Every finding on record at Sherbrooke Village

Based on observation, interview and record review, the facility failed to provide reasonable accommodation or intervention for pain management for two of two residents (Residents #118 and #2). One resident had uncontrolled pain for 20-hours after being discharged from a local hospital with a pelvic fracture. The facility did not administer any pharmacological or non-pharmacological approaches for pain control. The facility nurse did not try to get orders for pain medication from the on-call provider (Resident #118). Facility staff also failed to provide pain control interventions for one resident during a wound treatment (Resident #2). The sample was 24. The census was 121. Review of the facility's Pain Management policy dated 11/22, showed:-Policy: The Facility will use a systematic approach to Pain Management; Recognition, Evaluation, Treatment, & Monitoring of Pain. Individuals experiencing Pain may receive Pharmacological/Non-Pharmacological Interventions to assist in Pain Management. The Facility will provide Employees Education on Pain Management & Opioid Overdose.- Responsibility: Nursing personnel (Registered Nurse (RNs) and Licensed Practical Nurses (LPNs), Nursing Administration, Assistant Director of Nursing (ADON) and Director of Nursing (DON);-Procedure: Recognition: Evaluate/Prevent:-Recognize when Resident is experiencing Pain & Identify circumstances when Pain can be anticipated;-Evaluate Resident for Pain on admission and Routine Evaluations;-Manage/Prevent Pain, consistent with the Comprehensive Evaluation and Plan of Care;-Current Professional Standards of Practice, & Resident's Goals/Preferences;Observation for nonverbal indicators:-- Negative Vocalization (e.g., groaning, crying, whimpering, screaming);--Skin Conditions;-Verbal descriptors:--Hurting/Aching;--Burning;--Spasms;--Soreness, Tenderness, Discomfort, Pins, Needles;-Pain Evaluation: Nursing will complete a Pain Evaluation Tool, appropriate for the resident's cognitive status, to assist with evaluation of a resident's pain;-Evaluation of Pain by the Licensed Nurse or Medical Provider;--History of Pain & Treatment:---Non-Pharmacological, Pharmacological, & Alternative Medicine (CAM) Treatment;---Response/Effective to Treatment;---Ask the Resident to Rate the Intensity of his/her pain using a numerical scale, verbal or visual descriptor that is appropriate and preferred by the resident;---Reviewing the resident's current medical conditions (e.g., pressure injuries, diabetes with neuropathic pain, immobility, infections, amputation, oral health conditions, CVA (cerebrovascular accident, stroke), venous and arterial ulcers, and multiple sclerosis chronic disease of the central nervous system));---Identifying Key Characteristics of Pain:---Duration;---Frequency;--Location;---Timing;---Pattern (e.g., constant, or intermittent);---Radiation;-Obtaining Descriptors of Pain (e.g., stabbing. aching, pressure, spasms);-Identifying activities, Resident care or treatment that precipitate or exacerbate pain and those that reduce or eliminate pain;-Impact of Pain on Activities of Daily Living (ADLs) (e.g., sleeping, social activities, physical activity and mobility, emotions, intimacy, appetite, and mood, etc.);--Current Prescribed Pain Medications, Dosage, Frequency, Treatments, & Modalities;-Pain Management & Treatment:--Based on the Evaluation, Nursing in collaboration with the Physician/Prescriber, other health care professionals, the resident and/or the resident's representative will develop, implement, monitor, and revise as necessary interventions to prevent/manage a resident's pain beginning at admission;- Factors Influencing Treatment:--Cause, location, & severity of pain;--Resident's medical condition;--Resident's current medications;-General principles for analgesics (pain medication):--Evaluate the resident's medical condition, current medication regimen, cause and severity of the pain and course of illness to determine the most appropriate analgesic for pain therapy;--Consider evidence-based practice tools to assist in the evaluation of the residents pain;--Consider administering medication routinely instead of as needed (PRN) or combining longer acting medications with PRN medications for breakthrough pain;--Utilize the most effective and least invasive route for analgesic administration (e.g., oral (PO), anal, topical (on the skin), injection (below skin), infusion pump and/or transdermal);--Use lower doses of medication initially and titrate slowly upward until comfort is achieved;--Reassess and adjust the medication dose to optimize the resident's pain relief while monitoring the effectiveness of the medication and work to minimize or manage side effects;--Review medical conditions which may require several analgesics and/or adjuvant medications; Documentation will clarify the rationale for a treatment regimen and acknowledge associated risks;--Opioids will be prescribed and dosed in accordance with current professional standards of practice and manufacturers' guidelines to optimize their effectiveness and minimize their adverse consequences;--Nursing will notify practitioner if the resident's pain is not controlled by the current treatment regimen. 1.Review of Resident #118's discharge hospital paperwork dated 3/16/26 at 12:44 P.M., showed:-The resident was admitted to hospital for small facture (Fx) in the pubic symphysis (part of the pelvis);-Diagnoses: Left groin pain, chronic bilateral low back pain, obesity. diabetes, closed Fx of pelvis, and intractable (difficult to resolve) pain;-Goals: Control pain, maximize quality of life, and minimize further functional decline;-Strategies:--Activity/exercise program recommendation;--Conservative stepwise pain medicine strategy with multi-disciplinary approach;--Recommend healthy lifestyle strategies and compensatory methods as needed. Review of the hospital's After Visit Summary sheet (AVS), dated 3/16/26 at 2:33 P.M., showed:-Take these medications;- Acetaminophen 500 milligrams (mg) tablet commonly known as: Tylenol, take two tablets (1,000 mg total) by mouth every (Q) six hours as needed for pain. Last time this was given: 650 mg on 3/16/26 at 10:53 A.M.;- Cyclobenzaprine 10 mg tablet commonly known as: Flexeril take one tablet (10 mg total) by mouth three times a day (TID) as needed for muscle spasms, for muscle spasms. Last time this was given: 10 mg on 3/16/26 at 9:32 A.M.;- Hydromorphone 2 mg tablet commonly known as: Dilaudid take one tablet (2 mg total) by mouth every three hours PRN for pain. Last time this was given was 3 mg on 3/16/26 at 12:56 P.M.;- Gabapentin 600 mg tablet commonly known as: Neurontin (treats nerve pain) take two tablets (1,200 mg total) by mouth three times a day. Last time this was given 1,200 mg on 3/16/26 at 9:32 A.M. Review of the nurse progress note dated 3/16/26 at 4:38 P.M., showed a note by RN GG: Resident arrived at facility today via ambulance accompanied by two Emergency Medical Services (EMS) workers. Resident is alert & oriented (A&O) x4 (person, place, time and situation), able to make needs known and able to understand others. Admitting diagnosis is left groin pain. Residents does have a pubic, sacral (triangle bone of the spine), and lumbar (vertebra/spine) (L5) fracture. The resident is continent of bowel and bladder. The history (Hx.) of hypothyroidism (thyroid gland fails to produce sufficient hormones, slowing the body's metabolism), fibromyalgia (chronic disorder characterized by widespread musculoskeletal pain, fatigue, sleep disturbances, and cognitive issue), chronic bilateral low back pain without sciatica (nerve), osteoporosis (weakened bones), deep vein thrombosis (DVT, red blood cells that block of the in the vein), groin pain, coronary artery disease (CAD, narrowing or blockage of the heart), stroke and diabetes. RN GG said medications were verified with in-house Nurse Practitioner (NP) T. The only new orders given was to make Protonix (treat stomach acid) twice a day (BID) instead of once a day. Another new order for albuterol sulfate HFA (prescription bronchodilator inhale) 90 micrograms (mcg) inhaler. Resident is currently in bed, no acute distress noted at this time. Review of the electronic physician's order sheet (ePOS) dated 3/2026, showed:-An order dated 3/17/26 at 2:00 P.M., Tylenol Extra Strength Oral Give 1000 mg by mouth pharmacy tablet 500 mg-An order dated 3/16/26 at 2:15 P.M., Hydromorphone HCI Oral Give one tablet by mouth pharmacy tablet 2 mg;-An order dated 3/16/26 at 2:15 P.M., Cyclobenzaprine HCI Oral tablet 10 mg;-An order dated 3/17/26 at 6:00 A.M., Gabapentin Tablet 600 mg. Review of the Medication Administration Record (MAR) dated 3/2026, showed:-Gabapentin Tablet 600 mg, Give 1200 mg by mouth three times a day for neuropathy (nerve damage), start date 3/17/26 6:00 A.M., discontinue date 3/19/26 8:34 A.M.; given one out of one time;-Cyclobenzaprine HCI Oral Tablet 10 mg, give 10 mg by mouth every eight hours as needed for muscle spasms, start date 3/16/26 at 2:15 P.M., discontinue date 3/19/26 at 8:34 A.M., not given on 3/16 or 3/17 as ordered;-Tylenol extra strength PO table 500 mg give 1,000 mg PO Q six hours as PRN for pain, start date 3/16/26 at 2:00 P.M., discontinue date 3/19/26 at 8:34 A.M.; medication not administered on 3/16 or 3/17;-Hydromorphone HCI PO tablet 2 mg, give one tablet PO Q three hours as PRN for pain, start date 3/16/26 at 1:56 P.M., discontinue date 3/19/26 at 8:34 A.M., medication not administered on 3/16 or 3/17. Review of the nurse progress note skilled evaluation on 3/16/26 at 9:20 P.M., showed: Resident's pain: pain Issue: #001: New. Location: Generalized. Pain score: 4 (on a scale of 1-10). Dull. Aching. Frequency: Intermittent. PRN medication provided. See MAR for details. Mood is pleasant, no unwanted behaviors witnessed. Resident sleeps through the night. Resident's psycho-spiritual needs are met. Review of the facility's Pain Level Summary dated 3/17/26 at 12:18 A.M., showed the resident's pain level was a 4 out of 10. Review of the facility's Pain Level Summary dated 3/17/26 at 5:33 A.M., showed the resident's pain level was a 10 out of 10, entered by RN HH. Review of RN HH's progress note on 3/17/26 at 6:45 A.M., showed the resident told staff he/she was in excruciating pain. The resident said he/she been awake crying all night, which he/she has slept a little bit but has been awake. RN HH said the resident has been on their call light to request that Certified Nurses Assistants (CNAs) re-reposition him/her frequently just to move himself/herself back to the position he/she was in before staff moved him/her to begin with. The resident told staff he/she is a CNA themselves, but we have told him/her that they are a patient now and can't think of himself/herself as a CNA now. The resident won't leave the pillows positioned in the places that the CNAs put them in to keep him/her positioned in, and as soon as resident urinates, he/she wants changed at that moment. RN HH placed a call to the exchange to notify him of the increased pain the resident had. Nurse Partitioner R is on call, awaiting return call. Review of the nurse progress notes on 3/17/26, showed:-At 7:10 A.M., spoke to NP R and his/her recommendation was to send the patient back to discharged hospital for pain management immediately; -At 8:14 A.M., EMS notified; -At 9:01 A.M., EMS arrived at facility to transport resident to local hospital. During an interview on 4/9/26 at 12:50 P.M., RN GG said his/her primary goal during an admission are vitals (blood pressure, temperature, pain and respirations), weight and skin assessment. He/she will orientate the residents to the facility and provide them with their call light. When a resident complains of pain, RN GG will let the doctor know about the pain, then the doctor would provide new orders. RN GG put the orders in the electronic medical record (EMR) and faxed other narcotic (pain meds prescribed by a doctor) prescriptions to be signed by the doctor. RN GG said he/she cannot pull medication from the eKit (emergency supply of medications), it's out of his/her control. If there was an order for Tylenol, that could be pulled from eKit. RN GG did not recall the resident, the resident did not complain of pain, nor did he/she request medication to help control his/her pain. RN GG would not know if the resident was in pain due to his/her shift ended at 7:30 P.M. RN GG did recall the next day the resident was being sent out and he/she assisted RN HH by notifying EMS a transfer was necessary. RN GG said the medical doctor will not sign scripts that authorize narcotics until the next day. Residents need to understand that the facility will not have their pain medication at the facility. During an interview on 4/10/26 at 8:03 A.M., RN HH said he/she did not remember that specific resident without the resident's records in hand. RN HH cannot be positive if the resident had an order for Tylenol, however, had the resident had an order, he/she would have administered the medication. RN HH said the resident might have informed the nurse that the medication won't work. RN HH should have documented the Tylenol administration. The pharmacy usually drops medications off at the facility around 4:00 A.M. RN HH would normally place a call to the pharmacy to see the precise drop off time. RN HH can pull from the Ekit after he/she obtains an order. RN HH was in the resident's room a lot that night. RN did not recall if the prescribed narcotic came on the morning drop. RN HH said they typically call the physician to see if there is alternative medication that staff can get out of the eKit. RN HH was unfamiliar with what was pre-stocked in the eKit; he/she guessed Dilaudid was in there. During an interview on 4/10/26 at 8:14 A.M., Vendor 2 (pharmacy) said they did not have Resident #118's name or date of birth in their records for this facility. During an interview on 4/10/26 at 8:43 A.M., CNA II said the resident did ask for pain medications that night but never said he/she was in pain. Any time a resident says they are in pain, CNA II reports it to the nurse. During an interview on 4/10/26 at 8:43 A.M., Certified Medical Technician (CMT) JJ said, he/she did not recall the residents, they come and go quickly over there. CMT JJ usually informs the nurse when pain medications are not delivered, however, staff can pull from the eKit. First, staff need to make sure the medical doctor (MD) signs the script, which authorizes staff to pull from the eKit. If the MD did not sign the script for the pharmacy, the pharmacy won't deliver it. During an interview on 4/10/26 at 11:53 A.M., the Administrator said the facility only uses the one pharmacy; which is vender 2, out of KC. During an interview on 4/10/26 at 12:43 P.M., the DON said she expected the staff to verify medications and fax required scripts in a timely manner. If the script is at the pharmacy and signed, then the staff can pull the medication from the eKit. The DON would expect the staff to call the physician to obtain an alternative medication that is available to aid with the resident's pain. At the time of an admission, staff need to make sure a signed script comes with the patient when they are discharged from the hospital. The DON would expect her staff to do everything possible before sending the resident out for pain to the hospital. She would expect them to call the exchange and notify the pharmacy for why medications are delayed. DON would expect a non-pharmacological approach for repositioning and for staff to add documentation. The DON would expect the staff to be proactive by requesting the hospital provide/fill the script for the resident prior to discharge. During an interview on 4/13/26 at 11:16 A.M., NP R said she received an email about a new admission who had an order for Dilaudid, but the order was not signed. The staff requested to send the resident back to the discharged hospital for pain management. NP R said that the nurses are responsible to contact the physician or exchange to obtain pain medication. The pain medication should have been addressed during regular hours when the provider was on the office, and staff are told to ask the discharged hospitalist for medications to be brought with them. NPs cannot order/prescribe opioids. Even if they could, this facility needs to have a hard copy on file, not a verbal order. NP R would have tried other topical pain medication that possibly could have helped the pain. Since the facility did not have pain medication on hand, NP R chose to send the resident back to the hospital at the resident's request. NP R said the Flexeril and Tylenol maybe could have helped. These medications are in the eKit. NP R would have provided some sort of new order if there were options. NP R said his/her exchange message was pubic fracture, no pain and crying, who request to return to the hospital. 2. Review of Resident #2's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/22/25, showed:-Diagnoses included: Aphasia (impaired talking and understanding language), elevated blood pressure, end stage renal disease (severe kidney failure), and dependence of dialysis;-Cognitively intact; hearing loss, other reduced mobility, muscle weakness, falls, diabetes,-Fully dependent on staff for ADLs;-Pain was present occasionally. Review of the electronic physician's order sheet dated 3/2026, showed:-An order dated 1/15/26, Hydrocodone-Acetaminophen (Vicodin) (pain medication) oral Tablet 5-325 mg Q six hours for pain as needed;-An order dated 1/15/26, Pain Scale 1-10 Q shift;-An order dated 1/15/26, Acetaminophen PO tablet 500 mg, give two tablets by mouth every six hours as needed for pain; elevated temperature. During an interview on 4/6/26 at 3:07 P.M., the resident said there had been a wound on his/her coccyx for two to three months. The wound did get better but then got worse again. Review on 4/7/26 at 9:00 A.M., of the resident's care plan, in use at the time of the survey, showed:-The care plan did not address the pain on his/her coccyx related to the pressure ulcer;- Focus: Resident is at risk for pressure ulcer that development related to reduced mobility, episodes skin, free of redness, blisters or of incontinence;-Goal: Resident will have intact skin, free of redness, blister or discoloration by/through review date;-Interventions: Educate family, care givers as to cause skin breakdown, including transfers, positioning requirements, good nutrition, and frequent repositioning, shift weight every 15 minutes, the resident needs Q two hourly turns, more often as needed or requested. Review of the MAR dated 4/2026, showed:-An order dated 1/15/26, showed: Acetaminophen PO tablet 500 mg, give two tablets by mouth every six hours as needed for pain; elevated temperature; the medication was not administered for 14 out of 14 possible opportunities;-Hydrocodone-Acetaminophen oral tablet 5-325 mg Q six hours for pain;--The resident received the medication eight out of 12 possible opportunities;--The resident received pain medication on 4/9/26 at 7:00 A.M. Observation on 4/9/26 at 11:27 A.M., showed the Wound Nurse asked the resident if he/she is alright? The resident said, It hurts, there are two spots on my hip bone and anus. Observation and interview on 4/9/26 at 11:40 A.M., showed CNA T and CMT V used a mechanical lift to put the resident back to bed. CNA T said the resident does have a PRN pain medication. CNA T told the resident Go ahead and scream or yell. Do what you need to. When CNA T and CMT V turned the resident, he/she hollered and moaned. CNA T said, We tried not to hurt you. During an interview on 4/9/26 at 11:40 A.M., CMT V said when he/she works, the resident complained about pain frequently. CMT V shared the resident's complaint with the nurse but was unsure if the nurse administered any pain medication. During an interview on 4/9/26 at 11:40 A.M., CNA T said when the resident had pain, they would tell the nurse, but they were unsure if the nurse administered any pain medication. Observation on 4/9/26 at 12:00 P.M., showed the resident said, Man, I have so many sore spots. CMT V asked the resident what hurt? The resident said, It's so sore, oh my god! While the Wound Nurse continued to cleanse wounds, the resident continued to yell out in pain. At 12:14 P.M., the wound cleansing process was stopped, due to pain medication needed to be administered. During an interview on 4/9/26 at 12:14 P.M., the Wound Nurse said she would contact the provider for new orders related to pain management. During an interview on 4/12/26 at 12:00 P.M., the DON said she expected the staff to address the resident's comments of pain and administer medications as ordered. 2807190

Based on observation, interview, and record review, the facility failed to ensure staff exhibited appropriate infection control practices while providing feeding assistance to one resident (Resident #12). In addition, the facility failed to ensure food was served from a clean steam table on the [NAME] Hall. The sample was 24. The census was 121. 1. Review of Resident #12's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/6/26, showed:-Severe cognitive impairment;-Diagnoses included aphasia (language impairment), paraplegia (paralysis of lower portion of the body and of both legs), hemiplegia (paralysis on one side of the body), hemiparesis (weakness on one side of the body), and dementia. Observations on 4/8/26, of the main dining room during lunch, showed-At 12:44 P.M., Certified Nursing Assistant (CNA) L sat next to the resident at a table in the dining room. He/She scooped up a spoonful of soup, blew on the spoonful of soup and fed it to the resident. He/She continued to blow on the resident's soup spoon until the resident was finished with his/her soup;-At 12:58 P.M., CNA L cut up the resident's meatballs and blew on the spoon before feeding the meatballs to the resident. During an interview on 4/10/26 at 1:02 P.M., the Director of Nursing (DON) said she expected nursing staff to set food aside if it is too hot to feed to the resident. Staff blowing on the resident's food is an infection control concern and should not be done. 2. Review of the facility's [NAME] Hall daily cleaning schedule, undated, showed tasks included clean and sanitize prep tables. Observation on 4/6/26 at 11: 35 A.M., showed the [NAME] Hall steam table with brown, dried, and baked-on food around the steam wells. The steam well water was cloudy with sediment floating in it. The splash guards were cloudy and had dried, crusted liquid on them. Observation on 4/8/26 at 11:10 A.M., showed the [NAME] Hall steam table with brown, dried, and baked-on food around the steam wells. The steam table well water was cloudy and with sediment floating in it. The splash guards were cloudy and had dried, crusted liquid on them. Dietary Aide BB turned on the steam table. During an interview, Dietary Aide BB said he/she knew the steam table was filthy. He/She had already gotten in trouble about it for not cleaning it. He/She did not have enough time to clean the steam table like it should be cleaned. During an interview on 4/8/26 at 11:40 A.M., CNA CC said the steam tables have looked dirty for months. Dietary staff are responsible for cleaning the steam tables. During an interview on 4/10/26 at 1:02 P.M., the Administrator and DON said they expected the steam table on [NAME] Hall to be cleaned after every use.

