9/15/10 at 11:05 A.M. licensed nursing staff C revealed that he/she did a weekly wound assessment and never observed any packing in the wound. Licensed nursing staff C revealed that the hospice nurse also did a weekly wound assessment and never reported any packing observed in the resident ' s wound. Licensed nursing staff did read the admission papers and read about the packing but did not follow up on this since the hospice was managing the wound care treatments. The revised 4/04 facility policy " Pressure Ulcer Monitoring System " instructions included: 1) Upon detection of a pressure ulcer, (in-house developed, admitted or readmitted with), the licensed nurse will: a) Perform a complete assessment of the pressure ulcer. b) Alert the physician to the formation of the pressure ulcers assessment and obtain an order for [REDACTED]. c) Complete all sections of a patient ' s individual decubitus report. d) Document the pressure ulcer identified on the weekly pressure ulcer report. e) The licensed nurse will make an entry in the progress notes with regard to the wound and describe all areas. 2) On a weekly basis the designee will: a) Assess the pressure ulcer and documentation on a weekly basis. b) Provide assurance that the primary physician has been alerted to the following: i. Ulcers that do not appear to respond to treatment or do not improve. ii. Ulcers that worsen in condition or increase in size. iii. Any resident complaints of increased pain or discomfort, or a decrease in mobility or functioning levels, and iv. Signs of [MEDICAL CONDITION], presence of exudates, odor or necrosis, if not already noted by physician. 3) The following should be included in the nurse ' s documentation assessment on the resident ' s decubitus report: a) Location of the ulcer b) Size and depth of the ulcer (if greater than a Stage 2) c) Description of the ulcer d) Drainage from the ulcer (color, consistency and odor) e) Necrosis of ulcer f) The ulcer ' s response to treatment The undated facility policy " Medicaid Hospice Services " documented that the nursing facility and hospice must ensure that the coordinated plan of care reflects the participation of the hospice, the nursing facility and the resident. The undated facility policy " Administration of Medication " documented that a physician and/or nurse practitioner ' s medication order should include the dosage, the route, the frequency, the duration and other required considerations that are required for the administration of the medications. The 2009 International Guideline treatment of [REDACTED]. 1) Assess the pressure ulcer initially and re-assess the wound at least weekly, documenting the findings. 2) Assess and accurately document the physical characteristics such as location, Category/Stage, size, tissue types, wound bed and periwound condition, wound edges, sinus tracts, undermining, tunneling, exudates, necrotic tissue, odor, presence/absence of granulation tissue and [MEDICATION NAME]. The facility failed to provide the necessary treatment and services to promote healing and prevent infection for this resident related to not accurately assessing the pressure ulcer which contained packing that had been undetected for an undetermined amount of time, not providing the antibiotics on two different occasions as ordered by the physician and not re-assessing the infection of the wound after the antibiotic therapy had been finished. The resident was transferred to another facility on 8/11/10 per family ' s choice and continued with hospice services. The new facility assumed the wound care treatments. On 8/30/10 during wound care, the new facility nurse found a undetermined amount of wound packing under the edge of the wound. The new facility had no knowledge that the resident had any packing in his/her pressure ulcer.

The facility identified a census of 127 residents with 21 residents sampled. Based on observation, interview, and record review with facility failed to ensure staff implemented appropriate interventions, care, and treatment for 1 of 3 residents reviewed to prevent the development of an unavoidable unstageable pressure ulcer. (#154) Findings included: - The facility admitted resident #154 on 9/22/09, with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) 2.0 assessment dated [DATE], recorded the resident with long-term memory impairment, modified independence with decision-making, required extensive assistance of staff for bed mobility, dressing, eating, personal hygiene, total assistance of staff for toileting, bathing and staff implemented to use of a mechanical lift for transfers. This same MDS recorded the resident with two, stage-1 pressure ulcers. The Resident Assessment Protocol (RAPs) summary dated 10/6/09, recorded the resident as wheelchair bound, requiring extensive to total assistance for all activities of daily living including transfers and bed mobility, and contractures of his/her extremities. This summary documented the resident with two stage 1 reddened areas, one on the ankle, one on the buttocks, received skin preventative care to the areas, and had the potential for additional skin breakdown. Further review of the clinical record lacked documentation of the existence of a pressure ulcer on the resident's left heel. Review of the Nursing Pressure Risk Assessments documented the following information: -On 9/22/09 a score of 14 -On 11/6/09 a score of 14 -On 12/11/10 a score of 12 -On 1/11/10 a score 13 The Nursing Pressure Risk Assessment form indicated a score of 16 or less identified the resident at risk for pressure ulcers. The resident's plan of care dated 12/30/09 directed staff to perform: -weekly skin assessments -turn and reposition the resident on rounds at least every 2-3 hours -apply pressure relief devices that included wheelchair cushion, foam boots, low or alternating pressure air mattress -encourage adequate fluids and nutrition -moisture barrier ointment for preventative -perform a pressure risk assessment quarterly -notify the physician of any change in the resident's status -nutritional supplement as ordered -Registered Dietician to assess as needed -diet as ordered A dietary assessment review dated 9/24/09, recorded lab values dated 9/23/09: a low [MEDICATION NAME] of 2.5 grams/deciliter (g/dL) (normal 3.5-5.7 g/dL), low hemoglobin of 8.4 g/dL (normal 14-18 g/dL), low hematocrit