Based on observation, interview, and record review, the facility failed to ensure one resident received one on one activities (Resident #5) and failed to ensure two residents had activities provided (Residents #3 and #140). In addition, the facility failed to ensure activities were provided on the 300 hallway and failed to ensure activities posted on the activity calendar for the [NAME] hallway were conducted. The sample size was 24. The census was 121. Review of the facility's activities policy, dated 9/14/23, showed:-Policy: It is the policy of the facility to provide an ongoing program to support residents in their choice of Activities based on their comprehensive evaluation, care plan, & preferences. Facility-sponsored group, individual, & dependent activities will be designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident, as well as encourage both independence and interaction within the facility;-Procedure: Activities will include individual, small, and large group activities as well as indoor/outdoor activities, activities away from the facility, religious programs, exercise programs, community activities, social activities, in-room activities, individualized activities, and educational programs. 1. Review of Resident # 5's quarterly Minimum Data Set (MDS) a federally mandated assessment tool completed by facility staff, dated 3/23/26, showed:-Severe cognitive impairment;-Dependent on staff for toilet hygiene, personal hygiene, upper and lower body dressing, bed to chair and chair to bed transfers;-Diagnoses included depression, anxiety, heart failure and kidney disease. Review of the residents' care plan, in use at the time of survey, showed:-Focus: Requires assist for meeting emotional, intellectual, physical and social needs;-Interventions: One-to-one room visits and activities if unable to attend out of room activities. Preferred activities are pet visits. Review of the facility's list of residents on one-on-one activities, showed Resident #5 listed to receive one-on-one activities. Review of the Preferred Activities of the Residents List, showed the resident was to receive pet visits on Thursdays for 15 minutes. Review of the documentation provided by the facility's Activity Director (AD), showed a handwritten note on a plain piece of paper, dated 2/25/26. The activities staff talked with the resident about his/her family and the resident's cat for 15 minutes.-No further documentation of the resident's one on one visits was provided. During an interview on 4/9/26 at 10:30 A.M., the resident said he/she was never brought out by staff for activities. He/ She would have liked to see the staff member's dog again. The resident said his/her TV hasn't been working consistently due to the facility roof being worked on. The resident used to play cards and would like to do that again if possible. During an interview on 4/10/26 at 12:34 P.M., the Director of Nurses (DON) said that 15 minutes of pet therapy once a week was not adequate or acceptable. She would expect the resident to be brought out of his/her room if the resident requests for activities. She would expect some other type of meaningful one on one activity that the resident likes. The DON would also expect documentation of the one on one activities when they occur. 2. Review of Resident #3's quarterly MDS, dated [DATE], showed:-Diagnoses included chronic obstructive pulmonary disease (COPD, lung disease), muscle weakness, depression, and anxiety;-Cognitively intact. During an interview on 4/7/26 at 9:30 A.M., the resident said there were not enough activities provided. He/She said a lot of the activities felt babyish. 3. Review of Resident #140's quarterly MDS, dated [DATE], showed:-Diagnoses included depression, anxiety, and hypertension;-Cognitively intact. During an interview on 4/7/26 at 9:35 A.M., the resident said not enough activities were provided. He/She said staff told the residents the activity department was short staffed, and that is why activities were not being done. 4. Observations on 4/7/26 at 9:30 A.M., and 10:05 A.M., showed no activities being done on the 300 hallways. 5. Observations on 4/9/26 at 10:00 A.M. and 10:30 A.M., showed no activities being done on the 300 hallways. 6. Review of the activities calendar for [NAME] Hall, dated April 2026, showed:-On 4/7/26 at 10:00 A.M., Morning [NAME] and at 11: 00 A.M., Nails and Tales;-On 4/8/26 at 9:00 A.M., Morning Prayers; at 10:00A.M., Noodle Balls and at 11:00 A.M., Hungry Hippos (game). Observation on 4/7/26 at 10:15 A.M., showed the residents on [NAME] Hall sat in front of the TV watching an animated movie. No morning [NAME] occurred. At approximately 11:00 A.M., the residents on [NAME] Hall sat in front of the TV watching an animated movie while the Environmental Service Director used a loud cleaning machine on the carpeted area near the TV. No Nails and Tales occurred. Observation on 4/8/26 at 11:20 A.M., showed the residents on the [NAME] Hall sat in front of the TV watching an animated movie. No Hungry Hippo game occurred. During an interview on 4/7/26 at 11:00 A.M. Licensed Practical Nurse (LPN) E said activities never occurred on the [NAME] Hall. The residents that live on the [NAME] Hall frequently had behaviors. Especially in the evening the residents started to sundown (increased confusion that occurs late in the evening), and they needed something to do. The popcorn machine located on the [NAME] Hall has not been used in months. The [NAME] Hall needed an activities person full time to assist with the residents' behaviors and provide emotional support to the residents. The residents on [NAME] Hall were rarely brought over to the other side of the building where some activities did occur. During an interview on 4/8/26 at 11:30 A.M., Certified Nursing Assistant (CNA) CC said the activities calendar was a lie and a hoax. No activities occurred on the [NAME] Hall. The residents on [NAME] Hall needed activities to assist with their behaviors and provide some type of fun in their lives. No morning prayer, no noodle balls or Hungry Hippo occurred on 4/8/26. There was usually only two staff members on the [NAME] Hall, so it was difficult for the nursing staff to provide activities when there was other care related task they had to complete and maintain resident safety. 7. During an interview on 4/8/26 at 4:26 P.M., the AD director said she has been short-staffed and the activities for one on one and the [NAME] Hall activities were not being completed. The AD was aware that the activities on all the halls were not being done consistently. The AD said she was also working in central supply, so she was stretched thin. She was aware the residents required and requested more activities than they currently were receiving. On [NAME] Hall, the AD was hoping that some of the staff would take the initiative and do some type of activities on their own. 8. During an interview on 4/10/26 at 12:34 P.M., the Administrator and the DON said activities were expected to occur even when the activities department staff were short staffed. The activities were expected to be meaningful, intellectually stimulating and age appropriate.

Based on observation, interview, and record review, the facility failed to ensure medications were stored securely on locked medication carts, and to ensure medication and treatment carts were free from storage of personal items, expired medications, and improperly labeled medications. Five medication carts were observed and problems were found with each. The census was 121. Review of the facility's Storage of Medications policy, dated 11/18, showed:Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel (Registered Nurse (RN), Licensed Practical Nurse), pharmacy personnel, or staff members lawfully authorized to administer medications;-Procedure: Medication rooms, carts, and medication supplies are locked when not attended by people with authorized access;-AII medications dispensed by the pharmacy are stored in the container with the pharmacy label;-Medications labeled for individual residents are stored separately from floor stock medications when not in the medication cart;-Potentially harmful substances such as urine test reagent tablets, household poisons, cleaning supplies, disinfectants, are clearly identified and stored in a locked area separately from medications;-Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy, if a current order exists;-Storage areas are kept clean, well-lit, and free of clutter and extreme temperatures andhumidity;-Medication storage conditions are monitored at least quarterly (or as agreed upon between the facility and pharmacy) by the consultant pharmacist or pharmacy designee and corrective action taken if problems are identified;-Expiration Dating (beyond-use dating);--Expiration dates of dispensed medications shall be determined by the pharmacist at the time of dispensing;--Drugs dispensed in the manufacturer's original container will be labeled with the manufacturer's expiration date;--Certain medications or package types, such as intravenous (IV) solutions, multiple-dose injectable vials, ophthalmics (products related to the eye), nitroglycerin (used to treat chest pain) tablets, blood sugar testing solutions and strips, once opened, require an expiration date to insure medication purity and potency. 1. Observation on 4/7/26 at 3:07 A.M., of the 400 Hall treatment cart, showed:-The cart was unlocked;-The top drawer contained a Slim [NAME] meat stick, two Lantus (insulin glargine, a long-acting insulin) insulin pens without an open date, and one insulin pen with no identification or open date;-The second drawer contained one multi-vitamin liquid bottle with an open date of 7/20/15 and expiration date of 2/27, one multi-vitamin liquid bottle with no open date, one open bottle of Geri-Kot (senna, a laxative) with no open date, and one tube of diclofenac sodium (nonsteroidal anti-inflammatory) with no patient label;-The last drawer contained an open bottle of Miralax (stool softener) with no open date. 2. Observation on 4/7/26 at 3:33 A.M., of the 400 Hall CMT cart, showed:-The top drawer contained the following:--An undated, unlabeled medication cup with a white pill inside;--Two blister packs of Zofran (nausea) 4 milligrams (mg) with no patient labels;--One blister pack of loperamide (antidiarrhea) 2 mg with no patient label;--A bottle of hand lotion;--An open container of vanilla pudding, dated 4/6/26 at 6:00 P.M.;--A bottle of Lumigan eye drops (used to treat glaucoma) with no open date;--A bottle of dorzolamide hydrochloride-timolol maleate ophthalmic solution (eye drops used to treat eye pressure) with no open date;-The third drawer contained a container of Vitamin B with no open date;-The fourth drawer contained 18 loose pills of various sizes, colors, and shapes. 3. Observation on 4/7/26 at 3:07 A.M., of the [NAME] Hall nurse cart, showed:-The cart was unlocked;-The top drawer contained a bottle of nitroglycerin with no patient name; -The second drawer contained the following:--Five 24 gauge (g) needles with an expiration date of 11/1/23;--Four 22g needles with an expiration date of 10/23;--One culture swab with an expiration date of 6/25;--One bottle of artificial tears (eye drops) with an expiration date of 4/25;-The bottom drawer contained a bottle of sore throat spray with no patient label and a blister pack of loperamide 2 mg with no patient label and an expiration date of 6/25. 4. Observation on 4/7/26 at 3:07 A.M., of the [NAME] Hall treatment cart, showed:-An open package of Xeroform (sterile dressing) with no label;-Zinc oxide (barrier cream) ointments with no patient labels;-Hydrophilic wound barrier cream with no patient label. 5. Observation on 4/7/26 at 4:31 A.M., on the dementia unit cart, showed:-Two boxes of Assure Dose Control (calibrating glucometers) solution with an expiration date of 2/22/26;-One box of Assure Dose Control solution with an expiration date of 6/22/24; one box expiration date of 6/22/24;-A blister pack of risperidone (antipsychotic medication) 2mg with no patient label;-Six loose pills of various sizes, colors, and shapes;-Four boxes of Systane (eyedrop) solution with an expiration date of 12/24. 6. During an interview on 4/7/26 at 3:07 A.M., LPN MM, said any open medication without a date should be discarded. All medications need a patient identifier. Medication carts should not include pills left out from their packaging. During an interview on 4/7/26 at 3:52 A.M., LPN OO said medication carts should not be left unlocked. 7. During an interview on 4/7/26 at 3:52 A.M., Assistant Director of Nursing (ADON) NN said nurses are responsible for ensuring their carts are clean. During an interview on 4/7/26 at 4:41A.M., ADON NN said outdated glucometer solution could cause incorrect glucose readings by showing the reading is elevated or too low. This could cause staff to perform the wrong/incorrect treatment. He/She expected nurses to be vigilant and discard any medications on their carts that are expired. 8. During an interview on 4/10/26 at 12:43 P.M., DON said she expected medication and treatment carts to be free from clutter, pills, and expired supplies.

Based on interview and record review, the facility failed to send a copy of the transfer and discharge notices to the representative of the Office of the State Long-Term Care Ombudsman (resident advocate) for 11 out of 12 months. The census was 121.Review of the facility's Discharge and Transfer policy, last revised 9/17/25, showed a copy of a transfer or discharge notice must be provided to the Ombudsman. Review of the facility's admission and Discharge Report, dated 6/26/24 through 4/6/26, showed 39 residents discharged from the facility. Review of the Social Service Director's (SSD) monthly e-mails sent to the Ombudsman's office showed:-No transfer or discharge notifications were sent to the Ombudsman's office in April 2025, May 2025, June 2025, July 2025, August 2025, September 2025, October 2025, November 2025, December 2025, January 2026, and February 2026. During an interview on 4/8/26 at 2:15 P.M., the SSD said she was aware that she had missed a couple of months sending the transfer and discharge list to the Ombudsman's office. The SSD said it was her responsibility and the expectation was to send the information to the Ombudsman's office. During an interview on 4/10/26 at 12:34 P.M., the Administrator said she expected the SSD to send the required documentation for discharges and transfers to the Ombudsman's office.

Based on observation, interviews and record review, the facility failed to ensure wheelchairs for two residents (Resident #1 and Resident #109), the [NAME] Hall living room carpet, and the Lodge common area were maintained in a clean, comfortable and homelike environment. The sample size was 24. The census was 121.During an interview on 4/10/26 at approximately 7:00 A.M., the Administrator said the facility did not have a policy on cleaning wheelchairs or a wheelchair cleaning schedule. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/2/26, showed:-Cognitively intact;-Used a wheelchair;-Diagnoses included heart failure, high blood pressure, and renal (kidney) failure. Observation on 4/6/26 at approximately 12:00 P.M., showed the resident sat in his/her wheelchair in his/her room. The resident's wheelchair had thick amounts of dust, food particles and hair on the wheelchair frame and wheels. During observation and interview on 4/8/26 at 11:10 A.M., and 4/9/26 at 9:01 A.M., the resident sat in his/her wheelchair. The resident's wheelchair had a thick amount of dust, food particles and hair on the wheelchair frame and wheels. The resident said staff have never cleaned his/her wheelchair. 2. Review of Resident #109's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Used a wheelchair;-Diagnoses included heart failure, diabetes, and renal failure. Observation on 4/6/26 at approximately 9:00 A.M., showed the resident sat in his/her wheelchair and propelled him/herself through the facility's front lobby. The resident's wheelchair had a thick amount of dust and food particles on the wheelchair frame and wheels. During an observation and interview on 4/6/26 at 10:01A.M. and 4/8/26 at 11:20 A.M. the resident sat in his/her wheelchair in his/her room. The resident's wheelchair had a thick amount of dust and food particles on the wheelchair frame and wheels. The resident said he/she has never had his/her wheelchair cleaned. During an interview on 4/10/26 at 7:30 A.M., Licensed Practical Nurse (LPN) W said there was no wheelchair cleaning schedule, and the staff wiped the wheelchairs down as needed. During an interview on 4/10/26 at 9:30 A.M., Certified Nursing Assistant (CNA) X said the wheelchairs were cleaned by night shift and staff should clean the wheelchairs based on the resident's shower days. The residents' wheelchairs should be cleaned for the residents. During an interview on 4/10/26 at 12:34 P.M., the Director of Nursing (DON) said the night shift was expected to clean resident wheelchairs according to the day the residents' showers were scheduled. She would expect the residents' wheelchairs to be cleaned as scheduled and as needed. 3. Observation on 4/6/26 at 10:40 A.M. and 4/7/26 at 10:45A.M., showed the carpet in the [NAME] Hall living room had a large maroon colored stain located in front of the couches. During an interview on 4/8/26 at 11:30 A.M. CNA CC said the maroon spot was when a resident fell and bled on the carpet. The stain had been there a few days. During an interview on 4/7/26 at 12:40 P.M., the Environmental Services (EVS) Director said he was the only one that cleaned the carpets and was made aware of the stain on 4/7/26. It was his daily routine to check the carpets for any stains or issues. During an interview on 4/10/26 at 12:35 P.M., the Administrator and the DON said they would expect staff to try to clean the area after the incident occurred with a special blood cleaner the facility had on hand and place a request into the specialized computer software that notified the appropriate departments such as housekeeping or maintenance when issues arose. They expected all floors and carpets to be cleaned. Stained carpet was not homelike. 4. Observation on 4/6/26 at 8:31 A.M., 4/7/26 at 9:52 A.M., 4/9/26 at 12:50 P.M., and 4/10/26 at 9:46 A.M., showed a pest control glue trap sat on the folding tables in the windowed space across from the Lodge therapy gym. During interview on 4/10/26 at 10:32 A.M. Housekeeping Aide M said housekeeping staff cleaned the common areas on the Lodge daily, and pest control traps should not be left out on the tables, as it was not considered a homelike environment. During interview on 4/10/26 at 12:32 P.M. the Administrator and DON said they would expect all glue traps and pest control interventions to be removed from tabletops or surfaces in resident common areas.

Based on observation, interview and record review, the facility failed to ensure one resident was treated in a dignified manner (Resident #98), and failed to ensure staff followed the facility's cell phone policy, which affected 4 residents (Residents #12, #3, #100 and #140). The sample size was 24. The census was 121. Review of the facility's resident rights policy, dated 1/28/26, showed:-Policy: The facility shall treat residents with kindness, respect, and dignity and ensure resident rights are being followed. The resident/resident representative will be informed of their rights upon admission. Review of the facility's employment policies and procedures, undated, showed:-Personal cell phones: Use of personal cell phones or other similar devices while on duty is prohibited. Employees must understand that our first priority is the care and welfare of the residents. Use of personal cell phones is limited to breaks and meal periods. Ringers are to be silenced while on duty, and employees may not initiate or receive calls or text messages while caring for a resident or conducting company business. If the facility determines that an employee engages in personal cell phone/texting use during work hours, he or she may be subject to disciplinary action, up to and including termination. 1.Review of Resident #98's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/24/26, showed:-Cognitively intact;-Diagnoses included Parkinson's disease, dementia, and chronic obstructive pulmonary disease (COPD), a lung disease that cause the airway to become constricted and difficult to breathe. Observation on 4/7/26 at 745 A.M., showed the resident at the end of a hallway leading to the 300/400 dining room. The resident sat in his/her wheelchair. Certified Nursing Assistant (CNA) F walked by the resident. The resident asked CNA F to help him/her into the dining room. CNA F walked over to the resident and said he/she could not push him/her because the resident did not have his/her foot pedals. The resident looked at the aide but did not move. CNA F told the resident to use his/her feet and move towards the dining room. The resident moved a couple of feet but stopped. Unknown Aide LL walked by and asked the resident if he/she needed help. CNA F said to the aide that the resident could not find his/her foot pedals in his/her room today, and they could not push him/her without them. CNA F then turned to the resident and told the resident to move his/her feet again. The aide told the resident he/she was capable of moving his/her feet and could get him/herself to the dining room. The resident moved another couple of feet and then stopped. He/She looked at the aides with an uncomfortable look on his/her face. Unknown Aide LL then assisted the resident into the dining room. During an interview on 4/10/26 at 7:57 A.M., CNA J said if a resident asked for help, staff should have assisted the resident or found someone who could. During an interview on 4/10/26 at 8:02 A.M., Licensed Practical Nurse (LPN) K said if a resident asked for help, staff should have assisted the resident and should not have told the resident they would not help. During an interview on 4/10/26 at 1:05 P.M., the Administrator and Director of Nursing (DON) said residents should be treated and spoken to in a dignified manner. If a resident asked for help, they would have expected for staff to assist them. 2. Review of Resident #12's quarterly MDS, dated [DATE], showed:-Diagnoses included aphasia (impaired talking and understanding language), paraplegia (impaired motor and sensory in lower extremities), hemiplegia (severe or complete paralysis of one side of the body), hemiparesis (partial weakness or reduced movement on one side of the body) and dementia;-Severe cognitive impairment. Observation on 4/8/26 at 2:44 P.M., of the main dining room during lunch, showed CNA L sat next to the resident at a table in the dining room. While he/she fed the resident, he/she had ear buds in his/her ears and was looking at his/her phone. During an interview on 4/10/26 at 9:12 A.M., CNA L said cell phones were not to be used in resident care areas. He/She said on 4/8/26, he/she was on his/her phone while feeding the resident and was checking a text message. During an interview on 4/10/26 at 1:09 P.M., the Administrator and DON said staff should never be on their phones while feeding a resident or assisting residents in the dining room. 3. Review of Resident #3's quarterly MDS, dated [DATE], showed:-Diagnoses included COPD, muscle weakness, depression, and anxiety;-Cognitively intact. During an interview on 4/06/26 at 10:40 A.M., the resident said staff were on their phones a lot. He/She said staff used their phones and headphones while providing care. 4. Review of Resident #100's quarterly MDS, dated [DATE], showed:-Diagnoses included congestive heart failure, type two diabetes, chronic kidney disease, and major depressive disorder;-Cognitively intact. During an interview on 4/06/26 at 12:13 P.M., the resident said staff used their cell phones in the hallways. He/She said staff were on their phones a lot. 5. Review of Resident #140's quarterly MDS, dated [DATE], showed:-Diagnoses included depression, anxiety, and hypertension;-Cognitively intact. During an interview on 4/06/26 at 10:39 A.M., the resident said staff had phones out while providing care and took phone calls during care. 6. Observation on 4/08/26 at 11:00 A.M., showed CNA L sat in the 300 hallway lounge on the couch. Multiple residents were in the room. He/She was texting on his/her cell phone. Observation on 4/9/26 at 6:24 A.M., showed CNA G sat on a couch in the 300 hallway lounge. He/She sat next to a resident. He/She had headphones on and was looking at his/her phone. Observation on 4/9/26 at 6:53 A.M., showed CNA G in the hallway wearing headphones while looking at his/her phone. 7. During the resident council meeting on 4/7/26 at 2:34 P.M. five residents attended the group resident council meeting. The residents said there had been concerns noted to administration during previous resident council meetings regarding staff treating residents in a dignified manner. Residents reported care staff often come in and would turn the call light system off, telling residents I'm not your aide and then leaving without telling another staff member they required care. Staff were often heard laughing, talking loudly, or yelling at one another on the resident halls during the night shift, and have been observed on their cell phones while providing care. Resident council members noted this made them feel as if their dignity in the facility was diminished during these instances. 8. During an interview on 4/10/26 at 7:57 A.M., CNA J said staff was expected to be off of their cell phones in resident care areas. He/She said staff should only use their cellphones in the break room. 9. During an interview on 4/10/26 at 8:02 A.M., LPN K said cell phones were only to be used in the break room. He/She said staff should not be on their phones in resident care areas. 10. During an interview on 4/10/26 at 1:05 P.M., the Administrator and DON said cell phones and headphones should not be used in resident care areas. 28017622807190

Based on observation, interview, and record review, the facility failed to ensure food was served to residents at a safe and appetizing temperature (Residents #3, # 23, #76, #100 and #140). The sample was 24. The census was 121. Review of the facility's meal service temperature log, undated, showed:-Hot food needs to maintain at 135 degrees Fahrenheit (F) or above in steamtable;-Cold food needs to maintain at 41 degrees F or below. 1. Observation on 4/8/26 at 12:56 P.M., of lunch on the memory care unit, showed:-Soup measured 126.8 degrees F;-Meatballs measured of 129.3 degrees F. Observation on 4/9/26 at 8:54 A.M., of 300 hall breakfast trays, showed:-Cream of wheat measured 80 degrees F;-Scrambled egg measured 109 degrees F;-Biscuits and gravy measured 111.1 degrees F. 2. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/30/26, showed:-Cognitively intact;-Diagnoses included chronic obstructive pulmonary disease (COPD, lung disease), muscle weakness, depression, and anxiety. During an interview on 4/6/26 at 10:30 A.M., the resident said the food is always served cold. 3. Review of Resident #23's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Diagnoses included dementia, muscle weakness, and quadriplegia (paralysis of all four limbs and the torso). During an interview on 4/6/26 at 9:09 A.M., the resident said his/her food is normally served cold when he/she eats in his/her room. 4. Review of Resident #76's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Diagnoses included muscle weakness, seizures, chronic kidney disease, and heart failure. During an interview on 4/6/26 at 10:02 A.M., the resident said his/her food is served cold most days. 5. Review of Resident #100's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Diagnoses included heart failure, diabetes, chronic kidney disease, and depression During an interview on 4/06/26 at 12:17 P.M., the resident said his/her room trays are normally served cold. 6. Review of Resident #140's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Diagnoses included depression, anxiety, and high blood pressure. During an interview on 4/06/26 at 10:29 A.M., the resident said the food is always served cold. 7. During an interview on 4/10/26 at 9:05 A.M., the Dietary Supervisor said she expected food to be served to residents at a safe and palatable temperature. 8. During an interview on 4/10/26 at 12:58 P.M., the Administrator and Director of Nursing (DON) said they expected food to be delivered to the residents at a safe and palatable temperature. 2806805

Based on observation, interview, and record review, the facility failed to provide foot care and treatment in accordance with professional standards of practice for two residents (Residents #60 and #98). The sample was 24. The census was 121.Review of the facility's Podiatry (foot specialty) Services policy, revised 2/16/26, showed:-Policy: The facility will assist in arranging for residents as needed;-Responsibility: Social Worker (SW) and Licensed Nurse;-Procedure: On admission and as needed, the Licensed Nurse evaluates feet and toenails for any abnormalities. The Licensed Nurse will notify the resident's medical provider of any needs for podiatry services and obtain and order for podiatry consultation. The Licensed Nurse will notify Social Services (SS) of the need for arranging podiatry services. SS will arrange for podiatry services, including transportation if needed. The Administrator will engage the services of a properly licensed podiatrist to serve facility residents. 1. Review of Resident #60's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/12/26, showed:-Severe cognitive impairment;-Dependent on staff for putting on and taking off footwear and bathing;-Diagnoses included stroke and high blood pressure. Review of the resident's care plan, in use at the time of survey, showed no documentation regarding foot care. Review of the resident's physician order sheet (POS), dated 4/9/26, showed:-An order, dated 1/14/26, for diabetic nail and foot care every week on nights, every Monday;-No order for podiatry consult. Review of the podiatrist's appointment list, dated 2/25/26, showed the resident not listed. Review of the resident's shower sheet, dated 4/6/26, showed staff circled Yes for resident needed toenails trimmed. Observation on 4/7/26 at 6:07 A.M., showed the resident in bed with tight black socks on his/her feet that created indentations in the resident's ankles. Certified Nurse Aide (CNA) MM removed the resident's socks. The resident's feet had extremely dry skin, with thick flakes of dry skin coming off when the socks were removed. The resident's toenails were long and thick, approximately 1.5 inches (in) long, and curled over the tops of the resident's toes. During an interview on 4/10/26 at 7:30 A.M., Licensed Practical Nurse (LPN) W said he/she had been giving the resident weekly foot care. He/She checked the resident's heels and applied lotion without removing the resident's socks. He/She was not aware that the resident's toenails were long but remembered someone mentioned the resident had long toenails on admission, back in January 2026. 2.Review of Resident's #98's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Required partial to moderate assistance from staff with putting on and taking off footwear;-Diagnoses included Parkinson's disease (progressive neurological disorder), dementia, and chronic obstructive pulmonary disease (COPD, lung disease). Review of the resident's care plan, in use at the time of survey, showed:-Focus: The resident has diabetes and is at risk for high blood glucose (sugar) levels, infections, and delayed wound healing;-Interventions: Check the body for all breaks in skin and treat promptly as ordered by the physician;-The resident's care plan did not address foot care. Review of the podiatrist's appointment list, dated 2/25/26, showed the resident not listed. Review of the resident's POS, dated April 2026, showed no order for podiatry consult. Observation on 4/6/26 at 11:04 A.M., showed the resident in bed. LPN K removed the resident's socks. The resident's feet were extremely dry, with thick flakes of skin falling off when the resident's socks were removed. The resident's toenails were thick and approximately 0.5 in long. During an interview, the resident said he/she has not seen a podiatrist. 3. During an interview on 4/10/26 at 9:30 A.M., CNA X said during routine bathing and daily care, residents' feet should be cleaned, lotion should be applied, and clean socks should be applied. If there were issues with the resident's feet, the CNA should let the nurse know. 4. During an interview on 4/10/26 at 7:30 A.M., LPN W said nurses can file toenails but if they are too thick or if the resident is diabetic, the resident should be placed on the podiatry list. He/She expected the CNA who completed any type of bathing activity for the resident to let the nurse know if the resident required toenail trimming. He/She expected CNAs to apply lotion to residents' feet when giving a bath or changing the resident's socks. 5. During an interview on 4/10/26 at 12:34 P.M., the Director of Nursing (DON) said she expected nursing staff to identify any foot issues with the resident during bathing and skin assessments. She expected the nurses to place residents on the podiatrist list as needed. She expected staff to apply lotion to dry feet and file or trim the residents' toenails if needed.

Based on observation, interview and record review, the facility staff failed to use a gait-belt during a transfer for one resident (Resident #93). The sample size was 24. The census was 121. Review of the facility's Gait Belt Transfer policy dated 10/22, showed:-Policy: The Facility will utilize a Gait Belt for Residents who require one assist with Transfer to promote safety during Resident Transfers;-Responsibility: Nursing Assistants, Licensed Nurses (Licensed Practical Nurse (LPN) and Registered Nurses (RN), Nursing Administration, Assistant Director of Nursing (ADON) and Director of Nursing (DON);-Procedure:--Place Gait Belt around the Resident's waist over their clothing with the buckle forward;--Buckle/Fasten the Gait Belt;-- Slide open hand below belt to ensure the Gait Belt is snug but not too tight;-- Position your body close to the Resident; Face to Face;--Transfer Resident by firm grip on the Gait Belt with an underhand grip. Review of Resident's #98's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/24/26, showed:-Cognitively intact;-Uses a wheelchair;-Dependent on staff for toileting hygiene;-Requires partial to moderate assist from staff from siting to the standing position and bed to chair and chair to bed transfers;-Frequently incontinent of bowel and bladder;-Diagnosis include Parkinson's disease, dementia, and chronic obstructive pulmonary disease (COPD), a lung disease that cause the airway to become constricted and difficult to breathe. Review of the residents' care plan, in use at the time of survey, showed:-Focus: The resident has ADL performance deficit related to activity intolerance;-Interventions: Transfers with one staff member assist. Observation and interview on 4/6/26 at 11:04 A.M., showed the resident lay in bed with a strong odor of stool and urine. Certified Nursing Assistant (CNA) DD and Licensed Practical Nurse (LPN) K entered the room and assisted the resident with getting the resident cleaned and dressed. CNA DD placed the resident's wheelchair next to the resident's bed and instructed him/her move to the side of the bed and to stand up. CNA DD held the resident under his/her left arm and the resident held onto the wheelchair with his/her right hand. The resident had difficulty standing up straight and moving his/her feet. LPN K and CNA DD held onto the back of the resident's pants and had the resident pivot into the wheelchair. LPN K and CNA DD did not use a gait belt for the resident's transfer. LPN K said they messed up and said that he/she and CNA DD should have used a gait belt on the resident. The gait belt was used to provide a safe transfer in case the resident's legs gave out or he/she started to fall. During an interview on 4/10/26 at 9:30 A.M., CNA X said a gait belt was required anytime a resident required assistance getting out of bed or chair. CNA X said Resident #98 required a gait belt for transfers. It was to provide safety for the residents in case they started to fall. During an interview on 4/10/26 at 12:34 P.M., the DON said staff was expected to use a gait belt on all residents that required assistance with transfers and ambulation.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #74) with an external urinary collection device (a noninvasive external tube that drains the urine from the bladder) had appropriate physician orders to include catheter care instructions and monitoring. The sample was 24. The census was 121.Review of the facility's Lippincott Nursing Procedure Book, External Urine Collection Device Use, ninth edition, page 324, published 9/2/22, showed:-External urine collection device serves as an alternative to indwelling urinary catheters (sterile tube inserted into the bladder to drain urine) in cooperative residents who don't have signs of urinary retention;-An external urine collection device designed for male residents consist of a condom catheter or other device secure to the shaft of the penis and connected to a leg bag or drainage bag;-Complications are commonly due to equipment malfunction or trauma from improper application and removal can include penile irritation, skin breakdown, swelling, ischemic (dead) tissue loss and infection;-Document the assessment finding before, during, and after device use;-Record urinary output as directed by the facility;-Document the resident's tolerance of the procedure, an intervention implemented, and the resident's response to those interventions;-If the practitioner was contacted, record the date, time and information conveyed as well as any information received;-Document teaching provided to the resident and the resident's family, and their understanding of that teaching and any need for follow up teaching. Review of Resident #74's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/10/26, showed:-Moderate cognitive impairment;-Dependent on staff for toileting hygiene;-External or indwelling catheter: Not checked;-Always incontinent of bowel and bladder;-Diagnoses included stroke and neurogenic bladder (a condition that makes it difficult to empty the bladder). Review of the resident's care plan, in use at the time of survey, showed:-Focus: The resident has episodes of bowel and bladder incontinence;-Interventions included: Assist to bathroom as desired or indicated. Cleanse peri-area (genital and rectal area) after each incontinent episode.-The resident's care plan did not address an external urinary draining device. Review of the resident's physician order sheet, dated 4/7/26, showed no orders related to the resident's external urinary drainage device. Observation on 4/7/26 at 10:15 A.M., showed a pink basin on the resident's floor containing a urinary drainage bag filled with yellow urine. The catheter tubing was laying on the floor, and a condom catheter was attached to the end of the tubing. Grey duct tape was attached to the condom catheter. During an interview, Certified Nursing Assistant (CNA) O said the resident's family member placed a condom catheter on the resident and secured it with duct tape every evening. The resident had been wearing a condom catheter at night for over a month. CNA O thought the nurses knew about it. Every morning, he/she carefully removed the condom catheter and duct tape from the resident's genitals to ensure that the resident's skin did not become damaged. CNA O did not empty the resident's drainage collection bag; he/she let the resident's family member do it. During an interview on 4/7/26 at 1:00 P.M., Licensed Practical Nurse (LPN) S said he/she was not aware the resident had been wearing a condom urinary catheter and that a family member had been securing it with duct tape. LPN S expected the staff to have notified the nurse about this so that the family could be educated and the physician could be notified. Monitoring of the condom urinary device should include skin assessments, output amounts, and the characteristics of the urine to ensure an infection was not occurring. There should be physician orders for all urinary catheters and devices, and the use of a urinary catheter should be added to the resident's care plan. During an interview on 4/10/26 at 7:30 A.M., LPN W said he/she was not aware the resident was wearing a condom urinary device at night. There should be documentation and physician orders related to the resident's condom urinary device. LPN W expected staff to inform the nurse that duct tape was being applied to the resident's condom urinary device by a family member. During an interview on 4/7/26 at 12:10 P.M., the Director of Nursing (DON) said she was not aware the resident's family member was applying a condom urinary drainage device and securing it with duct tape. She expected staff to let the nurse or herself know that was occurring. She expected documentation of this in the progress notes, and for staff to document skin checks, physician orders, and monitoring related to the external urinary drainage device. She expected education to be completed with the resident's family member about the use of duct tape on the urinary catheter. 2804579

Based on observation, interview and record review, the facility failed to be free from medication errors of less than 5%. The facility's medication error rate was 11.11% with three errors out of 27 opportunities observed. Staff failed to monitor one resident's blood pressure (BP) prior to administration of Midodrine (a medication to treat low BP) (Resident #86). Staff also used improper technique and failed to follow the facility's policy when they instilled eyedrops for two different types of eye medications without pausing in between types of eyedrops, for one resident (Resident #92). The sample was 24. The census was 121. Review of the facility's Physician Orders policy dated 9/22, showed:-Policy: To provide guidance and ensure physician orders are transcribed and implemented in accordance with Professional Standards, State & Federal Guidelines.-Responsibility: Licensed Nurses, Nursing Administration, & Director of Nursing;-Physician Orders shall be provided by Licensed Practitioners (Physicians, Nurse Practitioners, & Physician's Assistants) authorized to prescribe orders.-Orders must be recorded in the Medical Record by the licensed nurse authorized to transcribe such orders;-Physician orders must be documented clearly in the medical record. The required components of a complete order;-Date and time of order;-Name of practitioner providing order;-Name and strength of medication/treatment;-Quantity/Duration;-Dosage/Frequency;-Route of administration;-Indication/Diagnosis;-Stop Date, indicated;-Physician orders that are missing required components, are illegible or unclear must be clarified prior to implementation. 1.Review of Resident #86's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/12/26, showed:-Severely impaired cognition;-Partial to moderate assistance required with activities of daily living (ADLs);-Diagnoses included: Dementia, hearing loss (HOH), and hypotension (low blood pressure). Review of the resident's care plan, in use at the time of survey, showed:-Focus: Hypotension;-Goal: Will remain free of complications related to hypotension through review date;-Interventions: Encourage adequate fluid intake and a healthy diet, give medications as ordered. Monitor for side effects and effectiveness. Review of the resident's physician orders sheet (POS) dated 4/6/26, showed;-An order date on 9/24/24, Midodrine 10 milligrams (mg) by mouth (PO) three times day (TID),-No order to check BP TID before administering Midodrine. Observation on 4/7/26 at 6:01 A.M., showed Certified Medication Technician (CMT) KK popped out a Midodrine tablet from the blister pack and into the medicine cup. CMT KK handed the resident the cup, and the resident swallowed the medication. CMT KK did not take a BP prior to the medication administration. During an interview on 4/7/26 at 6:01 A.M., CMT KK said he/she does not know what Midodrine medication is used for. The CMT said he/she really messed that up. He/She should have taken the resident's blood pressure first. CMT KK went back to take the resident's BP, and it was 130/74. Review of the medication administration record (MAR), dated 4/26, showed: During an interview on 4/10/26 at 12:34 P.M., the Director of Nursing (DON) said she expected staff to monitor residents' blood pressures prior to administration of any medications that require blood pressure checks. 2. Review of the facility's Eye Drop Administration policy dated 12/2017, showed:-Purpose: To administer ophthalmic solution/suspension into the eye in a safe, accurate, and effective manner;-Procedure: For general guidelines on medication administration, refer to 7.1: Equipment and supplies for administering medications and 7.2 medications administration-general guidelines; --Tilt resident's head slightly back;--With a gloved finger, gently pull-down lower eyelid to form pouch, while instructing residents to look up. Place other hand against resident's forehead to steady. Hold inverted medication bottle between the thumb and index finger and press gently to instill prescribed number of drops into pouch'' near outer corner of eye. Do NOT let tip of dropper touch the eye or any other surface. If resident blinks or drop lands on cheek, repeat administration;-While the eye is closed, use one finger to compress the tear duct in the inner [NAME] (inner canthus) of the eye for one to two minutes. This reduces systemic absorption of the medication. Alternatively, the resident may keep his/her eyes closed for approximately three minutes.'--Wipe off tears or excess solution with clean gauze, cotton ball, or tissue;--If another drop of the same or different medication is prescribed for administration in the same eye at the same time, wait 10 minutes, then repeat procedure above. Review of the Dorzolamide HCI- Timolol Mal manufactures dated 2024, showed:-When used with another eye drop, wait at least 5 minutes (min) before or after usage;-Step 1: Tear of safety seal;-Step 2: Unscrew the cap by lid and turn counterclockwise;-Step 3: Tilt your head back. Gently pull lower eyelid downwards to form a pocket between your eyelid and eye, while looking upward;-Step 4: Turn bottle upside down;-Step 5: Place the dropper tip of the bottle to your eye but be careful not to touch your eye with it. Gently press the bottle lightly with thumb or index finger until a single drop comes falls into your eye;- Step 5: Repeat steps 4 and 5 per physician's order. Review of Resident #92's MDS, dated [DATE], showed:-Severely impaired cognition;-Resident requires maximal assistance with ADLs from staff;-Diagnoses included: Kidney disease, hypertension (elevated blood pressure), Alzheimer's, Aphasia (language disorder-impaired words spoken, understood, and written), seizures (electrical disconnect between the neurons);-No diagnosis of glaucoma (pressure behind the eye). Review of the resident's care plan, in use at the time of survey, showed it did not address the need/reason for eye drops (gtts). Review of the resident's POS dated 4/6/26, showed;-An order dated 9/9/25, for Dorzolamide HCI- Timolol Mal (lowers ocular eye pressure related to (r/t) glaucoma) Ophthalmic (eye) Solution 2-0.5% instill both (ou) TID;-An order dated 9/9/25, for Brimonidine Tartrate ((treats glaucoma, ocular pressure) Ophthalmic Solution 0.2 %, instill 1 gtts in ou TID a day for glaucoma. Observation on 4/7/26 at 5:49 A.M., showed CMT KK pried the resident's eyelid open, while the resident resisted. CMT KK instilled one gtt of Brimonidine solution into the resident's eye and repeated the same process on the opposite eye. CMT KK held the second bottle of eye gtts, the dorzolamide timolol solution. CMT KK did not pause for any extended amount of time in between eye gtts and repeated the previous process above. During an interview on 4/7/26 at 5:49 A.M., CMT KK said the residents does not usually sleep this hard, and the resident had a hard time waking up this morning. During an interview on 4/10/26 at 12:43 P.M., the DON said she expected staff to follow policy and procedure regarding the facility's eye drop administration policy. The proper technique would be hand hygiene, gloves next and then pull the eyelid down and instill a drop into the eyelid. Then staff should wipe the extra solution off with a Kleenex and pause for 3-5 minutes between eye solutions. 28068052804579

Based on observation, interview, and record review, the facility failed to maintain medical records that were complete and accurately documented in accordance with acceptable professional standards and practices when staff documented treatments as completed when they had not been administered for one resident (Resident #23). The sample was 24. The census was 121. Review of Resident #23's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/30/26, showed:-Cognitively intact;-Diagnoses included dementia, muscle weakness, and quadriplegia (paralysis of all four limbs and the torso). Review of the resident's physician's order summary (POS), dated April 2026, showed:-An order, dated 1/5/26, for wound to right great toe. Morning shift, cleanse with wound cleanser, pat dry and apply dry dressing every 3 days until healed;-An order, dated 2/8/26, to change oxygen tubing weekly on Sunday evening shift;-An order, dated 3/10/26 for oxygen at 3 liters (L) via nasal canula (NC) as needed. Review of the resident's treatment administration record (TAR), dated April 2026, showed:-On 4/2/26, staff documented the wound treatment to the right great was completed;-On 4/5/26, staff documented the oxygen tubing change was completed. Observation on 4/6/26 at 9:05 A.M., showed the resident's oxygen tubing dated 3/15/26. During an interview, the resident said he/she used oxygen as needed. He/She had a wound on his/her right toe and he/she was unsure when the dressing was last changed. Observation on 4/7/26 at 6:54 A.M., showed the resident in bed. The dressing on the resident's right great toe was dated 3/26/26. During an interview on 4/10/26 at 8:08 A.M., Licensed Practical Nurse (LPN) K said the resident's right great toe wound was healed and the dressing was being used as a preventative measure. The dressing should be changed per the physician's orders. Staff should only mark the oxygen tubing change as completed if the tubing was changed. During an interview on 4/10/26 at approximately 7:00 A.M., the Administrator said he did not have a policy regarding medical record documentation accuracy. During an interview on 4/10/26 at 1:03 P.M., the Administrator and Director of Nursing (DON) said staff should not document treatments or orders as completed if they were not administered.

Based on interview and record review, the facility failed to ensure Certified Nurse Aides (CNAs) employed at the facility for more than a year received no less than 12 hours of in-service training per year, for two of five sampled employees. The census was 121.Review of the facility's Facility Assessment, dated 1/30/26, showed:-Staff Training/Education and Competencies:-Competencies covered annually:--Activities of daily living (ADLs);--Disaster planning;--Medication administration;--Measurements (vitals, intake, output);--Resident assessment;--Caring for people with dementia, Alzheimer's disease, and cognitive impairments;--Caring for people with mental and psychosocial disorders;--Non-pharmacological management of responsive behaviors;--Caring for residents with trauma/post-traumatic stress disorder (PTSD);-The facility assessment did not identify how many training hours were required annually for CNAs. 1. Review of CNA EE's employee record, showed:-Hire date 7/18/17;-On 4/6/26, the first day of survey, CNA EE completed 15.5 hours of training between 4:25 P.M. and 6:20 P.M. 2. Review of CNA FF's employee record, showed:-Hire date 9/1/24;-3.5 hours of training completed between 9/1/24 and 9/1/25. 3. During an interview on 4/10/26 at 10:31 A.M., CNA N said CNAs are provided training education through an online portal. Facility Administration sets certain courses to be completed, and CNAs are expected to complete 12 hours of training per year, from hire date to hire date. He/She assumed the facility Director of Nursing (DON) was responsible for auditing and ensuring training hours were completed. 4. During an interview on 4/10/26 at 12:35 P.M., the DON and Administrator said they expected all CNAs working at the facility to be provided 12 hours of continuing education on a yearly basis. Training should be completed gradually throughout the year and staff should not complete all training in one day, as this can impact staff's comprehension of the material.

Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice by not following physician orders for daily weights for one resident (Resident #1), and by leaving medications, including pain, blood pressure, and seizure medications in a medicine cup in the resident's room for the family member to administer (Resident #13) . The sample size was 24. The census was 121.Review of the facility's Physician Orders policy, dated 9/28/22, showed:-Policy: To provide guidance and ensure physician orders are transcribed and implemented in accordance with professional standards, state and federal guidelines. The licensed nurse is required to record the order in the electronic medical record (EMR), the physician order sheets (POS) and on the appropriate medication administration record (MAR) and treatment administration record (TAR). Review of the facility's Medication Administration-General Guidelines, dated 12/17, showed: Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by legally authorized personal to do so. Personnel authorized to administer medications do so only after they have properly orientated to the facility's medication distribution system (procurement, storage, handling, and administration). The facility has sufficient staff and medication distribution system to ensure safe administration;-Preparation:--Medications are prepared only by licensed nursing (Registered Nurse (RN), Licensed Practical Nurse (LPN), medical, pharmacy or other personnel authorized by state laws and regulations to prepare and administer medications;--The need for crushing medications should be indicated on the residents' orders and the Medication Administration Record (MAR) so that all personnel administering medications are aware of this need and the consultant pharmacist can advise on safety issues and alternatives, if appropriate, during medication regimen reviews;-Administration: Medications are administered only by licensed nursing, medical, pharmacy or other personnel authorized by slate laws and regulations to administer medications. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/2/26, showed:-The resident is cognitively intact;-Diagnoses included heart failure, high blood pressure, and renal failure. Review of the resident's care plan, in use at the time of survey, showed:-Focus: The resident has congestive heart failure (CHF), when the heart muscle is too weak to pump blood efficiently causing fluid to accumulate in the body.-Interventions: Check daily weight and fax a weekly log to the cardiac clinic. Review of the residents POS dated, 4/6/26, showed an order dated 11/1/25, Check daily weight and fax weekly weight log to the Heart Failure Clinic; Notify the physician or Nurse Practitioner (NP) if a weight gain of three pounds in 24 hours or five pounds in three days occurs; The nurse is to document signs and symptoms of fluid retention related to CHF as needed. Review of the residents' weights, dated March 2026, showed no daily weight documented on: 3/1/26, 3/4 through 3/9/26, 3/11 through 3/16/26, 3/21 through 3/26/26, and 3/31/26. Review of the residents' weights dated 4/1 through 4/6/26, showed no daily weight documented on 4/2 through 4/4/26. During an interview on 4/8/26 at 11:10 A.M., the resident said the staff did not weigh him/her daily. During an interview on 4/10/26 at 7:30 A.M., Licensed Practical Nurse (LPN) W said the night shift aides were expected to obtain daily weights. The nurses should document the weights in the EMR under the weight tab. During an interview on 4/10/26 at 9:30 A.M., Certified Nursing Assistant (CNA) X said the night shift aides were responsible for obtaining the daily weights and giving the weights to the nurse to document in the EMR. During an interview on 4/10/26 at 12:34 P.M., the Director of Nursing (DON) said she would expect staff to follow physician orders and obtain daily weights and document the weights in the EMR. The DON said she was aware the resident had CHF and required daily weights. 2. Review of the Resident's #23's Quarterly MDS, dated [DATE], showed:-Severe cognitive impairment;-Dependent on staff for all ADLs;-Diagnoses included Parkinson disease ( a progressive, incurable neurological movement disorder caused by the loss of dopamine-producing neurons in the brain), diabetes, chronic obstructive pulmonary disease (COPD), dysphagia (impaired swallowing), pressure ulcer of left hip, stage four (a severe, full-thickness wound extending to exposed bone, tendon, or muscle, often featuring deep tissue damage, tunneling, and high infection risk), pressure ulcer of the left lower back, stage three (full-thickness skin injury appearing as a deep, open, crater-like wound where subcutaneous fat is visible), pressure ulcer of sacral region, stage three and diabetes. Review of the resident care plan, in use at the time of survey, showed the care plan did not address if the resident's family members were allowed to administer prescribed medications. Review of the resident's POS, dated 3/25/26, showed:- An order, dated 12/12/25, for sodium chloride (salt tablet) by mouth (PO) 1 milligrams (mg);- An order, dated 8/21/25, for carbidopa-levodopa (Parkinson medication) PO 25-100 mg three times daily;- An order, dated 8/21/25, for metoprolol tartrate (elevated blood pressure (BP)12.5 mg PO twice daily;-An order, dated 8/22/25, for gabapentin (nerve pill) capsule 300 mg, give one capsule PO daily;-An order, dated 8/22/25, to crush / sprinkle all meds every shift;-An order, dated 8/22/25, for a multivitamin (vitamin) PO daily;-An order, dated 8/22/25, for metformin (controls diabetes) PO tablet 1,000 mg;-An order, dated 8/22/25, for sertraline (mood stabilizer) PO tablet 100 mg, give one tablet daily;-An order, dated 8/22/25, for divalproex sodium (seizure) one capsule delayed release sprinkles 125 mg PO twice a day;-An order, dated 2/25/26, for tramadol (pain) tablet 50 mg, give one tablet every 12 hours. Observation on 4/9/26 at 8:49 A.M., showed the resident's family member in the resident's room, who fed him/her breakfast. The resident's bedside table had a medicine cup, with apple sauce, crushed medications and a spoon. No staff was present in the resident's room. During an interview on 4/9/26 at 8:51 A.M., Certified Medication Technician (CMT) LL said the resident would not accept medication from staff the resident did not recognize. CMT LL said he/she handed the medicine cup to the family member to feed it to the resident between bites of breakfast, but did not remain in the room to see if the resident took the medication. At 8:57 A.M., CMT LL said the medicine cup included the following medications: multivitamin, Vitamin C, Metoprolol, Tramadol, Gabapentin, iron, sodium, Metformin, Quetiapine, Sertraline, Carbidopa-Levodopa, and Depakote. During an interview on 4/10/26 at 12:43 P.M., the DON said she expected staff to administer residents' medications. Family members should never administer medications to residents. If staff provided a prepared medication cup to a family member, the staff member must remain at the resident's side. The DON said the resident was at risk for elevated blood pressure, seizures, and unmanaged pain because the staff member did not verify that the medications were taken.