of 26.2% (normal 42-52%), and a weight of 143 pounds. The dietary assessment further documented the resident at nutritional risk due to the [DIAGNOSES REDACTED]. Review of a facility transfer record documentation to an acute care hospital on [DATE] recorded a dark bruise on the posterior portion of the resident's left heel. The resident's clinical record lacked documentation of a measurement or size of the wound. Review of the clinical record revealed a hospital transfer form dated 11/6/09 and recorded the resident was readmitted to the facility and a physician order [REDACTED]. heel. Review of a skin assessment dated [DATE], documented " bilateral heels have discoloration from previous pressure areas " . Review of a skin assessment dated [DATE], documented " no pressure areas noted, skin prep applied twice daily to bilateral heels at site of previous areas " . Review of a skin assessment dated [DATE] at 9:00 A.M., recorded " an area on the resident ' s left heel approximately 3 inches long by 1 inch wide, covered with black eschar " . Review of the resident ' s clinical record revealed the resident in an acute hospital from 12/7/09 to 12/11/09. Review of hospital physician ' s history and physical dated 12/7/09, documented the resident with severe [MEDICAL CONDITION]. Review of an acute care hospital consultation dated 12/9/09; recorded wound recommendations to the resident's pressure ulcers on the left plantar heel with a non-stageable pressure ulcer covered with eschar at an increased risk for skin breakdown and impaired wound healing due to immobility, pressure, poor nutritional status and decreased tissue perfusion. Hospital laboratory results dated [DATE] recorded a low hemoglobin of 8.6, low hematocrit of 25L, low sodium of 135 milliequivalent per liter (mEq/L)(normal 136-144 mEq/L), low potassium 3.4 (normal 3.6-5.1 mEq/L), low calcium 7.4 (8.4-10.2 milligram/deciliter), and low magnesium 1.7 (1.8-2.5 milligram/deciliter). During an interview on 1/19/10 at 4:00 P.M., licensed nursing staff B acknowledged the physician ' s documentation of a pressure ulcer to the resident ' s left heel. Review of the physician orders [REDACTED]. Review of a skin assessment dated [DATE], recorded an abrasion to the bottom of the resident's left heel that measured 2 centimeters (cm) by 1.5 cm. Review of the next documentation recorded on 12/30/09, recorded the left heel wound measured 2 ? inches long by 1 inch wide, with a dry, dark brown flat surface. Review of a dietary readmission assessment dated [DATE], recorded the resident with a weight of 121 pounds, with documentation the resident received a fortified food plan and a can of Glucerna supplement twice daily and observation revealed the resident received these recommendations. Review of the next recorded skin assessment dated [DATE], recorded a " left heel pressure ulcer 2 inches wide and 1 inches in length " . Review of a skin assessment dated [DATE] recorded a " left heel ulcer, unstageable at this time, heel is black " . Observation on 1/14/10 at 10:45 A.M. revealed the resident lay on an air mattress in bed with Prafo boots on both feet. The resident's left heel covered by a sock, under which a soft [MEDICATION NAME] dressing covered with tape, covered the wound. Licensed nursing staff F removed the dressing that contained a small amount of gray exudate and revealed an area 4.5 centimeters (cm) long by 1.8 cm in width and the surface covered with black eschar. Staff cleansed the wound with soap and water, let the area air- dry and then applied skin prep to the surface. The resident flinched and grimaced with the application of the skin prep. Licensed nursing staff A then questioned the resident about his/her pain with the procedure. Review of staff documentation of the wound treatment on 1/14/10 as follows, " left heel, edges soft with scant serosanguineous drainage, measured 4.5 cm by 1.8 cm, brown eschar, unstageable, unable to see the wound bed " . Interview 1/14/10 at 10:45 A.M., with licensed nursing staff A reported staff perform wound measurements every Thursday and them on the skin assessment treatment forms. The clinical record lacked documentation of consistent weekly documentation and measurements of the resident's wound. Interview on 1/14/10 at 2:00 P.M., with licensed nursing staff E revealed the resident received pain medication for his/her complaints of pain and grimaces or signs of pain with wound treatments. The facility provided policy for Pressure Ulcer Monitoring System, dated 4/04, directed upon detection of a pressure ulcer, (in-house developed, admitted or readmitted with), the licensed nurse will: a) perform a complete assessment of the pressure ulcer; b) alert the physician to the formation of the pressure ulcers, the assessment, and obtain an order for [REDACTED]. On a weekly basis, the Director of Nursing or designee will: a) assess the pressure ulcer and documentation on a weekly basis; b) provide assurance that the primary physician has been alerted to the following: 1) ulcers that do not appear to respond to treatment or do not improve. 2) Ulcers that worsen in condition or increase in size. The nurse obtaining any orders for a change of treatment will update the " treatment change " portion of the weekly pressure record to maintain the current treatment plan. The following should be included in the nurse ' s documented assessment on the resident's decubitus report: a) location of ulcer; b) size and depth of ulcer (if greater than Stage 2); c) description of the ulcer; d) drainage from the ulcer (i.e., color, consistency and odor.); e) necrosis of ulcer; f) the ulcer ' s response to treatment; g) how the ulcer is affecting the resident (i.e., pain, discomfort, loss of body image, etc); and what steps are being taken (i.e., pain medication, social service interaction. The clinical record lacked evidence to show staff accurately and consistently assessed this resident's skin integrity as per the facility policy, and the residents individualized comprehensive care plan. The clinical record further lacked evidence to demonstrate facility staff appropriately identified the presence of this resident's pressure ulcer. The facility failed to ensure this physically dependent resident at risk for pressure ulcer development did not develop a facility acquired unavoidable unstageable pressure ulcer.