Based on observation, interview and record review, the facility failed to provide adequate treatment and services for two residents with pressure ulcers (wounds related to prolonged pressure on bony prominences) (Resident #2 and #13) and interventions to prevent pressure ulcers for one resident (Resident #23). The facility failed to provide ordered treatments and a timely wound consult for Resident #2. The facility failed to provide dressing changes when dressings were saturated, for Resident #13. The facility failed to provide Residents #13 and #23 with low air loss mattresses set to the correct settings, which would put the residents at risk for increased pressure on bony prominences. The sample size was 24. The census was 121. Review of the facility's Wound Management policy, dated 11/22, showed:-Policy: To promote wound healing of various types of wounds, the facility will provide evidence-based treatments in accordance with current Standards of Practice and Physician orders;Procedure: Wound Management:- Wound treatment will be provided in accordance with Physician's order;--Cleansing method;--Type of dressing;--Frequency of dressing change;-Charge Nurse will notify Physician in the absence of treatment orders;-Dressing changes may be provided outside of the frequency parameter in certain situations;-- Urine, feces, or other bodily fluids have saturated through the dressing;-- Dressing is dislodged;--Dressing is soiled;- Wound dressings will be applied in accordance with manufacturer's recommendations.-Treatment selection will be based on the etiology of the wound;--Pressure injuries will be differentiated from non-pressure wounds;- Treatments will be documented on the Treatment Administration Record (TAR).-The effectiveness of treatments will be monitored through ongoing evaluation of the wound(s).--Considerations modification:--Lack of progression towards healing.--Changes in wound characteristics.--Changes in the resident/resident representative's preferences/goals (e.g., comfort care associated with end of life in accordance with his/her rights. 1. Review of Resident #2's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed:-Diagnoses included: Aphasia (impaired talking and understanding language), elevated blood pressure, end stage renal disease (severe kidney failure), and dependence of dialysis;-Cognitively intact;-Fully dependent on actives of daily living (ADLs)-Number of pressure ulcers: Zero are present, none present upon admission.-Pressure reducing device for bed. Review of the Braden Scale for Predicting Pressure Ulcer Risk, effective date of [DATE] at 7:30 P.M., showed a score of 17 which meant the resident was At Risk for developing a pressure ulcer. Review of the resident's care plan, in use at the time of the survey, showed:- Focus: Resident is at risk for pressure ulcer development related to reduced mobility;-Goal: Resident will have intact skin, free of redness, blister or discoloration by/through review date;-Interventions: Educate family, care givers as to causes of skin breakdown, including transfers, positioning requirements, good nutrition, and frequent (Freq) repositioning, shift weight every (Q)15 minutes, the resident needs Q two hour (HR) turns more often as needed or requested. Review of the electronic physician's order sheet dated 3/26, showed:-An order date of [DATE], showed: Wound care: Coccyx (tailbone) Cleanse wound with wound cleanser and allow to dry. Apply calcium (Ca+) alginate (AG) (highly absorbent, seaweed-derived fibers used for moderate-to-heavy exuding wounds, such as ulcers and burns) cut to fit wound bed and cover with bordered gauze island dressing (sterile adhesive bandage) each shift and as needed (PRN) if soiled or nonintact;-An order date [DATE], showed: Wound Care: Perineal (around genitals) area-apply zinc oxide (barrier cream) to perineal area four times daily and PRN after each incontinent episode;-An order date [DATE], showed: Complete Skin Observation Tool Form on night shift on Monday. Completion of this form will satisfy the order. Review of the TAR dated 3/2026, showed:- Wound care: Coccyx, cleanse wound with wound cleanser and allow it to dry. Apply calcium alginate cut to fit wound bed and cover with bordered gauze island wound dressing; staff missed one treatment out of 18 opportunities. Review of the skin observation tool dated [DATE], showed: The resident has redness noted to the sacrum (back part of pelvic bone) and coccyx area, zinc oxide applied as ordered, skin tear (ST) to left hand, dressing (drsg) dry and intact, no new skin issues noted at this time. Review of the skin observation tool dated [DATE], showed: Treatment (Tx) orders for current skin issues. Skin warm, dry and intact. No new skin issues observed, barrier cream applied to coccyx after incontinent episode;- Resident has open area on coccyx that appears to have some tunneling. Packed with calcium alginate and covered with bordered gauze;-Coccyx, pressure with measurements of 3 centimeters (cm) by 2.5 cm. Review of the nurse's progress note on [DATE] at 7:43 P.M., showed the Aide reported an open area on the resident's coccyx appeared to be worsening. When this nurse went in to assess he/she observed open area on coccyx that appeared to have some tunneling (a severe, chronic wound that forms narrow, deep tracts or channels extending from the wound bed into subcutaneous tissue or muscle), 3 cm length by 2 cm width. This nurse covered area with calcium alginate and covered with bordered gauze. The nurse reported the change in condition to Nurse Practitioner (NP) Q who ordered a wound consult and to leave the area covered until new orders are given. Wound nurse also notified. Review of the Wound Nurse progress note on [DATE] at 7:50 A.M., showed: Resident assessed on [DATE] following report from charge nurse of worsening open area to coccyx. Per report, aide noted decline in appearance of area. Upon assessment, open wound to coccyx noted measuring 1. 7 cm by 2.2 cm by 0.1 cm with no concern for tunneling. Wound bed yellow fibrinous exudate (drainage). Area cleansed and dressed in calcium alginate and covered with bordered gauze for protection. Resident tolerated assessment and intervention without difficulty and will continue to be monitored closely for any further changes in condition. Charge nurse notified. Review of the TAR dated 4/2026, showed:-Wound care: Coccyx, cleanse wound with wound cleanser and allow it to dry. Apply calcium alginate cut to fit wound bed and cover with bordered gauze island;-Wound treatment missed two out of 14 opportunities. Review of the Nurse progress note on [DATE] at 6:33 P.M., showed the resident was seen for weekly wound assessment of coccyx. Wound red and yellow with no drainage noted at this time. Wound measures 2.3 cm by 2.1 cm by 0.1 cm. Educated resident on offloading pressure to area, but resident does not like to lie in bed and wants to remain in wheelchair (WC). Charge nurse notified. Review of the Nurse progress note on [DATE] at 2:32 P.M., showed: Wound care: Coccyx - Cleanse wound with wound cleanser and allow to dry. Apply calcium alginate cut to fit wound bed and cover with bordered gauze island dressing each shift and PRN if soiled or nonintact. Nurse was unable to complete the dressing changed and notified NP T. During an interview on [DATE] at 3:07 A.M., the resident said there has been a wound on his/her coccyx for two to three months. The wound did get better but then got worse again. Observation on [DATE] at 11:27 A.M., showed the Wound Nurse asked the resident if he/she was alright? The resident said, It hurts, there are two spots on my hip bone and anus. The resident's bed had a regular mattress. Observation on [DATE] at 11:40 A.M., showed Certified Nursing Assistant (CNA) T and Certified Medical Technician (CMT) V used the Hoyer (mechanical lift) to put the resident back to bed. The coccyx dressing was dated 4/9, but very soiled and dried. Another wound just above the coccyx was open and not covered with a bandage or dressing. During an interview on [DATE] at 11:40 A.M., CMT V said when he/she worked, the resident complained about pain frequently. CMT V said he/she shared the resident's complaint with the nurse, but CMT V was unsure if the nurse administered any pain medication. During an interview on [DATE] at 11:40 A.M., CNA T said they told the nurse about the pain but were unsure if the nurse administered any pain medication. Observation on [DATE] at 12:00 P.M., with the Wound Nurse, showed a coccyx wound and deep tissue injury (DTI) between 3-6 o'clock (location of the injury in comparison to the wound). The resident continued to yell in pain. At 5-6 o'clock there was a skin tear. A steady stream of blood flowed from the open wounds. During an interview on [DATE] at 12:00 P.M., the Wound Nurse said the resident is being followed by an outside wound clinic. The resident had an appointment set up, but the Wound Nurse was not sure of the date. The wound started [DATE] as a skin tear. The Wound Nurse first saw the wound on [DATE]. When the resident was scheduled to see the wound specialist, the resident was out of the facility due to dialysis appointments. That was why the resident needed to see an outside wound specialist. The resident has a donut (a pillow with a hole in the center) because he/she does not like the facility cushions. There are no orders from the medical doctor or wound doctor currently for the new wound above the coccyx, due to the wound starting off as a skin tear. The Wound Nurse said the coccyx measurements were 5.1 cm by 1.9 cm by 0.4 cm, negative for tunneling. The Wound Nurse read off the date on the bandage that read date 4/9. At 2:09 P.M., the Wound Nurse said the Wound Nurse NP gave new orders for the adhesive concern above the coccyx wound, the wound treatment was changed, and they will plan to continue care with an outside wound clinic. During an interview on [DATE] at 12:00 P.M., the Director of Nursing (DON) said, she expected staff to follow physician's orders. The DON did not know if the wounds were pressure or non-pressure without review of the resident's chart. The facility social worker should schedule any appointments outside the facility as soon as possible. When the wound became worse, the staff should have notified someone to clarify if the treatment should remain intact or if new orders were required. Staff just made the appointment for an outside wound clinic, the appointment is scheduled for [DATE] at 8:30 A.M. The care plan should have been updated with interventions. The DON was unaware if the staff thought about or attempted to change the resident's dialysis days to accommodate the wound specialist days in the facility. A physician's order is required for a resident to obtain a low air mattress (LAL). 2. Review of the Resident's #13's quarterly MDS, dated [DATE], showed:-Diagnoses included Parkinson disease (is a progressive, incurable neurological movement disorder caused by the loss of dopamine-producing neurons in the brain), pressure ulcer of left hip, stage 4 (a severe, full-thickness wound extending to exposed bone, tendon, or muscle, often featuring deep tissue damage, tunneling, and high infection risk), pressure ulcer of left lower back, stage 3 (full-thickness skin injury appearing as a deep, open, crater-like wound where subcutaneous fat is visible, but muscle, tendon, or bone are no),, pressure ulcer of sacral region, stage 3, diabetes, non-pressure chronic ulcer of skin of other sites with flat layer exposed (wound not on bony prominence), chronic obstructive pulmonary disease (ineffective breathing (COPD), dysphagia (impaired swallow) and severe protein - calorie malnutrition (a critical deficiency in protein intake-often coupled with inadequate caloric consumption);-Severe cognitively impairment (impaired brain function);-Dependent on staff for all ADLs;-Incontinent bowel and bladder;-Weight of resident is 117 pounds (lbs.);-Number of stage 3 pressure ulcers that were not present on admission, three;-Number of stage 3 pressure ulcers present on admissions, one;-Number of stage 4 pressure ulcers present, zero;-Skin and Ulcer/Injury Treatments included: Pressure reducing device for bed;-No other Treatment listed, such as turning and repositioning, nutrition or hydration intervention, pressure ulcer/injury care, or application of ointments/medication marked on MDS. Review of the Vendor 1 operations manual, dated 11/2017, showed:-The mattress must be set according to the resident's weight, comfort, and clinical condition to ensure proper immersion and pressure redistribution;-The guidelines instructed staff to utilize the AHCPR (Agency for Health Care Policy and Research) hand-check method to confirm appropriate firmness (25-40 millimeter (mm) or 1 to 1.5 inches between the resident and mattress surface) to prevent bottoming out;-Improper firmness settings, kinked air lines, excessive linen layering, or failure to follow operational modes may negatively affect pressure redistribution and increase the risk for skin breakdown;-The mattress is only one component of care and must be used in conjunction with appropriate repositioning, skin assessment, and wound care practices;-Linen Note: Deep-pocketed sheets are recommended (not included). Multiple layering of linens or under pads beneath the resident can negatively affect the mattress's pressure management capabilities and should be avoided unless recommended by a caregiver. Review of the facility's Braden Scale for Predicting Pressure Ulcer Risk, effective date of [DATE] at 1:39 P.M., showed: a score of 12 which meant the resident was High Risk for developing a pressure ulcer. Review of the resident's care plan in use at the time of survey, showed:-Focus: Resident has a pressure ulcer sacrum stage 4, left lower back stage 4, left hip stage 4, left hand stage 4; family has been noted to be removing the wound drsg at times and education has been provided to family;-Goal: The resident's pressure ulcers will show signs of healing and remain free from infection by/through review date. Resident is responding to antibiotics (ABT) for wound infection. Wound is showing improvement;-Interventions: Administer treatments as ordered and monitor for effectiveness, Access/record/monitor wound healing, measurements length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the medical doctor (MD); LAL, Q two HR turns, weekly Tx to include measurements of each area of skin breakdown's width, length, depth and type of tissue and exudate. Review of the electronic physician's order sheet dated [DATE], showed:-An order dated [DATE], showed: Complete skin observation tool form on day shift Q Tuesday. Completion of this form will satisfy the order;-An order dated [DATE], showed: Bilateral heel protectors to be worn at all times, Q shift;-An order dated [DATE], showed: Turn resident Q two hours;-An order dated [DATE], showed: Wound Care: Sacrum - Cleanse wound with Dakin's full strength (a potent, broad-spectrum antiseptic designed to treat and prevent skin and tissue infections) and allow it to dry. Skin prep periwound (skin around the wound). Apply gentamicin ointment (a prescription, broad-spectrum aminoglycoside antibiotic used to treat primary and secondary bacterial skin infections, such as impetigo, infected burns, cuts, or skin ulcers) and Ca+ and AG with silver (highly absorbent, antimicrobial, conformable wound dressing made from seaweed fibers and ionic silver. It manages moderate to heavy exudate by turning into a gel) cut to fit to wound bed and fill cavities lightly, cover bordered gauze daily and PRN if soiled/nonintact Q shift;-An order dated [DATE], showed wound Care: left (L) lower back - Cleanse with Dakin's full strength. Pat dry. Skin prep to periwound. Apply gentamicin and calcium alginate cut to fit to wound bed and fill cavities lightly, cover with gauze island dressing daily and PRN if soiled/nonintact Q Day shift and night;-An order dated [DATE], showed: Wound Care: L hip - Cleanse with Dakin's full strength. Pat dry. Skin prep to periwound. Apply gentamicin, Santyl (a prescription debriding agent used to remove necrotic (dead) tissue from chronic dermal ulcers and severe burns), and calcium alginate cut to fit to wound bed and fill cavities lightly, cover with gauze island dressing daily and PRN if soiled/nonintact Q Day and night shift;- An order dated [DATE], showed: Wound Care: L hand- Cleanse with wound cleanser. Skin prep periwound. Apply calcium alginate silver cut to fit to wound bed and cover with bordered gauze island daily and PRN if soiled or non-intact Q shift;-An order dated [DATE], showed: Provide air mattress on his/her bed -sacral wound with eschar (dry, dead tissue) and bony prominences/L hip and L elbow with stage 1 (reddened but intact skin) pressure wound(s). Review of the Medication Administration Recorded (MAR), and TAR dated 4/26, showed bilateral heel protection to be worn at all times Q shift; marked as completed for 11 of 12 opportunities. During an interview on [DATE] at 8:18 A.M., Family Member A said the resident was admitted to the facility about 1 1/2 years ago. The wounds were not healing due to the staff not changing the dressing frequently, and the family needing to come in to feed the resident. The wounds have so much heavy drainage. The wounds on the hip and tailbone are infected. There is so much drainage repeatedly, and the dressings are only changed daily. You can see the drainage on the sheets. Family Member A would prefer the wounds to be changed twice daily (BID), not just daily. Observation on [DATE] at 8:18 A.M., showed a LAL mattress on his/her bed. The resident lay turned towards the door in bed with a wedge (medical device to keep resident on side, relieves pressure to tailbone). Right (R) dressing dated 4/5, 7:00 A.M.-7:00 P.M., serosanguinous (thin, light red) drainage shown through the dressing. The resident wore bilateral heel protective boots. There was a bandage on the resident's L great toe and coccyx. There was a large amount of drainage on the resident's blanket. Observation on [DATE] at 12:35 P.M. and [DATE] at 9:29 A.M., showed the LAL mattress pump set at 9, which meant the weight was set for 500 lbs. Observation on [DATE] at 6:52 A.M., showed the resident in bed with protective boots on. The LAL mattress was set at 9, which accommodated a 500 lb. person. The resident lay on his/her right side, exposing his/her L lateral hip. The L lateral hip dressing was saturated and bulky, dated 4/7. Observation on [DATE] at 8:24 A.M., showed the resident's left lateral hip dressing saturated and bulky. Observation on [DATE] at 8:57 A.M., showed staff in the room. The bed was set at 9, which showed a weight for a 500 lb. person, and the resident was soiled. At 9:03 A.M., The Wound Nurse told staff to clean the resident up. When CNA AA unfastened the brief, the left lateral hip dressing was saturated to the point it was dislodged from the actual site of the wound. There was dried drainage on the blanket that was under the resident's buttocks. At 9:07 A.M., the CNA exited the room. At 9:11 A.M, CNA ZZ returned with the Wound Nurse. The resident was soiled from fecal material. Staff pulled the resident over and wound had solid, dried drainage visible on the island dressing dated [DATE]. The blanket was folded hotdog way and placed under the resident's lower back. At 9:23 A.M., the left lateral island dressing was bulky yellow and coming off the wound where it had dried. The left lower back dressing was white with dried drainage marks on the island dressing. Durning an interview on [DATE] at 8:57 A.M., CNA AA said the resident was soiled and his/her wounds just leak. At 9:11 A.M., CNA AA said staff fold the blanket to make it easier to pull/elevate the resident higher in bed. CNA AA used the blanket because it was the first thing he/she saw. Observation on [DATE] at 9:01 A.M., showed the resident's LAL mattress set at 9; a setting needed for a 500 lb person. Durning an interview on [DATE] at 9:23 A.M., the Wound Nurse said the dressings were compromised by edges folded in on themselves. The Wound Nurse said the resident defecated, and pink to red tissue appeared through the brief. The drainage was seropurulent (wound drainage or discharge that is a mixture of serum (clear, thin fluid) and pus (thick, opaque fluid)). The resident was on two rounds of antibiotic for about six weeks. The left-hip has a stage 4 pressure ulcer; measurements of 4.7 cm by 5.5 cm, with 95 % granulation (new tissue growth) slough (mass of dead tissue separating from living skin) 5% pink tissue around with tunneling (at 11o'clock, 4.5 cm undermine (pocket) from 11:00 o'clock to 2:00 o'clock with the deepest being 2.5 cm. A resident's brief can hold moisture and possibly compromise wound dressings. The Wound Nurse would need to check the facility's policy, but the family requested a brief be left on. The residents' lower back wound measurements were 4.5cm by 6.5 cm by 0.4 cm, with the deepest point at 2:00 o'clock. The floor nurses should use the PRN order when they notice the dressings are compromised/ soiled. The sacrum had serosanguinous drainage, and they used full Dakin Solution to cleanse the wound. The wound had macerated (skin that is white, wrinkled, soggy, or soft due to prolonged exposure to moisture, such as wound exudate, sweat, or urine) edges. The resident's tailbone was actively bleeding with a steady stream. There is a deep tissue pressure injury at 9 o'clock with granulation some epithelia (appearing light pink or white, this is aregenerative process) tissue with no slough. The Wound Nurse will call the MD for new orders related to the new breakdown from 7:00-11:00 o' clock. The new breakdown could be caused from the adhesive from the dressing. The measurements are 11.6 cm by 8.4 cm with undermining from 1:00-5:00 o'clock, 2.3 cm, depth 0.1 cm. The Wound Nurse said the left great toe was new to him/her, and the site is not open. The resident's left hand has a wound which they use wound cleaner, skin prep, silver AG and gauze dressing. The left hand wound measured 2.4 cm by 1.6 cm by 0 .3 cm and undermining depth of 0.3 cm. The LAL mattress is to prevent more skin break down. The Wound Nurse was unfamiliar with the mattress setting. The settings are given to the charge nurse and there should be an order. If there are no orders, he/he would expect the nurse to obtain orders. The Wound Nurse said the setting at 9 is needed for a 500 lb. person, and the resident is not suited for this setting. The setting is too high and could risk the wounds getting worse. The Wound Nurse would need to brush up on the policy and setting requirements while obtaining an MD order. The Wound Nurse was unsure if the folded blanket could cause any risk to the wounds, but the blanket was used to prevent shearing to the resident. During an interview on [DATE] at10:43 A.M., the DON said the facility does not have a specific low air matters policy, and they are going around the building to get the names of the manufacturers to call and get their recommendations. After that they will contact the MD to obtain new recommended settings for each individual resident. There was no monitoring of the LAL settings prior to the survey begun this week, and there were no problems brought to the facility's attention. Staff can utilize a flat sheet with a LAL mattress, but Resident #13 should not have a blanket under him/her. At 10:48 A.M., the DON read the setting of the pump was on 9 for 500 lbs. The blanket did not allow the bed to function properly. Review of the nurse's progress note dated [DATE] at 3:19 P.M., showed an order from MD to set LAL mattress setting according to the resident's weight. Observation on [DATE] at 8:14 A.M., showed the resident had a blanket folded under him/her and bed set at 1. The resident did not have his/her right protective heel boots on. During an interview on [DATE] at 9:04 A.M., Family Member B said he/she changed the wound dressings because they were soaked. 3. Review of Resident #23's quarterly MDS, dated [DATE], showed:-Diagnoses included dementia, muscle weakness, and quadriplegia (paralysis of all four limbs and the torso);-Cognitively intact. Review of the resident's care plan, in use at the time of the survey, showed:-Focus: The resident is at risk for pressure ulcer development due to quadriplegia, incontinence and assistance needed with bed mobility;-Goal: The resident will have intact skin, free of redness, blisters or discoloration by/through review date;-Interventions: Follow facility policies/protocols for the prevention/treatment of skin breakdown. Inform the resident/family/caregivers of any new area of skin breakdown. The resident needs assistance to turn/reposition at least every two hours, more often as needed or requested. Review of the Vendor 3 operations manual, undated, showed:-Indications: pump and mattress system, is indicated for the prevention and treatment of any and all stage pressure ulcers when used in conjunction with a comprehensive pressure ulcer management program. It can be used in a hospital, homecare, or other healthcare environment.-Operating instructions: determine the patient's weight and set the control knob to that weight setting on the control unit. Review on [DATE] at 8:46 A.M., the resident's weight summary, showed the resident's most recent weight, taken on [DATE], was 181.5 pounds. Review of the resident's physician's orders summary (POS), dated 4/2026, showed:-No order for air loss mattress usage or settings. Observation on [DATE] at 2:06 A.M., showed the resident awake in bed. The mattress was set to 320 with normal pressure. Observation on [DATE] at 4:54 A.M., showed the resident awake in bed. The mattress was set to 320 with normal pressure. Observation on [DATE] at 6:25 A.M., showed the resident in bed awake. The mattress was set to 320 with normal pressure. 4. During interviews on [DATE] at 12:43 P.M. and 1:16 P.M., the DON said the physician orders should indicate firmness and to check every shift. The correct settings are based on the resident's weight and manufacturer's recommendations. She would expect the mattress settings to be checked by nursing staff every shift. The DON expected the staff to use PRN orders for wound Tx. 5. During an interview on [DATE] at 11:23 A.M., The Medical Director said he was unsure if a high/firm bed setting could make the wounds worse. He would expect the staff to use the PRN order if the dressing was compromised, saturated or coming off; that is the purpose of the PRN order. He would expect staff to follow physician's orders and facility policy.

Based on observation, interview and record review, the facility failed to ensure residents received appropriate activity of daily living (ADL, daily care) care to meet the needs of residents by leaving one incontinent resident (Resident #98) soiled and wet for an extended period. The sample was 24. The census was 121.Review of the facility's Perineal Care (cleansing of the genitals and anal area) policy, undated, showed:- Perineal care which includes care of the external genitalia and the anal area, should be offered during the daily bath and it the resident is incontinent for urine or stool; The procedure promotes cleanliness and prevents infection. It also removes irritating and odorous secretions. Review of Resident's # 98's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/24/26, showed:-Cognitively intact;-Dependent on staff for toileting hygiene;-Required partial to moderate assist from staff for personal hygiene;-Frequently incontinent of bowel and bladder;-Diagnoses included Parkinson's disease, dementia, and chronic obstructive pulmonary disease (COPD), a lung disease that cause the airway to become constricted and difficult to breathe. Review of the residents' care plan, in use at the time of survey, showed:Focus: The resident has occasional episodes of bowel and bladder incontinence and is at risk for infection and skin breakdown;-Interventions: Assist the resident to the bathroom as desired; Offer to use the toilet before and after meals and at bedtime; Clean perineum after each incontinent episode. Observation and interview on 4/6/26 at approximately 9:00 A.M., showed the resident lay in bed and was heard from the hall yelling Nurse. The resident said he/she had been yelling for help for about 30 minutes because he/she needed to use the bathroom. At 10:01 A.M., the resident lay in bed and had a strong odor of stool present. The resident's call light was wrapped around the bed frame and out of the resident's reach. The resident said he/she could not reach his/her light and needed help going to the bathroom. At 10:32 A.M., the resident lay in bed. The resident's call light was wrapped around the resident's bed frame and out of the resident's reach. The resident said he/she was soiled and wet and no one has been in to check on him/her and he/she could not reach his/her call light. At 11:04 A.M., the resident lay in bed with a strong odor of stool and urine. Certified Nursing Assistant (CNA) DD and Licensed Practical Nurse (LPN) K entered the resident's room and had the resident turn to his/her right side. CNA DD removed the resident's brief. The resident's brief and bed pad were saturated with urine. The resident also had a large amount of diarrhea in his/her brief. The resident said he/she had not been changed all night or morning. During an interview on 4/10/26 at 7:30 A.M., Licensed Practical Nurse (LPN) W said incontinent residents were checked on every one to two hours. The CNA's and the nurses all made rounds on the incontinent residents to ensure they were clean, dry and odor free. Having the resident wait for over two hours to be cleaned was too long of a time. During an interview on 4/10/26 at 9:30 A.M., CNA X said incontinent residents were to be rounded on every two hours to ensure they were clean and dry. Resident #98 used the bathroom and should have been offered to use the restroom when the resident requested. Frequent checks were important so that the resident did not get skin breakdown. During an interview on 4/10/26 at 12:34 P.M., the Director of Nurses (DON) expected the staff to check on incontinent residents every two hours. She expected the residents to be clean, dry and odor free. 2806805280719028045792978188

Based on observation, interview and record review, the facility failed to provide reasonable accommodation of individual needs and preferences by failing to ensure a call light was in reach for one resident (Resident #98). The sample was 24. The census was 121.During an interview on 4/10/26 at approximately 7:00 A.M., the Administrator said the facility did not have a call light policy. Review of Resident's # 98's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/24/26, showed:-Cognitively intact;-Dependent on staff for toileting hygiene;-Frequently incontinent of bowel and bladder;-Diagnoses included Parkinson's disease, dementia, and chronic obstructive pulmonary disease (COPD), a lung disease that cause the airway to become constricted and difficult to breathe. Review of the resident's care plan, in use at the time of survey, showed:-Focus: The resident has a risk of falls due to a history of falls and gait problems:-Interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed; The resident needs a prompt response to all requests for assistance. Observation and interview on 4/6/26 at approximately 9:00 A.M., showed the resident lay in bed and was heard from the hall yelling Nurse. The resident said he/she had been yelling for help for about 30 minutes because he/she needed to use the bathroom. At 10:01 A.M., the resident lay in bed and had a strong odor of stool present. The resident's call light was wrapped around the bed frame and out of the resident reach. The resident said he/she could not reach his/her light and needed help going to the bathroom. At 10:32 A.M., the resident lay in bed. The resident's call light was wrapped around the resident's bed frame and out of the resident's reach. The resident said he/she was soiled and wet and no one had been in to check on him/her and he/she could not reach his/her call light. At 11:04 A.M., the resident lay in bed with a strong odor of stool and urine. The residents' breakfast tray was still in his/her room and the call light was wrapped around the bed frame. The resident said he/she could not reach the call light and needed help getting cleaned up. Observation on 4/7/26 at 6:25 A.M., and 7:15 A.M., showed the resident lay in bed with his/her eyes closed. The resident's call light was tucked in between the cushion of a recliner that was located next to the resident's bed. The call light was positioned about two feet away from the resident. During an interview on 4/10/26 at 9:30 A.M. Certified Nursing Assistance (CNA) X and Licensed Practical Nurse (LPN) K said the call light should be within the residents reach at all times. After providing care the staff should make sure the residents had their call light in reach. During an interview on 4/10/26 at 12:34 P.M., the Director of Nurses (DON) said all residents' call lights were expected to be within reach at all times.

Based on observation, interview and record review, the facility failed to ensure one resident's (Resident #1's) feet were free from dry skin and failed to ensure skin assessments were accurate. The facility also failed to address the resident's foot care needs on the care plan. The sample was four. The census was 92. Review of the facility's skin integrity policy, dated 7/5/25, showed: -Purpose: To establish best practice guidelines for skin integrity monitoring and maintenance to reduce potential risk of skin breakdown where clinically appropriate; -Policy: Skin evaluations shall be completed upon admission and routinely, as per the care plan, to monitor skin integrity. Skin integrity risk factors will be evaluated upon admission and routinely, as per the care plan. Appropriate interventions will be initiated based on the risk factors identified. Lotion and moisture barrier products shall be available and applied as per the care plan. Minimize, as much as possible, any friction or vigorous rubbing of the skin while providing care. Any skin abnormalities noted shall be communicated to the licensed nurse. The licensed nurse shall notify the provider as needed for appropriate skin care orders. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/1/25, showed: -Cognitively intact; -Diagnoses included vascular dementia, chronic obstructive pulmonary disease (COPD, lung disease), and chronic kidney disease (CKD, impaired kidney function). Review of the resident's Physician Order Summary (POS), showed: -An order, dated 12/3/24, for head to toe skin assessment to be completed every Thursday on evening shift; -An order, dated 1/15/25, cleanse Left plantar (sole) foot, apply xeroform (non-adherent dressing), cover with Abdominal gauze pad (ABD) and wrap with kerlix (sterile gauze bandage) every night shift; -No orders for any lotion or preventive ointments for the resident's dry skin. Review on 1/17/25, of the resident's skin monitoring bathing reviews, showed: -On 12/10/24, no skin concern areas noted; -On 12/17/24, no skin concern areas noted; -On 12/24/24, no skin concern areas noted. Review on 1/17/25, of the resident's most recent skin observation tool, showed: -Skin observation completed on 12/31/24, noted a blister on the left foot covering 3/4 of the foot; -Skin observation completed on 1/9/25, noted no new skin issues. Review on 1/17/25, of the resident's most recent shower sheets, showed: -The resident received a shower on 1/13/25. Dry skin on the resident's feet not documented; -The resident received a shower on 1/16/25. Dry skin on the resident's feet not documented. Review of the resident's care plan, dated 10/8/24, showed: -Focus: The resident has potential for pressure ulcer development; -Goal: The resident will have intact skin, free of redness, blisters or discoloration by/through review date; -Intervention: Administer treatments as ordered and monitor for effectiveness. Reposition for comfort throughout day and night. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate (fluid that leaks from blood vessels); -The resident's care plan was not updated for the resident's foot blistered, discovered on 12/20/24, or dry skin on the resident's feet. Observation on 1/17/25 at 8:02 A.M., showed the resident lay in his/her bed. The resident's left foot had a pressure relieving boot on. A bandage on the resident's left foot was dated 1/16/25. The resident's right foot had a pea size amount of skin peeling off the great toe. The right heel was dry and flaky. Dry skin flakes were on the resident's mattress near the resident's feet. Observation on 1/17/25 at 10:45 A.M., of the resident's left foot, showed: -The sole of the resident's foot had a reddened, raw like area covering approximately 3/4th of the sole of the foot. The area was a large, circular area in the middle of the sole of the foot and down the right side of the sole of the foot; -Blood was observed in various areas along with peeled skin; -The skin on the resident's foot was dry and flaky. During an interview on 1/17/25 at 11:15 A.M., Certified Nursing Assistant (CNA) B said he/she was made aware of the resident's foot wound on 12/20/24. Skin assessments were done on the resident once a week. He/She was aware of the resident's dry skin. He/She would expect the resident's skin assessments to include his/her dry skin. During an interview on 1/17/25 at 11:57 A.M., Licensed Practical Nurse (LPN) A said he/she was made aware of the resident's left foot wound on 12/20/24. He/She was aware of the resident's dry skin on his/her feet. He/She did not know if the dry skin was being treated with anything. The resident has skin assessments completed every week. He/She would expect the resident's shower sheets and skin assessments to be complete and accurate. During an interview on 1/17/25 at 12:48 P.M., the Director of Nursing (DON) and Administrator said they were not aware of the resident's dry skin on his/her feet. The DON said she was made aware of the wound on the resident's left foot on 12/20/24. She contacted the wound doctor and set the resident up with wound clinic services. They would expect the resident's dry skin to be documented in the resident's skin assessments and shower sheets. They would expect nursing staff to put lotion on the resident's feet if they notice dry skin and to alert the charge nurse. She would expect for shower sheets and skin assessments to be complete and accurate. MO00247280

Based on interview and record review, the facility failed to immediately report an allegation of injury of unknown origin to the Department of Health of Senior Services (DHSS) within the required two-hour time frame, when Resident #1 wandered onto another unit, wearing only a brief, with a cord tied around his/her waist and a bloodied face. The sample was two. The census was 74. Review of the facility's Abuse Prevention policy revised [DATE], showed: Alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source are reported immediately, but not later than two hours after the allegation is made if the events that caused the allegation result in serious bodily injury. If the events that cause the allegation do not involve abuse and do not result in serious bodily injury, are reported immediately, but not later than 24 hours after the allegation is made, to the administrator of the facility and to other officials (including State Survey Agency). Review of Resident #1's medical record, showed: -admitted [DATE]; -No documented diagnoses. Review of the resident's progress notes, showed: -On [DATE] at 6:40 P.M., the resident arrived from the hospital via stretcher with two emergency medical services (EMS) personnel. He/She was accompanied by his/her family member. His/her native language was Bosnian. His/her family member translated needs for him/her. He/She denied pain. No distress. Skin intact. No active bleeding noted. He/She was alert and oriented times zero. He/She was extremely confused. He/She was able to make needs known. No agitation was noted. Range of motion (ROM) was with in normal limits. He/She refused toileting and a shower. Safety precautions were put in place. Review of the resident's admission fall risk evaluation dated [DATE] at 9:18 P.M., showed: -Disoriented times three at all times; -No falls in the past three months; -Balance problem while standing and walking; -Predisposing disease, blank; -Fall risk score 4. Review of the resident's Nursing Admission Evaluation and Baseline Care plan form dated [DATE] at 9:34 P.M., showed: -Communication: Could not communicate with staff and required an interpreter; -Exam: Well nourished, alert and confused; -No skin issues; -No presence of pain; -ROM was within limits in all joints; -Required partial to moderate assistance with mobility. Walking evaluation not attempted due to medical condition or safety concerns; -Assistive device: Wheelchair; -No history of falls; -Behaviors: Agitated. Review of the resident's progress notes, showed: -On [DATE] at 4:50 A.M., Licensed Practical Nurse (LPN) B noted he/she was made aware the resident had bruising and blood on his/her face. Upon assessment the resident had blood to bridge of his/her nose and bruising under his/her right eye. The resident could not explain what happened due to a language barrier. LPN B called the resident's physician and left a voicemail. He/She notified the resident's family and on call nurse. He/She cleaned the areas of concern and applied a dressing. At 5:20 A.M. the resident was transported to the hospital. Review of the facility's investigation summary date [DATE] (time unknown), showed: -The resident was admitted to the facility on [DATE] with diagnoses of atrial fibrillation (irregular heart beat), paranoia, anxiety, restlessness, agitation, history of falling, closed head injury and dementia with behaviors; -Staff noted a change of condition on [DATE] at approximately 4:00 A.M. The resident guarded his/her right arm, had discoloration near right eye and bleeding near the bridge of his/her nose; -An investigation was initiated with the following completed immediately; -Physician, family, and Director of Nursing (DON) notified; -Incident report reviewed; -Pain/skin evaluation reviewed; -Nurses notes reviewed; -Physician orders reviewed; -Staff interviewed; -Residents interviewed; -Staff denied witnessing any incidents/accidents or rough handling during care; -Blood spatter noted on floor, near the closet in unoccupied resident room [ROOM NUMBER]; -Certified medication technician (CMT) A observed the resident walking down the hallway with an unsteady gait, wearing a brief and nonskid sock, with blood on his/her face and hands. He/She could not understand the resident. He/She contacted the nurse; -Certified nurse assistant (CNA) C said he/she saw the resident lying in bed at approximately 3:15 A.M. Around 4:00 A.M., he/she went to get the resident and observed him/her with dried blood on his/her face. He/She transferred him/her back to 200 hall. The nurse assessed him/her; -LPN B said he/she noted the resident was in bed asleep at 3:00 A.M. He/She received a call from CMT A at 4:00 A.M. informing him/her the resident was on 200 hall with blood on him/her. The resident's face showed some discoloration and he/she guarded his/her right arm. LPN B contacted the physician to request transfer to hospital; -It was determined the resident's injuries most likely occurred due to a fall contributed by his/her unsteady gait; -No documentation of injury of unknown origin reported to DHSS within two hours or 24 hours. During an interview on [DATE] at 9:44 A.M., assisted living (AL) Director of Nursing (DON) said the resident was admitted on [DATE]. He/She fell around 4:00 A.M. on [DATE]. He/She was sent to the hospital. The AL DON was not notified of the fall. The resident's family said it was an assault. When asked how the fall occurred, the AL DON said he had not reviewed the resident's progress notes. A police officer called and said he/she interviewed the resident and he/she was extremely confused. The officer was not going to submit a report. The AL DON was told the incident was being treated as a fall. During an interview on [DATE] at 1:00 P.M., CMT A said around 4:00 A.M., he/she saw a resident pushing on the door of the 400 hall. He/She walked towards the resident and asked him/her to come closer. The resident was only wearing a brief, nonskid socks, and had a black, electrical wire wrapped around his/her waist. The resident's face was bloody. The resident had a laceration on his/her forehead and nose, and purple bruising on the right side of his/her face. The resident did not speak English. CMT A called LPN B and notified him/her of the situation. CNA C arrived to the 400 hall with a wheelchair and propelled the resident back to the 200 hall. The resident's injuries were serious. The resident was confused, and his/her gait was unsteady. He/She did not know how the resident sustained the injuries. Registered Nurse (RN) D asked him/her to submit a written statement on [DATE] at 3:50 P.M. During an interview on [DATE] at 1:11 P.M., LPN B said he/she received a call from CMT A at 4:10 A.M. CMT A said the resident was standing in the hall with blood on him/her. CNA C brought the resident to the nurse's station on the 200 hall. The resident had a skin tear on his/her nose and discoloration under his/her right eye. LPN B did not notice a laceration on the resident's head. The resident could not raise his/her right arm. The resident did not have any injuries when he/she was admitted to the facility. LPN B did not know how the resident sustained the injuries. He/She assumed the resident fell . The resident was very confused and had an unsteady gait. LPN B reported the incident to RN D at approximately 4:34 A.M. He/She notified the physician and resident's family member. RN D asked him/her to submit a written statement on [DATE] at 3:00 P.M. During an interview on [DATE] at 1:19 P.M., CNA C said the resident was assigned to him/her. The resident resided on the 200 hall. The resident was agitated and confused when he/she arrived at the facility. The resident wanted to go home. He/She put the resident to bed at 1:35 A.M. He/She was wearing a hospital gown. CNA C did rounds at 3:00 A.M. and the resident was still asleep. He/She received a call from LPN B stating the resident was on another hall. He/She did not know how the resident got on the other hall. The resident could barely walk. The resident must have gone out the door next to his/her room. He/She went to get the resident from the 400 hall. The resident was seated in a chair. He/She was only wearing a brief, with a black cord wrapped around his/her waist. His/Her face was bruised and bloody. Staff never found the resident's hospital gown. CNA C took the resident to the nurse's station. The resident's injuries looked serious. He/She did not know how the resident sustained his/her injuries. He/She assumed the resident fell . He/She was asked to submit a written statement on [DATE]. During an interview on [DATE] at 9:00 A.M., RN D said he/she was on call on [DATE]. He/She received a call from LPN B at 4:00 A.M. LPN B said the resident had a fall with some bruising. LPN B did not give specifics about the resident's injuries. RN D told LPN B to call the resident's family and physician and send the resident to the hospital. Staff did not see the resident fall or find him/her on the floor. The nurse found blood in an unoccupied resident room, near a closet. We assumed it was a fall. If we were not certain the resident fell , then it should have been an injury of unknown origin. When there is an injury of unknown origin, staff notify the Administrator and complete a state report. He/She notified the Administrator of the incident on [DATE] at 7:45 A.M. The Administrator said himself and the Regional Nurse would take care of it. The Administrator did not tell him/her to contact DHSS. RN D arrived at the facility on [DATE] at 10:09 A.M. He/She reached out to LPN B and CMT A for an explanation of what happened. He/She did not get a statement from CNA C. During an interview on [DATE] at 2:29 P.M., the Administrator said when a resident has an injury of unknown origin, the facility starts the investigation and reports it to the state agency within two hours. They concluded the incident was an unwitnessed fall. The Administrator would not expect staff to report a fall to DHSS. They found blood splatter in room [ROOM NUMBER], near the closet. He talked to the resident's family member on [DATE], and he/she said the resident fell . MO00241705 MO00241708

Based on observation, record review, interview, and facility policy review, the facility failed to properly contain COVID-19. This failure resulted in an Immediate Jeopardy, when resident (Resident (R) 69) was identified to have COVID-19 and was in the communal area, unmasked for several hours increasing the risk of exposure for staff and other residents residing on the [NAME] Unit. The failure placed residents and staff on the [NAME] Unit at risk for exposure, contracting COVID-19, and adverse outcomes up to and including death, and to failed to ensure Emergency Medical Technicians (EMT) wore source control. On 10/24/22 at 9:00 PM, the Director of Nursing and Administrator were notified of the Immediate Jeopardy (IJ) at F880-K Infection Control. The Immediate Jeopardy began on 10/24/22 when the survey team identified that R69 was sitting in the communal area, unmasked for several hours. The facility provided an acceptable removal plan on 10/25/22 at 5:12 PM. The removal plan included identifying other residents, who resided on the [NAME] Unit, who had the potential to be affected, monitor for signs and symptoms, and conduct testing on all residents. The facility would reeducate staff on PPE use and ensuring all resident who are identified COVID-19 positive will remain in their room. Through interviews with facility staff, observation of TBP and the communal area on the [NAME] Unit, clinical record review, and review of staff in-services, the survey team verified all elements of the facility's IJ Removal Plan and therefore removed the IJ on 10/25/22 at 4:01 PM. Review of the facility's policy and procedure, COVID-19 Infection and Prevention Guidelines, revised 10/2022, indicated, Transmission-Based Precautions (TBP) are initiated when a resident exhibits symptoms or tests positive. TBP are also indicated when a resident has close contact and is residing on a unit with others who are moderately to severely immunocompromised. A See Nurse Before Entering sign is placed outside the resident's room. Supplies such as N95 masks, gowns, gloves, eye protection are kept outside the room. Transportation and movement of the resident outside of the room is limited to medically essential purposes. 1. On 10/24/22 at 12:59 PM, the Infection Preventionist (IP) stated the facility had their first positive staff outbreak on 10/08/22 and on 10/11/22, R62, R23, and R13, who resided on the [NAME] Unit, tested positive. The IP stated on 10/14/22 an agency Licensed Practical Nurse (LPN), who worked primarily on the [NAME] Unit, tested positive. The IP stated on 10/17/22, R50 tested positive. The IP stated on 10/23/22 R241, R69, and R8 tested positive. The [NAME] Unit housed residents that were negative for COVID-19 as well as those residents who tested positive for COVID-19. Review of R69's Profile Face Sheet, provided by the facility, revealed an admitted [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the R69's Interdisciplinary Notes, dated 10/23/22, provided by the facility, revealed the Medical Doctor (MD) was made aware of COVID-19 positive results and said to continue to monitor the positive residents and to follow up with the MD with any changes of condition. On 10/24/22 from 10:40 AM to 1:22 PM, R69, who was confirmed COVID-19 positive on 10/23/22, was observed seated in the television area on the [NAME] Unit, which was across from the nurses' station in the center of the unit and open to air. R69 was in a Broda (reclining wheelchair) chair, and his/her mask was pulled under his/her chin leaving his/her nose and mouth uncovered. On 10/24/22 at 12:36 PM, three Certified Nurse Aides (CNA) were observed standing approximately three feet from R69's uncovered mouth. On 10/24/22 from 12:54 PM to 1:22 PM, CNA2 assisted R69 with his/her lunch meal in the TV area. CNA2 was wearing a surgical mask and no other PPE. Observations throughout the [NAME] Unit on 10/24/22 between 10:30 AM through 4:00 PM, revealed there were no signs on residents' doors, indicating precautions, for those residents who were COVID-19 positive. A container of PPE was hanging on each resident's door. On 10/24/22 at 11:29 AM CNA2 stated he/she never wore an N95 mask because he/she has a hard time wearing one and he/she just closes his/her mouth if a resident is coughing. On 10/24/22 at 12:01 PM, LPN1 stated he/she had been instructed to wear goggles throughout the [NAME] unit today and in each resident's room. He/she stated prior to today, staff were only instructed to wear goggles in residents' rooms who tested positive. On 10/24/22 at 12:59 PM, the IP stated all residents who were positive should be in their room. If the resident were positive and had a roommate, they would shelter in place. He/she stated his/her expectation was that R69 would remain in his/her room after testing positive for COVID-19. The IP stated the facility never discussed having signage regarding COVID-19 in the building on the entrance to the facility or the [NAME] Unit with the outbreak. The IP stated resident rooms on precautions should have a stop sign by the resident room number. On 10/24/22 at 4:25 PM, the IP stated when the facility had their first positive case in the facility (10/08/22) they did not change anything they just continued having staff wear N95 masks and practice handwashing. He/she stated that each room where a resident resided and was COVID-19 positive should have a PPE caddy with gloves, N95 masks, goggles, gowns, and a sign indicating COVID-19 precautions. During an interview on 10/24/22 at 4:48 PM, the Medical Director stated the facility should identify the source and isolate the patient. He/she stated if a resident was positive for COVID-19 and in a common area the risk to others to contract COVID-19 increased. The Medical Director stated that he was not aware a resident who was COVID-19 positive was out of his/her room. On 10/24/22 from 11:29 AM through 12:05 PM, Housekeeper (HK) 1 was observed cleaning rooms. On 10/24/22 at 12:00 PM, HK1 entered R50's (who was positive for COVID-19) room. HK1 donned an N95, gloves, and gown. HK1 did not don goggles. HK1 was interviewed at 12:05 PM and stated that he/she knew what PPE to wear based on what was on the door. HK1 stated he/she did not need goggles for R50's room. There was no sign on the door indicating what PPE should be worn. On 10/24/22 at 12:30 PM, CNA3 was observed at R241's (who was positive for COVID-19) bedside setting up the resident's lunch tray. CNA3 was wearing a surgical mask and goggles. CNA3 exited the room and grabbed new silverware off the food cart. CNA3 re-entered the room again and exited. CNA3 took R241's roommate her lunch tray and then used alcohol-based hand rub as he/she exited. CNA3 continued to serve meals to residents who were not COVID-19 positive. CNA3 stated that only R50 and R8 required additional precautions at this time. CNA3 confirmed he/she did not wear additional PPE in any of the rooms he/she was serving meals to. CNA3 stated he/she usually would for R50, but it was a busy day, and they were short staffed. On 10/24/22 at 1:06 PM, Certified Medication Tech (CMT) 2 was observed standing at the medication cart behind R69, in the TV room. CMT2 wore a surgical mask and eye protection. CMT2 approached R69 and administered medications. CMT2 was not wearing any other PPE. On 10/24/22 at 1:08 PM, CMT2 stated R69 was positive for COVID-19, but stayed in the TV room. CMT2 stated he/she should have a surgical mask on except when he/she was eating. CMT2 stated that staff were to wear N95 masks (although CMT2 was wearing a surgical mask) at all times when around R69 in the common areas. On 10/24/22 at 1:09 PM, Dietary Aide (DA1) was observed walking out of R241's room after picking up the resident's lunch tray. DA1 wore a surgical mask pulled below his/her nose and no other PPE. R241 tested positive for COVID-19 on 10/23/22. On 10/24/22 at 6:23 PM, R8 (who was positive for COVID-19) was observed sitting in the [NAME] Unit hall without a mask on. CNA1 and LPN3 approached R8, both were wearing surgical masks and not wearing eye protection, gown, or gloves while pushing him/her in his/her wheelchair back into his/her room. CNA3 stated R8 was positive for COVID-19. During an interview on 10/26/22 at 11:55 AM, CNA 2 stated he/she was aware there should be gowns and gloves on every resident's door who was on TBP. During an interview with the DON and the Administrator on 10/27/22 at 12:54 PM, the DON stated the IP had assumed staff were doing what they needed to do instead of confirming. The DON stated that moving forward the IP would review every COVID-19 positive resident and all updates of COVID-19 positive residents during every morning meeting with staff. During an interview with the Executive Director on 10/27/22 at 6:49 PM, he/she stated he/she tested positive for COVID on 10/07/22 and did not return to work until 10/17/22. He/she stated he/she was aware of the outbreak on the [NAME] Unit. He/she stated staff knew that R69 was a fall risk, but staff were aware of the importance of keeping R69 in his/her room. He/she stated his/her expectation was that all staff should follow CDC and corporate protocols by keeping R69 in his/her room since he/she was COVID-19 positive and monitor him/her as much as possible. 2. Review of the facility's policy titled, Procedure: COVID-19 Infection and Prevention Guidelines, dated October 2022, revealed, Masking - Source Control - refers to use of respirators or well-fitting facemasks to cover a person's mouth and nose to prevent the spread of respiratory secretions when breathing, talking, sneezing, or coughing. Masks are used to prevent transmission from asymptomatic or presymptomatic residents and healthcare personnel. When [CONDITION(S)]-CoV-2 Community Transmission levels are high, source control is recommended for everyone in a healthcare setting when they are in areas of the healthcare facility where they could encounter residents. Visitors are to follow posted instructions about wearing a mask. During observation on 10/26/22 at 12:55 PM, two Emergency Medication Technicians (EMT) were observed to walk through the [NAME] Rehab hall and enter R291's room. Neither EMT was wearing a face mask or any PPE. At 12:57 PM, a third EMT (EMT1) walked through the [NAME] Rehab hall and entered R291's room. EMT1 was not wearing a face mask or any PPE. At 12:59 PM, LPN6 confirmed none of the EMTs were wearing face masks. LPN6 called for another staff member to bring face masks. During interview on 10/26/22 at 1:02 PM, the Receptionist, who sits at the lobby and signs in visitors, stated that he/she did not see the first two EMTs that entered the facility, however the third EMT asked him/her how to get to the resident's room. The Receptionist stated he/she had not realized at the time that EMT1 was not wearing a face mask. During interview on 10/26/22 at 5:19 PM, the Director of Nursing (DON) stated there were signs on the door that instructed visitors to wear face masks. The DON stated he/she was unaware the EMTs had entered the facility without face masks and stated the receptionist should stop them and ask them to wear face masks. The facility provided an acceptable removal plan of the immediate jeopardy on 10/25/22 at 4:01 PM. The survey team validated the immediate jeopardy was removed on 10/25/22 at 5:12 PM following the facility's implementation of the plan for removal of the immediate jeopardy. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level.

Based on observation, interview and record review, the facility failed to ensure the resident's right to be free from abuse was not violated when Certified Nursing Assistant (CNA) L physically abused one resident (Resident #12) when he/she grabbed the resident's right arm, resulting in bruising and threw the resident into bed. This resulted in the resident sustaining a skin tear to the left arm. The sample size was nine. The census was 117. The Administrator was notified on 10/1/19 at 1:15 P.M., of the past non-compliance which occurred on 9/18/19. On 9/18/19 the Interim DON became aware of the violation of the resident's right to be free from abuse. The staff member was suspended and later terminated. The facility in-serviced the staff on the abuse policy and procedures. The investigation was completed. Staff and residents were interviewed and the residents on the staff member's assignment had skin assessments completed. The deficiency was corrected on 9/24/19. Review of the facility's Abuse Prevention policy, revised 9/2018, showed: -Policy statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse and physical or chemical restraint not required to treat the resident's symptoms; -Abuse: Is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish, including abuse facilitated or enabled through the use of technology. Abuse also includes the deprivation by an individual, including a care taker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being; -Mental abuse: Is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation, abuse that is facilitated or caused by community associates or enabled through the use of technology, such as smart phones and other personal electronic devices. This would include keeping and/or distributing demeaning or humiliating photographs and recordings through social media, electronic mail or multimedia messaging; -Mistreatment: Is inappropriate treatment or exploitation of a resident; -Willful: As used in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm; -The community goal is to achieve and maintain an abuse-free environment; -Training: The community will provide training for associates at new hire orientation and through ongoing programs that include, but not limited to, such topics as: -Prohibiting and preventing each form of abuse, neglect, exploitation and misappropriation of resident property; -Understanding behavior symptoms of residents that may increase the risk of abuse and neglect and how to respond. These symptoms, include, but are not limited to aggressive and/or catastrophic reactions of residents, resistance to care, outbursts or yelling out; Prevention: Implement preventative measures to address factors that may lead to abusive situations, for example: -Provide associates with opportunities to express challenges related to their job and work environment without reprimand or retaliation; -Instruct associates regarding appropriate ways to address interpersonal conflicts; -Help associates to recognize and deal appropriately with signs of burnout, frustration, stress and emotions that may lead to resident abuse; -Train associates to understand and manage a resident's verbal or physical aggression; -Monitor associates on all shifts to identify inappropriate behaviors towards residents (e.g., using derogatory language, rough handling of residents, ignoring residents while giving care, directing residents who need toileting assistance to urinate or defecate in their clothing/beds, etc.); -Protection: The community will protect residents during abuse investigations: -Respond immediately to protect the alleged victim and integrity of the investigation; -Provide protection from retaliation. Review of Resident #12's face sheet, showed [DIAGNOSES REDACTED]. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/5/19, showed: -Cognitively intact; -Extensive assistance of one person required for bed mobility; -Extensive assistance of two persons required for transfers; -Extensive assistance of one person required for toilet use; -Moving on and off toilet: Not steady, only able to stabilize with human assistance; -Range of motion impairment on one side, both upper and lower extremities; -[DIAGNOSES REDACTED]. Review of the resident's progress notes, showed: -On 9/18/19 at 8:28 P.M., the certified medication technician (CMT) alerted writer to resident having some bleeding. Upon assessment a skin tear, 7.5 centimeters (cm) was noted on his/her left forearm. Area was cleaned with normal saline and covered with steri-strips (adhesive strips used to close wounds) and an adhesive foam dressing. Bruised areas on the right hand and forearm were noted as well. Resident complained of mild pain to his/her left arm. Review of the resident's undated care plan, showed: -Activities of daily living (ADL) function/rehab potential: The resident required assistance with daily ADL care: --Goal: Have daily ADL care needs met; --Interventions, last updated 10/18/17, included: Needed one person minimal assistance with transfers, one staff support with transfers. Needed limited to moderate assistance with toileting, staff support with toileting; --Intervention, last updated 4/24/18, included: Use gait belt (belt used for safe transfers) at all times; -Incontinence related to immobility as evidenced by urinary incontinence. Has history of stroke: --Goal: Have no moisture associated skin damage; --Interventions, last updated 10/18/17, included: Keep call light within reach of right hand at all times. Encourage to call for assistance as needed; -Falls: Potential for falls related to impaired mobility and history of stroke: --Goal: Remain free of injury related to falls; --Interventions, last updated 10/18/17, included: Encourage to call for assistance with transfers. Keep call light in reach. Review of Licensed Practical Nurse (LPN) GG's written and signed statement, dated 9/18/19, showed: -At 8:11 P.M., Certified Nursing Assistant (CNA) L sat down at the nurse's station and began charting. He/she began a conversation regarding Resident #12. He/she stated I just wanted to let you know Resident #12 and I got into it. LPN GG asked what happened. CNA L said the resident was acting like he/she couldn't stand and almost fell and if he/she would have fallen it would have been on his/her aide and then the resident tried to hit him/her. He/she had to snatch the resident's a** up from his/her wheelchair and throw him/her in bed. LPN GG was called to the resident's room and he/she noticed blood everywhere and the resident's left arm had a big gash on it. He/she went to grab the treatment cart and placed gauze over the gash. He/she got CNA L and showed him/her the resident's arm and CNA L said okay. During an interview on 9/30/19 at 3:10 P.M., LPN GG said he/she was at the nurses station charting and CNA L asked to use the computer to chart. He/she told CNA L yes. CNA L started to chart and then out of nowhere, he/she said I just want to let you know that me and Resident #12 got into it. CNA L continued to say that he/she was asking the resident why he/she couldn't stand up. The resident tried to smack him/her. CNA L then said, I snatched his/her ass up off the toilet and put him/her in the wheelchair and then I snatched his/her ass up out of the wheelchair and threw him/her into bed. LPN GG said he/she suspected abuse, so he/she got up and went to the other nurse's station and was looking for a write up slip. When he/she came back, CMT FF said he/she needed him/her to come into the resident's room. The resident was on the edge of the bed, bleeding. There was blood everywhere. He/she went to get the treatment cart. When he/she was coming down the hall, he/she asked where CNA L was. He/she was told in another resident's room. LPN GG found CNA L coming out of another resident room after helping another CNA provide care. When CNA L came out of the room, he/she told him/her to come with him/her for a second. LPN GG walked CNA L down to the resident's room and said look what you did. He/she said he/she didn't do that and LPN GG told CNA L that he/she was the only one to care for the resident that night and he/she believed he/she did do it. LPN GG had CNA L write a statement. LPN GG then went into the resident's room to do the dressing to the resident's arm and the interim Director of Nursing (DON) was already in there. There was a large blood clot that had formed on top of the wound. LPN GG documented the measurements of the wound, but in addition to the measurements of the wound, he/she measured the blood clot and how high it was and it was 2 finger widths big. He/she didn't want to remove the blood clot, so he/she placed steri-strips on it and placed a non-adhesive dressing on it. He/she asked the resident what happened and the resident said that the CNA did it. The resident told LPN GG the CNA hit him/her and got angry because he/she told him/her that he/she needed help. The resident is paralyzed on the left side. He/she was telling the CNA he/she needed help. CNA L didn't use a gait belt. He/she just snatched him/her up and was real rough with him/her. The resident also said the CNA turned his/her television off and moved his/her call light over on the night stand between the 2 beds. The resident had no roommate at the time. LPN GG found the resident's call light located away from the resident, out of reach, where the resident said CNA L had placed it. LPN GG had no further interaction with CNA [MI] When he/she came out from taking care of the resident's arm, another staff found CNA L's badge on the ground. He/she walked out on his/her own, staff did not walk him/her out. The resident had reddened fingerprints and new bruising that started on his/her right arm. The resident is a diabetic, so LPN GG looks at his/her hands daily when checking accu-checks. Before supper that day, he/she did the resident's accu-check and none of the bruises were there. He/she never saw a bruise on the resident's bottom. There were no other staff at the nurse's station when CNA L admitted what he/she had done. Review of an unsigned hand written statement, dated 9/18/19, and labeled as from CNA L, showed: -At about 7:30 P.M., he/she went into the resident's room to put the resident to bed. He/she said he/she needed to use the restroom. CNA L took the resident into the bathroom. When he/she stood up, the resident acted like he/she could not stand and almost fell . CNA L's arm braced the resident from slamming into the bar on the back of the toilet. At this point the resident started yelling at CNA L and attempted to slap CNA L with his/her right hand. CNA L grabbed the resident's hand and told him/her not to hit him/her. The resident stood up and CNA L put a brief on him/her and put him/her in the wheelchair. When CNA L transferred the resident from the chair to the bed, he/she picked the resident up from his/her right side and put him/her in bed and covered him/her up. When he/she left the room the resident was fine and had no injuries. CNA L told the charge nurse that the resident was upset with him/her and had been violent with him/her and that he/she had to throw the resident into bed. During an interview on 9/30/19 at 12:56 P.M., CNA L said he/she went in to put Resident #12 to bed. He/she took him/her to the bathroom, the resident grabbed a hold of the bar with his/her hand, stood up and he/she went to turn the resident so he/she could sit on toilet. The resident started to lose his/her balance and started to fall, so he/she sat the resident down, but he/she flopped. When the resident flopped back, CNA L's arm was between the resident and the back of the toilet. The resident is a one person pivot with a gait belt. He/she flopped into his/her arm, instead of the bar. Right at this time the resident became belligerent with him/her. He/she could not remember what the resident said. There was no argument, everything was fine. The resident did try to hit him/her around this time. He/she was trying to finish taking care of the resident. The resident did hit him/her multiple times. CNA L had not worked with the resident in the recent past and he/she was not sure if the resident had an issue with hitting in the past. When the resident hit him/her, in all honesty, I was a bit angry. He/she assisted the resident back into his/her chair after he/she was done with the toilet. When the resident swung to hit him/her, he/she grabbed the resident's arm because he/she tried to hit him/her in the face. CNA L told the resident not to hit him/her. Then he/she took the resident to bed. The resident was still being belligerent. At this point the resident was actively hitting him/her, which didn't bother CNA L because the resident was hitting him/her in the arm and not the face. When he/she transferred the resident into bed, he/she picked the resident up and used the gait belt. He/she grabbed the gait belt and moved the resident over into the bed. The resident may have flopped on the bed. He/she helped the resident put his/her legs in the bed. He/she put the television remote on the table. He/she was not sure where the resident wanted it. The resident was pissing me off the entire time so he/she just put the remote on the table, covered the resident up and left the room. He/she untied the call light from the side of the bed and placed it on the table, in reach. When he/she told the nurse what happened, he/she said he/she threw the resident, but technically, physically he/she cannot throw the resident because the resident outweighed him/her. He/she did not use excessive force. He/she never got report on the resident from the off going staff on how to care for the resident. The surveyor asked for clarification as to why in his/her statement he/she said the resident swung at him/her but did not hit him and CNA L said when the resident initially swung at him/her, no he/she didn't hit him/her because he/she caught the resident's hand. The resident swung at him/her multiple times. The resident was hitting him/her in the arms. The facility had provided him/her no training on staff burn out or aggressive residents. The resident was the last person he/she had to put to bed. The surveyor asked CNA L to clarify why others may say he/she was arguing with the resident and CNA L said he/she was talking to the resident about his/her ability to stand, and they may have thought it was argumentative. He/she asked the resident why he/she was acting. The resident had no injuries when he/she left the room. It was an hour after he/she left the room that the nurse asked him/her to go in there with him/her. The resident had a massive skin tear on his/her arm, which they said he/she did, but when he/she transferred the resident to bed, he/she was standing on the right side of the resident and stood on the right side of the bed. The skin tear was on the left side, the side the resident has weakness on. Review of the facility's investigation report of resident abuse, dated 9/20/19, showed: -Comments: The interim DON was called into Resident #12's room at approximately 8:45 P.M., by CNA HH. The resident was sitting on his/her bed while LPN GG was cleaning the wound on the resident's left arm. The resident stated the following: -He/she had called for assist to use the bathroom and CNA L responded. CNA L wanted the resident to walk and he/she advised him/her he/she could not. CNA L then assisted the resident to a standing position, likely using the bar next to the commode which is his/her normal process. While standing, his/her knees started to buckle. The resident reported CNA L yelled at him/her and told him/her to stand up. When he/she stated he/she could not, CNA L told the resident yes you can, you just won't. At that point, the resident said CNA L roughly pushed him/her back onto the commode seat. The resident admits that he/she tried to hit CNA L because he/she was being so rude. When CNA L was assisting the resident back into his/her chair, the resident reports CNA L threw him/her at which time he/she struck his/her arm and head on the bed assist device which is next to the chair. CNA L also switched off his/her television and placed the call light out of reach before leaving the room. At this time, he/she started crying and called for help. CMT FF responded to calls and found the resident cradling the left arm which was actively bleeding; -CNA L had come to the nurse's station immediately after leaving the resident's room and reported that he/she had to snatch the resident out of his/her wheelchair and throw him/her into bed. LPN GG immediately told CNA L to write a statement and clock out, that his/her actions were unacceptable; -The facility advised facility staff that CNA L's actions constituted abuse which is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Review of the resident's skin evaluation form, dated 9/18/19 at 9:35 P.M., showed: -Site: Left forearm; -Type: Skin tear; -Treatment: Cleansed with normal saline, steri-strips and covered with an adhesive dressing; -Cause: Trauma; -Length: 7.5 cm, width 2 cm. Review of the resident's skin evaluation form, dated 9/18/19 at 9:37 P.M., showed: -Site: Right hand; -Type: Bruise; -Description: Two small quarter sized bruises. During an interview on 9/30/19 at 10:57 [NAME]M., the interim DON said she was aware of the bruises to the resident's right arm and it was reported that it was caused by CNA L's hands. There were redden areas to the wrist/forearm area the evening of the incident. The area around the lower forearm appeared to be created by the palm of the hand or [MEDICATION NAME] trauma and it has since turned into a bruise. CNA L has been terminated. Further review of the resident's progress notes, showed: -On 9/19/19 at 8:17 P.M., on incident follow up for skin tear to left forearm; -On 9/20/19 at 10:19 P.M., resident continues on incident follow up for skin tear to the left forearm; -On 9/21/19 at 7:02 [NAME]M., day three indecent follow up skin tear left forearm, dressing clean, dry and intact. Resident reports pain of 2 out of 10 (based on a scale of 0 to 10, where 0 indicates no pain and 10 indicates the worse pain possible). Observation on 9/30/19 at 8:24 [NAME]M., showed the resident not in his/her room. The resident room was located five rooms away from the nurses station, at the end of the hall. Observation and interview on 9/30/19 at 8:38 [NAME]M., showed the resident in his/her room in a wheelchair. He/she had a large bandage to his/her left, inner, lower arm from the wrist to approximately an inch below his/her elbow. The dressing was dated 9/29/19. When asked about how the injury occurred, the resident said I am so shocked, the nurse assistant came in and said he/she was going to put him/her to bed and he/she said okay, but he/she had to go to the bathroom first. The CNA said ok and propelled him/her into the bathroom in the wheelchair. The resident said he/she always locks his/her wheelchair and then places his/her hands on the bar to help push up. He/she needed staff to help him/her because he/she did not have enough strength to get him/herself standing by him/herself. The CNA said get up, stand up and the resident said he/she will if the CNA helped him/her and the CNA said no you can stand and the resident said no I can't, I need help. The CNA helped him/her up, but didn't give him/her a chance to get his/her balance before starting to let go and the resident said oh, I'm going to fall and the CNA said if you do, it is an act. The resident said that he/she was not acting, it was not an act. The CNA pushed him/her onto the toilet and it hurt. He/she swung at the CNA and the CNA grabbed him/her by the right arm, hard and it hurt. It caused a bruise that he/she still had. The resident lifted his/her right arm. Observation of the resident's right arm showed three fingerprint sized bruises on the inner, upper part of forearm, just below the elbow and a larger elongated bruise near the inner wrist area. The resident said after he/she was done going to the bathroom, the CNA then assisted him/her to the wheelchair and propelled the wheelchair to the bed. The CNA picked him/her up and threw him/her into bed in an angry way. His/her left arm must have hit the arm rail and it hurt. Before the CNA left the room, he/she asked him/her to put the remote control for the television on his/her bedside table. The CNA took it and placed it across the room, turned off the television and said you are not watching television. The CNA then took the call light that was wrapped around the bedrail and moved it behind the bedside table, out of reach, so he/she had no way to reach staff. The CNA then left the room. His/her arm hurt so bad. He/she reached over and touched it and it was all bloody. The light was off, so he/she couldn't see it but he/she felt it. He/she tried to see who was outside the room door and one of the other staff, CMT FF walked by and he/she yelled for him/her. He/she came in and said what's wrong. The resident told him/her to turn the light on and he/she will show him/her. CMT FF said oh, my god! How did that happen? The resident said that the CNA did it. CMT FF said he/she will get the nurse. There was blood all over his/her night gown and all over his/her sheet. It was all bloody. Several people came. They made the CNA who hurt him/her and who did it come in and see his/her arm and how it looked. The CNA looked and said he/she never touched the left arm. He/she now has a dressing that staff have to change almost every day. It was awful and now he/she is shaken up. It gave him/her a feeling of insecurity, like it's not safe anymore. Observation at this time, showed the resident started to cry. The resident said he/she should be able to feel safe. Everyone else has been good to him/her. That was the first time he/she remembered the CNA taking care of him/her. Everyone else is good. He/she was quite shocked. He/she believed the CNA had to have been already mad before he/she came in. Something was wrong, he/she did not act rational. The CNA knew nothing about taking care of old people. He/she was so rough. The resident said he/she had the jitters because of the incident and he/she did not like talking about it because it re-traumatizes me. When he/she talks about it, it makes his/her heart patter. The CNA did not use a transfer belt to transfer him/her into bed, he/she just threw him/her. Further observation and interview on 9/30/19 at 1:37 P.M., showed the resident sat in a reclining chair in his/her room. He/she said he/she had been told he/she has a bruise on his/her bottom, but he/she does not feel it. Observation of the room, showed the resident in the second bed from the door, closest to the window. The left side of the bed closest to the window and the right side of the bed closest to the door. The resident said when he/she was thrown into bed, he/she was on the right side of the bed. Observation of the resident's bathroom, showed the toilet directly in front of the door. There is a grab bar on the left side of the toilet. The resident said he/she just hopes the CNA never gets the chance to hurt anyone else. During an interview on 9/30/19 at 9:25 [NAME]M., CNA II said he/she went into the resident's room to ask CNA L a question. They, CNA L and the resident, were having an argument regarding if the resident could stand. They were at the bedside. As he/she was leaving, the resident was hitting at CNA L and he/she just went to answer another call light. Later, CNA L was at the nurses station and he/she was talking to the nurse saying the resident was hitting at him/her. He/she walked away from the nurses station and did not hear anything else. During the argument, the resident's voice was raised. CNA L sounded rough. During an interview on 9/30/19 at 11:41 [NAME]M., Social Service Designee (SSD) KK said he/she is the SSD for the long term care residents. He/she spoke to the resident regarding the incident, but was not part of the investigation. The resident said he/she was glad the facility was investigating the allegation and that it scared him/her. The resident is glad CNA L is gone. During an interview on 9/30/19 at 12:33 P.M., Family Member LL said he/she first got the call at night, he/she believe Wednesday the 18th of September. The nurse called at approximately 9:30 P.M. and said he/she wanted to inform Family Member LL that the resident was in an altercation with a CN[NAME] The resident had a deep gash on his/her arm, the CNA had been walked out of the building and State was called. The next morning, he/she went into the resident's room. The resident is alert and oriented. He/she had a stroke that affected his/her mobility, but not his/her mind, and he/she had left side weakness. The resident said there was a staff member the night before who said I need to get you ready for bed. The resident said he/she needed to go to the bathroom first. The CNA wheeled him/her into the bathroom. Due to the stroke the resident cannot get up on his/her own. The resident reached for the rail and asked for help. The resident said the CNA threw him/her onto the toilet. The CNA said come on, come on, he/she needed to get the resident to bed. The resident said he/she did not have his/her balance yet and the CNA said he/she didn't care. The resident has a contracted left arm and when the CNA was dressing the resident for bed, he/she screamed because he/she yanked his/her contracted arm. The CNA got mad and threw the resident into bed then he/she took the resident's call light and remote away. The resident's arm was hurting, he/she felt it and it was wet. He/she didn't have his/her call light, someone walked by and he/she called them in and told them what happened. The resident said he/she was covered with blood, the skin was removed from his/her arm. This was from being pushed into bed. The nurse already told the resident that the CNA had admitted it. The resident said he/she felt pretty defenseless against the CN[NAME] During an interview on 9/30/19 at 2:48 P.M., CMT FF said he/she was passing medications and working his/her way down the hall. He/she heard someone yelling help me, help me. There was another resident he/she was with at the time, then a family member came to him/her and postponed him/her. When he/she came back, he/she heard help, help and he/she went into the resident's room. The resident said honey, can you help me? The resident started to tell him/her what happened, but he/she cannot remember what the resident said. He/she told the resident to wait and let him/her get the nurse. He/she went and got the nurse and told LPN GG to come to the resident's room. He/she had not seen the arm injury yet when they went back to the room, they both went in together. It was bleeding profusely. The resident's entire chest and abdominal area of his/her shirt was covered with blood. There was actually a blood clot on the resident's arm, about a half inch thick, so it had been bleeding for a while. The sheet was bloody. The interim DON happened to be in the building when it took place but she was in a meeting. Someone went and got her to talk with the resident. He/she left after the nurse went in. He/she never talked to CNA [MI] He/she had never been trained on staff burnout or aggressive residents. The resident is always very nice and he/she has never known him/her to be mean or aggressive. During an interview on 9/30/19 at 3:33 P.M., the interim DON said the resident required assistance to transfer, he/she can bear weight but not walk. The care plan would be more accurate than the MDS, but she would expect they both be accurate. The training provided to staff regarding abuse covers the main points on preventing, recognizing and reporting abuse. This is training that CNA L had taken. During staff training, it talked a little about de-escalation but nothing specific to staff burnout. The facility has some training in the orientation regarding residents who have behaviors, but nothing recent related to helping residents who are resistive to care. The resident did not have a bruise on his/her bottom from the toilet. CNA L should not have been left alone at the nurse's station after the allegation. When staff heard CNA L arguing with the resident, they should have poked their head in and see if they needed help. In this incident, she was not sure the staff person realized the gravity of the situation. The resident's remote control was on the other side of the room when she first entered the room, not in reach of the resident. There was a reddened area on the resident's right arm. MO 947

Based on observation, interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan by failing to follow up timely after a fall when one resident experienced a fall from bed, staff assisted the resident to lower to the ground, heard a loud pop and failed to assess the cause of the pop or report the pop and/or the resident's request for pain medication to the physician. Staff improperly transferred the resident back to bed after the fall. The evening shift certified nursing assistant (CNA), responsible for the resident at the time of the fall, failed to inform the oncoming night shift CNA that the resident had fallen. When the resident complained of pain to the night shift CNA, he/she failed to notify the nurse of the expressed pain. This resulted in one resident (Resident #105) having a delay of approximately 13 ½ hours from the fall until the resident was sent to the hospital for treatment. The resident expressed pain to staff on all shifts following the fall. The fall resulted in a fractured femur that required surgical repair. The facility failed to assess and follow up for one resident (Resident #70) who had a change in condition after returning to the facility from the hospital after a fall. The resident experienced shortness of breath and reported discomfort to the sternal (mid chest) area. A CNA reported the change in condition to the nurse who failed to follow up on the resident's condition. The resident expired later that day. In addition, the facility failed to appropriately assess and document a wound for one resident (Resident #93). The sample was 25. The census was 125. 1. Review of Resident #105's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated [DATE], showed: -Cognitively intact; -No behaviors or mood concerns; -Extensive assistance of two person physical assist required for bed mobility, transfers and toilet use; -Limitation in range of motion impairment on both sides, upper and lower extremities; -Wheelchair used for mobility; -[DIAGNOSES REDACTED]. -Occasional pain that did not affect sleep or day-to-day activities. Review of the resident's care plan, in use at the time of the survey, showed: -Activity of daily living (ADL) functional/rehab potential: Resident requires assistance with daily ADL care: -Will have daily ADL care needs met: -Extensive assistance with transfers. Two person staff support with transfer using sling with Hoyer lift (mechanical lift). Hoyer lift to be used with two person assist at all times. Extensive assistance with mobility. Two staff support with mobility. Uses a wheelchair device for mobility. Half assist rails for bed positioning, bed mobility. Incontinent of bladder at times, please toilet when needed. Usually continent of bowel, needs assist times two to toilet. Extensive assistance with toiling. Need two staff support with toileting; -Falls: Resident has potential for falls related to limited movement with impaired balance: -Resident will remain free of injury related to fall; -Encourage resident to call for assistance with transfers; -Pain: Resident has chronic pain related to [MEDICAL CONDITION] Arthritis ([MEDICAL CONDITION] joint disease causing inflammation and pain) as evidenced by complaint of pain at level 4 at times on scale of ,[DATE] (scale used to measure pain based on a resident's response of ,[DATE], 0 indicates no pain and 10 indicates the worse pain possible): . He/she states that the pain is consistent but tolerable at ,[DATE]. Now receives additional scheduled pain medication: -Resident will demonstrate adequate pain control as evidenced by verbalizing satisfaction with level of comfort and ability to participate in ADLs; -Report uncontrolled pain to physician. Perform a comprehensive assessment of pain to include location, characteristics, onset, duration, frequency, quality, intensity or severity and precipitating factors of pain. Instruct resident on pain scale values (,[DATE]) and encourage to notify staff when pain levels are increasing and/or medication is not effective. Monitor for non-verbal signs of pain such as grimacing, irritability, moaning, body language, guarding, etc. daily. During an interview on [DATE] at 9:10 A.M., the assistant administrator said on [DATE] therapy did a screen on the resident that showed the resident only required assist of one for bed mobility. Nursing staff were educated on the change with bed mobility and the decision to use a sliding board for transfers. When therapy works with a resident and once they feel they can change the resident's care levels, they start training staff on the floor. Then in huddle, they report their new recommendations and it is then added to the care plan. The MDS coordinator did not update the care plan but the information was passed on in report. On [DATE], the care plan should have been updated. Review of the resident's physician order [REDACTED]. -An order dated [DATE], up in wheelchair per Hoyer lift; -An order dated [DATE], for [MEDICATION NAME]/[MEDICATION NAME] ([MEDICATION NAME], narcotic pain medication with Tylenol) ,[DATE] milligram (mg). One tablet by mouth every 6 hours as needed for pain; -An order dated [DATE], may have half assist rails for bed positioning and mobility and assist with transfers; -An order dated [DATE], sliding board transfer use for wheelchair to bed to wheelchair transfer. Resident requires contact guard assist and occasional verbal cues on safety and assist to position the chair and bed properly. Do not leave the sliding board in the resident's room, as needed. Review of the resident's pain assessment, documented under resident vital stats, showed: -On [DATE] at 12:26 P.M., a pain level of 0 (indicated no pain) numeric scale. Review of the resident's progress notes, showed: -On [DATE] at 9:10 P.M., the CNA had the resident on the bedpan, resident had finished toileting when CNA asked the resident to roll off of the bedpan. Resident attempted to roll off as directed, momentum carried the resident out of bed to the side of the bed where he/she ended on his/her knees and holding the side rail. Range of motion within normal limits. Resident did not strike head. Vital signs: temperature 97.8, pulse 97, blood pressure ,[DATE], oxygen saturation (percentage of oxygen in the blood) 97%. Physician notified of incident. Resident's family notified of incident. Resident resting in bed, will monitor as needed. Review of the resident's Medication Administration Record [REDACTED] -No documentation of the as needed [MEDICATION NAME]/[MEDICATION NAME] administered on [DATE]; -[MEDICATION NAME]/[MEDICATION NAME] administered on [DATE] at 8:00 A.M. Review of the resident's controlled medication log, showed staff removed one [MEDICATION NAME]/[MEDICATION NAME] ,[DATE] mg tablet on [DATE] at 10:00 P.M. During an interview on [DATE] at 3:14 P.M., Nurse K said the resident called his/her family member and complained of pain. The family member called and requested pain medication be given. It was administered. The administration should have been documented. Further review of the resident's progress notes, showed: -The next note, dated [DATE] at 3:24 A.M. (6 hours and 14 minutes after the resident's fall), resident continues on follow up for a fall with no apparent injuries. No complaints or distress. Currently resident in bed. Call light is in reach; -On [DATE] at 6:32 A.M., no behaviors to note; -On [DATE] at 4:32 P.M., (late entry): -At 7:50 A.M., CNA reported that the resident was having pain to his/her right knee. Upon assessment, resident's right leg was turned outward. His/her leg swollen, hot to touch and painful; -At 8:00 A.M., paged Physician J, awaiting call back. As needed [MEDICATION NAME] ,[DATE] mg one tab and routine [MEDICATION NAME] (narcotic pain medication) 12 micrograms (mcg) one patch applied to the upper left chest. This writer informed CNAs not to get resident up for breakfast until further notice; -At 8:30 A.M., Physician J notified of the resident having pain to the right leg. New order received to get STAT (immediately) x-ray of right femur (long bone of the leg), right hip and right knee; -At 8:40 A.M., mobile x-ray company notified of new order, awaiting arrival; -At 8:50 A.M., notified resident's family of the above new orders; -At 9:00 A.M., mobile x-ray company technician arrived to do STAT x-ray of right femur, hip and knee. As needed [MEDICATION NAME] ,[DATE] mg was effective, some relief noted but resident still had facial grimacing; -At 9:40 A.M., results of x-rays are here and showed acute fracture distal femur; -At 9:50 A.M., paged Physician J, awaiting call back; -At 10:15 A.M., Physician J returned page. This writer notified physician of x-ray results. New order received to send the resident to the hospital for evaluation; -At 10:20 A.M., notified the resident's family member of new orders to send the resident out and x-ray results; -At 10:35 A.M., called hospital and report was given to emergency room nurse; -At 10:45 A.M., called ambulance company for STAT transport services to the hospital; -At 10:55 A.M., the ambulance company arrived to transport the resident via two emergency medical technicians per stretcher. Resident was stable at time of departure. Review of the resident's Situation, Background, Assessment, Recommendation (SBAR) professional communication form, dated [DATE] at 8:00 A.M., showed: -The change in condition, symptoms or signs is/are: Right leg pain; -This started on [DATE]; -Since this started it has gotten: Worse; -Things that make the condition or symptoms worse are: Any type of movement when doing ADLs; -Things that make the condition or symptoms better are: As needed [MEDICATION NAME] ,[DATE] mg and no movement to right leg; -Needs more assistance with ADLs, decreased mobility, weakness or [MEDICAL CONDITION] (weakness on one side of the body); -Describe symptoms or signs: Right leg pain, cannot be moved without complaints of pain; -Increase in pain noted and reported to right leg; -X- ray, transferred to hospital. Further review of the resident's pain assessment, documented under resident vital stats, showed: -On [DATE] (no time specified), 7 (midway between severe and very severe pain) faces scale (numeric scale assessed using the resident's facial expression when the resident is unable to verbalize a number); -No further documentation of pain in (MONTH) 2019. Review of the resident's hospital records, showed: -admitted [DATE]; -Right knee x-ray results, dated [DATE] at 2:16 P.M., showed there is a displaced (removal from normal position) distal (far end) femur fracture ([MEDICAL CONDITION] end of the right leg long bone). The distal fracture fragment (a small part broken from a larger entity) is displaced laterally (to the side) 2.3 centimeters (cm). There is override (slipping of either part of a fractured bone past the other) of the fracture line of about 4.5 cm. The femur and bones of the knee are osteopenic (having osteopenia, reduced bone mass) and there is severe [MEDICAL CONDITION] arthritis of the right knee. The distal femur fracture shows posterior (back side) displacement of 4.1 cm. There is a knee joint effusion (increased fluid buildup); -Portable right femur two view x-ray, dated [DATE] at 3:01 P.M., showed total right hip arthroplasty (surgical procedure to reconstruct the hip) is observed in anatomic alignment. Diffuse (wide spread) osteopenia is present. An oblique (situated in a slanting positron) distal right femoral diaphysis (portion of the long bone between the ends) fracture is present with nearly one shaft (diameter of the bone) width lateral and posterior displacement of the distal fracture fragment. There is mild anterior (front side) angulation (deviation from a straight line) of the distal fracture fragment. Three compartment right knee [MEDICAL CONDITION] ([MEDICAL CONDITION] joint disease) is observed. Review of the facility's fall policy, revised (MONTH) (YEAR), showed: -The purpose of this procedure is to provide guidance for evaluation of a resident in the event a fall occurred and to assist associates in identification of potential causes of the fall; -If a resident sustains a fall, or is found on the floor without a witness to the event, associates shall evaluate for possible injuries and provide first aid or treatment as indicated; -A licensed nurse shall notify the resident's attending physician and resident representative of the event. The licensed nurse shall document the fall in the resident's clinical record; -A licensed nurse shall observe clinical status for 72 hours after an observed or suspected fall, and document findings in the resident clinical record; -An incident report shall be completed for resident falls by a licensed nurse after the fall occurs. Observation during the initial screening of residents, on [DATE] at 10:29 A.M., showed the resident in room in bed. A head/neck pillow in place. The resident had facial grimacing and a pained look. The resident said he/she was in pain and declined to talk further. During an interview on [DATE] at 1:57 P.M., the Director of Nursing (DON) said CNA L was the only staff person in the room at the time the resident fell . He/she was placing the resident on the bed pan. During an interview on [DATE] at 3:28 P.M., CNA L said he/she was the CNA assigned to the resident the evening of the fall. Staff know how to care for residents based on the care plan that is available in the electronic medical record. Staff also pass on shift report. Based on shift report, the resident required assist of one with bed mobility. He/she did not view the care plan. The last time he/she had cared for the resident prior to the night of the fall was approximately 6 months ago. The resident utilized a hand rail on both upper sides of the bed for mobility. At the time of the resident's fall, he/she stood on the right side of the bed and the resident fell off the left side of the bed. The resident did not really fall. He/she rolled to the left and the entire bottom half of the resident's body started to fall off the bed. He/she grabbed the resident's shirt while yelling for the nurse to come in. Nurse K saw what was happening and started to move the bed further away from the wall so he/she could fit between the bed and the wall. At the time of the resident's fall, the bed was not completely against the wall but it was close enough that the nurse could not fit. Additional CNAs came into the room to help. Nurse K assisted to lower the resident to the floor. While lowering the resident to the floor, there was a loud pop. The nurse then completed an assessment of the resident. The resident was able to move all extremities and did not say he/she had pain at that time. Once the nurse was done with the assessment, CNA T, another CNA and him/herself assisted the resident to bed. The nurse said to just lift the resident into bed. Some staff grabbed the resident's legs and other staff grabbed the resident's upper body. The staff then got the resident situated in the bed and the resident started to complain of right knee pain. The nurse had gone to the nurse's station so he/she went and told the nurse the resident had pain and asked if he/she could get the resident an ice pack. The nurse said that was fine. He/she checked on the resident several more times and he/she seemed relatively ok. He/she was the CNA for the resident until his/her shift ended at 11:15 P.M. and he/she was not sure who the CNA was who took over after the end of the shift. During an interview on [DATE] at 8:42 A.M., Family Member M said he/she was notified of the resident's fall. The resident had to have a surgical procedure to have a rod placed in his/her femur to repair the fracture. During an interview on [DATE] at 8:46 A.M., Family Member N said he/she was still trying to find out the circumstances surrounding the fall. The resident told him/her that he/she fell while transferring to the bed and said the person transferring him/her fell on top of him/her as well. The facility is saying the resident fell while being removed from the bed pan. The facility reported he/she was holding onto the bed rail. His/her bed should have been against the wall. The resident had surgery yesterday ([DATE]). The facility said they did the x-ray at the facility and the fracture did not require surgery so family was surprised when it was found out the resident did require surgery. Right now the resident is out of it and is on pain medications. Surgery went well. During an interview on [DATE] at 10:23 A.M., CNA O said he/she worked on evenings [DATE] and assisted the resident after the fall. He/she was not assigned to the resident. He/she was going to check on another resident and walked past the resident's room. He/she saw the nurse and two CNAs in the room and the nurse was standing over the resident. They said CNA L was putting the resident on the bed pan when the fall occurred. After the nurse assessed the resident, he/she said two staff need to be at the top of the resident and two at the bottom in order to transfer the resident back to bed. CNA O said he/she had never worked with the resident before. CNA L and the nurse said the resident required a Hoyer lift but the way he/she was positioned on the floor, the bed was in the way to get the Hoyer lift there. He/she did not know why staff did not move the bed to allow room for the Hoyer lift. There were two other CNAs who assisted to transfer the resident to bed. The two other CNAs grabbed the resident's thighs and he/she was at the top of the resident and pulled him/her by the shirt at the shoulder area. He/she held the resident's shirt and not the shoulders so he/she would not hurt the resident. The nurse did not help. The resident was yelling really bad that he/she was hurting. Staff had said something about a pop they heard, but he/she was not in the room at the time the pop was heard. The nurse and the CNA responsible for the resident said the leg had popped. After staff got the resident into bed, the resident was saying his/her leg was hurting bad and it appeared red. The nurse said he/she was going to call the doctor. During an interview on [DATE] at 10:57 A.M., CNA P said he/she was the CNA assigned to care for the resident on the night shift, [DATE] through the morning of [DATE]. No one passed on in report that the resident fell and he/she knew nothing of the fall or the need to monitor the resident post fall. When he/she did his/her first round on the resident, he/she just looked in the doorway. The resident looked back at him/her. The television was on. The resident did not say anything. At 1:00 A.M. or 2:00 A.M., he/she went to check on the resident. His/her bed was way up both the legs and head of bed were raised. When he/she went to let it down the resident yelled out and said his/her leg hurt. He/she checked the resident's brief for incontinence and when done the resident said he/she was fine. Normally, the resident would have said something about having the fall, but the resident was just a little out of it. He/she did not tell the nurse about the pain and just assumed it was the same complaints as usual. He/she did not know there was a fall. Typically staff pass on in report if there is a fall. During an interview on [DATE] at 11:31 A.M., CNA Q said he/she was the CNA assigned to care for the resident the day shift of [DATE]. He/she was told nothing about the fall. Nothing was passed on in report. Upon entering the resident's room, the resident was in a lot of distress. He/she identified the pain to be in the right leg. The resident was not one to complain. Later that morning, CNA T, who had worked the evening shift, informed him/her of the fall. The fall should have been passed on in report. He/she reported the pain to the day shift nurse. During an interview on [DATE] at 11:40 A.M., Nurse R said he/she was the nurse assigned to the resident on the day shift, [DATE]. He/she was told in report from the night nurse that the resident was on incident follow-up, that he/she didn't hit floor but was lowered to floor. He/she was told nothing about any report of pain or injury. After CNA Q reported the pain the resident was experiencing, he/she went to the room and assessed the resident. The resident's right knee and leg were swollen, hot to the touch, and turned outward. When he/she went to go near the leg, the resident started to scream. He/she called the doctor and reported the resident's symptoms. The doctor said to get x-rays. The x-rays came back as broken. He/she asked the DON if they should send the resident out and she said call the doctor first. He/she placed a call to the doctor and called the family. When the doctor called back we sent the resident out to the hospital. During an interview on [DATE] at 3:02 P.M., Nurse S said he/she was the nurse assigned to the resident on the night shift, [DATE] through the morning on [DATE]. He/she was told of the fall and that the resident had no injury and range of motion was fine. He/she was told that they used two staff to put the resident on the bed pan but when they took the resident off, they only used one person. The resident required two person with a Hoyer for transfers and two person assist for bed mobility. To the best of his/her knowledge, the resident slept though the shift. He/she was never informed of the resident having pain. He/she never had to go into the room to provide care. It was in the morning when they were messing with him/her that staff realized there was pain. During an interview on [DATE] at 3:14 P.M., Nurse K said he/she was the nurse assigned to care for the resident on evening shift [DATE], the evening of the fall. The resident required assist of one with activities of daily living and assist of two with a gait belt for transfers. Right now therapy staff are the only staff that can use the sliding board. He/she was in the hall when he/she heard CNA L call out and ask for help. He/she entered the resident's room and asked what happened. The resident was between the bed and wall, in a kneeling position. Both arms were reached up and holding onto the side rail. He/she moved the bed to get access to the resident and had to support him/her to keep him/her from hitting his/her face. When assisting the resident to the floor, he/she heard a loud pop but he/she did not know what it was. He/she would have assumed if it was a bone the resident would have screamed. The pop was so loud that he/she startled and yelled out. He/she did a visual check for deformities and did not see any bones sticking out or any misshapen legs. He/she checked the resident's eye response, obtained vital signs and completed range of motion. The resident denied pain at that time. He/she then called the physician and family. He/she was not in the room when staff assisted the resident back to bed. After talking to the family, the family called back and requested to talk to a supervisor. He/she transferred the call to the other building where the supervisor was. The supervisor then called and told him/her the family member said the resident wanted pain medication. The CNA also got ice for the resident's leg. During an interview on [DATE] at 3:41 P.M., Physician J said he/she was called the evening of the resident's fall and then again the next morning. He/she was not told of a loud pop. That evening, [DATE], he/she was called by the nurse who said that the CNA was trying to help the resident get off the bed pan and dropped him/her and that he/she fell to the ground. It was reported that the resident had no pain, no injury and was ok. If he/she would have been told there was a pop and the resident required pain medication, he/she would have ordered the x-rays immediately. The resident is chronically debilitated already and this will make things more difficult for him/her. During an interview on [DATE] at 7:45 A.M., CNA T said he/she worked on evenings on [DATE]. He/she assisted after the fall, but was not assigned to the resident. Prior to the fall, he/she assisted CNA L to transfer the resident from the wheelchair to bed with the use of a Hoyer lift and then assisted CNA L to get the resident on the bed pan. He/she told CNA L to let him/her know when he/she need help to take the resident off the bed pan. He/she was in a different room and heard a noise and CNA L scream for the nurse. When he/she entered the room, he/she saw the nurse between the bed and wall. He/she helped move the bed away. The nurse assisted the resident down to the floor because the resident was still holding on. There was a loud pop and the nurse said oh, my! What was that? The nurse said staff need to put the resident back into bed. He/she cannot remember who all helped. The nurse instructed staff to grab the resident and lift him/her to bed. He/she held the resident at the bottom. The resident said his/her knee hurt and it was red. CNA L gave the resident ice. The resident did report pain. During an interview on [DATE] at 2:24 P.M., the DON said staff know how to care for residents by viewing the care plan. Staff should be assessing residents for pain during rounds. They should observe for pain or ask if the resident had pain. If the resident had pain after the fall this should be documented. After the fall, the resident should have been transferred back to bed with the Hoyer lift. Staff should never lift a resident by grabbing onto the arms and legs. The evening shift nurse should have completed the SBAR for the fall. If the nurse heard a loud pop when lowering the resident to the floor, this should have been reported to the physician. 2. Review of Resident #70's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Supervision, oversight, encouragement, or cuing required for bed mobility, walking in the room, walking in the corridor, locomotion on and off the unit and eating; -Limited assistance required for personal hygiene, toilet use, dressing and transfers; -[DIAGNOSES REDACTED]. -No pain, no falls; -Oxygen therapy not indicated as used. Review of the resident's care plan, showed: -Has potential for falls related to recent admission to community: -Resident is at risk for falls related to change in environment. Resident wants to remain free from injury related to falls; -Keep pathways clear and provide adequate lighting, reeducate to call for assistance when feeling unsteady; -No documentation of the resident's need for oxygen therapy. Review of the resident's medical record, showed the resident designated as do not resuscitate (DNR, no life saving measures desired). Review of the resident's progress notes, showed: -On [DATE] at 6:56 P.M., fall documentation: resident noted to be lying on floor by CNA at 10:00 A.M., on [DATE]. Resident noted to be on back with his/her head near the air conditioning unit and his/her legs were stretched out in the room. Resident stated I fell and hit my back on the air conditioner unit. Resident screamed out my back hurts when range of motion and assessment was attempted. Resident refused range of motion. This writer advised CNAs not to move resident. Complaints of back pain as needed Tylenol administered. At 10:25 A.M., paged the physician, awaiting call. At 10:40 A.M., Power of Attorney (POA) notified and requested for resident to be sent to the hospital. At 10:40 A.M., hospital emergency room nurse notified about resident's changed in condition. At 10:55 A.M., 911 called. Resident stayed on the floor with charge nurse at his/her side the whole time, until emergency medical technicians (EMTs) transferred him/her to the stretcher; -On [DATE] at 6:59 P.M., received report from hospital that all x-rays negative for fracture and breaks. Stated resident was in pain and described it as severe pain; -On [DATE] at 7:03 P.M., resident returned to the facility via ambulance. Chief complaints is shortness of breath. Resident placed on 3 liters (L) oxygen to keep oxygen saturation (percentage of oxygen in the blood) above 93% (normal 95% through 100%); -On [DATE] at 7:56 P.M., follow up note. Resident refused skin assess due to severe back pain after hitting back on air conditioning unit; -On [DATE] at 2:48 A.M., readmit status, resident returned from hospital after fall. Purple bruising to the left upper extremity. Complaint of pain ,[DATE] (based on a scale of 0 to 10. 0 Indicates no pain and 10 indicates the most severe pain) back pain but refused Tylenol. Helped adjust bed and pillows for comfort, resident on 3L oxygen, no shortness of breath or complaints. Reminded to use call light before he/she gets out of bed for precaution as he/she is used to being independent and without oxygen. Bed in low position, call light and personal items in reach. Vital signs: Temperature 97.9, blood pressure ,[DATE], heart rate 87, respirations 18, oxygen saturation 97% on 3L oxygen. Neurological check within normal limits; -On [DATE] at 2:55 P.M., resident continued on follow-up. No distress or discomfort. Resident refused to eat lunch. By mouth fluids encouraged. In room with call light in reach; -On [DATE] at 3:16 P.M., resident with recent fall. Recommending physical therapy evaluation to follow to assess mobility and balance; -On [DATE] at 2:49 A.M., resident continued on follow-up for a fall with bruising. No complaints of or distress, currently resting in bed, call light in reach; -On [DATE] at 1:07 P.M., resident was given wrong medication. Resident was given [MEDICATION NAME] (narcotic pain medication) ,[DATE] milligram (mg) one tab by mouth which was meant for his/her roommate. But by me being new and not told of the resident's confused mental status, when asked if he/she was (roommate's name) the resident answered yes. Medication was given and as soon as it was realized the medication was given to the wrong person, immediately notified coworker and assistant director of nursing (ADON) of the medication error. Physician notified and instructed to monitor resident for the next 6 hours. Family member notified. Vital signs: Blood pressure ,[DATE], heart rate 88, respirations 16, oxygen saturation 96% on 2L of oxygen. Resident assisted to wheelchair with CNA and this writer, to eat lunch. Resident sitting in chair with no complaints noted at this time; -On [DATE] at 2:54 P.M., resident sitting in chair relaxing. Has no complaints of pain noted at this time; -On [DATE] (note entered at 7:57 P.M., over three hours after the resident expired, and did not specify what time this observation occurred) Resident had complaints of irregular heartbeat. Did a manual pulse check of the radial pulse and the results was 66 beats per minute. Call sent out to physician and family; -No further documentation of assessments of the resident, monitoring of the resident, documentation of change in condition and/or vital signs taken. During an interview on [DATE] at 12:31 P.M., Physician EE said he/she was notified of the fall and when the resident received the wrong medication. The next notification he/she received was when the resident expired. He/she was not notified of a change in the resident's condition. During an interview on [DATE] at 1:06 P.M., the resident's family member said he/she was notified of the fall and when the resident received the wrong medication. The next notification made was after the resident expired. Further review of the resident's progress notes, showed: -On [DATE] at 8:37 P.M., called to resident's room at 4:30 P.M., resident slumped in chair. Checked for vital signs. No vital signs present. Resident non-responsive. Resident deceased at 4:45 P.M. Physician notified, confirmed death [DIAGNOSES REDACTED]. Family notified, had concerns about earlier medication error. Family wanted coroner to do autopsy. Pathologist notified of request and the events of the medication error. Pathologist findings were that the amount of the dose given was not enough to be the cause of death. So t (TRUNCATED)

Based on observation, interview and record review, the facility failed to provide protective oversight for one of three sampled residents who was at high risk for falls. The resident was at a high risk for falls and injury, due to a recent craniotomy (surgical removal of part of the bone from the skull to expose the brain) and subsequent use of [MEDICATION NAME] (an anti-clotting medication used to decrease the clotting ability of the blood, thereby increasing the risk of bleeding which can become severe or life-threatening). The facility implemented an intervention of a one to one (1:1) sitter for the nighttime hours. The facility did not have a policy or specified instructions for staff who performed 1:1 duties. The sitter left the resident unattended, he/she fell during that time and sustained serious injury, resulting in his/her death (Resident #1). The census was 136. Review of Resident #1's primary care physician's hospital discharge summary, dated 2/24/19, showed the resident was admitted to the hospital on [DATE], for surgical removal of a cerebellar (cerebellum is part of the brain, at the back of the skull, which coordinates and regulates voluntary movements such as posture, balance, coordination, and speech, resulting in smooth and balanced muscular activity) cyst. The cerebellar craniotomy was performed on 1/28/19, and initially the resident did very well after the surgery. Later that evening, the resident's mental status deteriorated, due to the development of a large intracranial hematoma (a collection of blood within the skull) from the earlier brain surgery. A repeat craniotomy, for removal of the hematoma, was done early the next morning. The resident developed [MEDICAL CONDITION] and was placed on a ventilator, after the second brain surgery. The final pathology report showed the cyst was a hemangio[DIAGNOSES REDACTED] (a highly vascular, benign tumor that can occur in the brain, spinal cord and retina). The resident slowly improved, but continued to be very confused. The resident's confusion cleared up some, but he/she continued to have some [MEDICAL CONDITION] (serious disturbance in mental abilities that results in confused thinking and reduced awareness of the environment, usually due to an infection). The physician did not think the resident could tolerate 3 hours of therapy per day, nevertheless he/she was discharged to the skilled nursing facility on 2/12/19. During an interview on 3/12/19 at 10:09 A.M., the resident's primary care physician said after the resident's second brain surgery, on 1/29/19, the resident was confused, had poor judgment and fell a couple of times in the hospital. Review of the admission nurse's note, dated 2/12/19 at 4:54 P.M., showed the resident arrived on a stretcher at 4:45 P.M., via an ambulance. Review of the next nurse's note, dated 2/12/19 at 5:19 P.M., showed the resident was admitted for skilled care, from the hospital, with [DIAGNOSES REDACTED]. The resident verbalized understanding the use of the call light, and his/her spouse was at the bedside. The resident's medications were verified with his/her primary care physician. Review of the resident's physician order [REDACTED]. Review of the resident's nursing Admission Observation/Evaluation, dated 2/12/19 at 7:40 P.M., showed the following: -The resident was alert, with clear speech and understood verbal and written instructions; -The resident had difficulty chewing and swallowing; -The resident was continent and incontinent of bowel; -Neurological assessment showed the resident had no decreased strength of his/her right or left hand grasp; -Neurological assessment showed the resident's pupils were equal in size (pupils should be round and equal in size, between 2 to 5 millimeters); -Neurological assessment showed pupillary reactivity to light (pupillary reaction to light is an important neurological examination, performed to assess for increased intracranial pressure due to a [MEDICAL CONDITION]) was left blank, indicating reactivity to light was either not assessed or his/her pupils were not reactive to light; -Unsteady gait; -No history of falls. During an interview on 3/18/19 at 11:56 A.M., the Director of Nursing (DON) said no admission fall assessment was completed on 2/12/19. Review of the resident's Activities of Daily Living (ADL)/Daily Care List (a care plan for the aides, which they access via the computer), no creation date, under the resident's safety category, showed a start date of 2/12/19, for the following: -1:1 monitoring, evening and nights; -Floor mats in place when in bed; -Keep bed in lowest position; -Monitor confusion throughout the day and night, and provide 1:1 staff supervision as indicated. Review of the resident's fall care plan, no date, showed he/she was at high risk for falls due to falls prior to his/her admission to the facility, confusion, communication limitations and left cerebellar tumor with recent craniotomy on 1/28/19. There was a start date of 2/13/19, for the following interventions: -Floor mats in place when resident in bed; -Keep bed in lowest position; -1:1 staff monitoring as indicated. During an interview on 3/13/19 at 11:17 A.M., the DON said 1:1 staff observation was put into place because the resident was a high risk for falls and the goal was for the resident to remain free of falls. No order was requested from the physician as it was part of the resident's care plan for fall prevention. Further review of Nurse A's nurse's note, dated 2/13/19 at 6:31 A.M., showed the resident was found on the floor, next to his/her bed at 5:15 A.M., and neurological checks (specific neurological guidelines to follow, which could indicate a serious head injury) were unremarkable. The resident had problems articulating in full sentences, but was able to answer yes and no questions. The resident denied any injury. There was no information regarding staff 1:1, resident observation. Further review of the nurse's note, dated 2/13/19 at 8:56 A.M., showed the Interdisciplinary Team (IDT, a group of health care professionals with various areas of expertise who work together) reviewed the resident's fall and updated his/her care plan with interventions. There was no information regarding what interventions were put into place. Further review of the nurse's note, dated 2/13/19 at 2:56 P.M., showed the resident was sitting in the dining room and fell on the floor. The resident sustained [REDACTED]. The resident denied pain and neurological checks were started. There was no information regarding staff 1:1, resident observation. During an interview on 3/6/19 at 9:15 A.M., the DON said the resident had two falls within the first 24 hours of his/her admission. The resident had no injury after the first fall, but sustained an abrasion to the right side of his/her forehead after the second fall. They discussed the resident's falls the next morning, on 2/13/19, during their clinical huddle (daily manager's morning meeting to discuss resident concerns), and added interventions to prevent falls. They added floor mats when in bed and bed in the lowest position to his/her care plan. Further review of the nurse's note, dated 2/13/19 at 10:34 P.M., showed the resident's spouse was with the resident from 6:45 P.M. to 11:00 P.M. There was no information regarding staff 1:1, resident observation. During an interview on 3/6/19 at 9:15 A.M., the DON said they started 1:1 staff monitoring on 2/14/19 and the resident's spouse was to stay with the resident every day, until 7:00 P.M., then the facility staff would provide 1:1 care until 7:00 A.M., the next morning. Further review of Nurse A's nurse's note, dated 2/14/19 at 1:24 A.M., showed the resident was on observation for two falls the previous day. The resident was restless, swinging his/her legs out of bed at times, but was able to be redirected. The resident's bed was in its lowest position, was locked in place, mats were on the floor beside the bed. The resident was provided continuous monitoring for safety, via a sitter at his/her bedside. Further review of the nurse's note, dated 2/14/19 at 10:01 A.M., showed the resident was alert, oriented to him/herself only, and was able to follow commands. The resident was educated on the risk of trying to stand without help, but continued to scoot to the end of his/her chair and tried to stand up. A hematoma with an abrasion remained on the resident's forehead. The resident required the assistance of two staff for transfers and was unable to propel him/herself in the wheelchair. Further review of the nurse's note, dated 2/14/19 at 10:56 P.M., showed the resident's nurse was told by the evening shift nurse supervisor, that the resident's spouse was to stay with the resident until the night shift 1:1 aide arrived to be with him/her. The resident's spouse left at 7:15 P.M., but later returned to retrieve his/her cell phone, when the resident became agitated. The spouse could not calm the resident, so he/she left again. The resident kept trying to get out of the recliner, was striking at staff and was quite strong. The resident refused to take his/her medications and balled his/her fist at the nurse. The evening nurse supervisor came over, sat with the resident, and got the resident to take his/her medications. Further review of the nurse's note, dated 2/14/19 at 11:42 P.M., showed the resident's nurse gave report to the resident's 1:1, Certified Nurse Assistant (CNA-aide), at 11:15 P.M. The CNA then entered the resident's bedroom and said, I'm too late. The resident was face first on the floor mat, on his/her stomach. The resident denied hitting his/her head, hand grasps were strong and equal, and the resident said he/she was at the hospital. The resident had given the hospital answer before, and knew his/her birthday and spouse's name. The day shift nurse was to call the resident's spouse and physician in the morning. The facility's Emergency Response System (ERS-separate software system for tracking all resident incidents) was not accessible. There was no documentation regarding the continuation of neurological checks. Review of the DON's nurse's note, dated 2/15/19 at 9:25 A.M., showed a call was placed to the resident's neurologist/surgeon regarding the possible use of a helmet to provide protection. The message was to be forwarded to the physician as soon as possible. Further review of the nurse's note, dated 2/15/19 at 2:21 P.M., showed the resident's physician was called by the Assistant Director of Nursing (ADON), regarding the resident's behaviors and the possible need for a 1:1 sitter, due to the resident's increased risk for falls and injury. The physician gave orders for [MEDICATION NAME] (an antidepressant medication used to treat anxiety, [MEDICAL CONDITION], and depression) at 7:00 P.M. and to monitor the resident's behaviors during the night. Review of the resident's physician order [REDACTED]. Review of the DON's nurse's note, dated 2/15/19 at 3:18 P.M., showed the DON called one of the resident's family members. The family member was concerned about the resident's falls and concerned about the facility's request for the family members to help with the resident's 1:1 monitoring, needed for his/her impulsive behavior. The DON told the family member the IDT had discussed the resident's falls daily, updated his/her plan of care as the level of monitoring increased, and the facility was providing 1:1 care during the evening and night hours. The resident's primary care physician was aware and the facility had placed a call to the resident's neurologist/surgeon, to explore the option of protective head gear (helmet). The family member told the DON they wanted to transfer the resident to another facility, because the facility had not met the family's expectations related to safety concerns. Review of the DON's nurse's note, dated 2/15/19 at 3:39 P.M., showed the DON called the resident's neurologist/surgeon back to see if there would be a need for specific protective head equipment, due to resident's several falls. The DON was advised of no specific type was needed because there was no cranial defect from the surgery. Further review of the nurse's note, dated 2/15/19 at 10:00 P.M., showed the resident was able to slowly feed him/herself dinner. There was not a staff person scheduled that evening, to provide 1:1 service to the resident so after dinner they put the resident at the CNA table and then transferred him/her to the recliner by the TV, near the dining room, where he/she slept. Further review of the nurse's note, dated 2/16/19 at 1:56 A.M., showed the resident was still without a 1:1 staff for the night shift. The resident remained in the recliner, fully reclined, in the Great Room within eyesight of staff. Further review of the nurse's note, dated 2/16/19 at 10:23 P.M., showed the resident continued to have poor safety awareness and impulsive actions (no descriptive behaviors given). A 1:1 sitter was at his/her bedside. Further review of the medical record, showed no nurse's notes for 2/17/19. Further review of the nurse's notes, showed a 1:1 sitter was at the resident's bedside, during the nightshift, for 2/18/19 and 2/19/19. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/19/19, showed the following: -Cognitive impairment, rarely understood; -Usually understood with clear comprehension of ability to understand others; -No behaviors; -Required extensive assistance of two staff for transfers and bed mobility; -Required extensive assistance of one person for eating, personal hygiene and dressing; -Required limited assistance of one person for bathing and two persons for toilet use; -Not steady, only able to stabilize with human assistance, when moving from seated to standing position; -Not steady, only able to stabilize with human assistance, when transferring between bed and chair or wheelchair; -Only able to stabilize with human assistance, when moving off toilet; -Required a wheelchair for mobility; -No impairment in range of motion of upper and lower extremities; -Always continent of bowel; -Indwelling urinary catheter; -Trouble falling asleep; -Felt tired or had little energy; -Moved or spoke slowly. Further review of the nurse's note, dated 2/19/19 at 1:07 P.M., showed the resident was able to propel him/herself in the wheelchair, was alert but forgetful and was able to make his/her needs known. Further review of the nurse's note, dated 2/19/19 at 11:37 P.M., showed the resident was awake, alert, quiet and with good behavior during the spouse's visit. There was also a male visitor and the resident seemed to follow his/her conversation. The resident's speech was difficult to understand at times and he/she did try to get out of the recliner, but was easily redirected. The resident's 1:1 sitter started at 7:00 P.M. Further review of the nurse's notes, showed a 1:1 sitter was at the resident's bedside, during the nightshift, for 2/20/19 and 2/21/19. Further review of the nurse's note, dated 2/21/19 at 11:50 A.M., showed the resident continued to require two staff for transfers, had no coughing or choking problems during his/her meal, was able to propel him/herself in the wheelchair and made no attempts to transfer him/herself without assistance. Review of a social service note, dated 2/21/19 at 5:04 P.M., showed the resident's spouse planned on taking the resident home, when his/her therapy was discontinued. Further review of the nurse's note, dated 2/21/19 at 10:44 P.M., showed the resident's speech was difficult to hear because he/she spoke very low. The resident made no attempts to get out of his/her chair, but started wheeling him/herself back to his/her bedroom. Further review of Nurse A's nurse's note, dated 2/22/19 at 2:16 A.M., showed a 1:1 sitter was at the resident's bedside. Further review of the nurse's note, dated 2/22/19 at 9:46 P.M., showed an out of town family member had visited the resident that evening and the resident seemed to respond appropriately to him/her. The resident's speech was still difficult to understand because he/she spoke softly. Further review of the nurse's note, dated 2/23/19 at 1:01 A.M., showed a 1:1 sitter, and a family member, were at the resident's bedside. Further review of the nurse's note, dated 2/23/19 at 9:34 P.M., showed many family members were there until 8:00 P.M., the resident made no attempts to stand up or get out of bed and a 1:1 sitter was with him/her after 8:00 P.M. The resident's speech remained difficult to hear because he/she spoke softly. Further review of the nurse's note, dated 2/24/19 at 6:55 A.M., showed the resident was alert and oriented times two (oriented to person and place), required a 1:1 sitter due to frequent falls. The resident was listed as a high fall risk and was to always be within sight of a staff member. Further review of the nurse's note, dated 2/24/19 at 11:40 P.M., showed the resident was difficult to understand, due to soft speech. An out of town family member was with the resident, during the night shift, as well as a 1:1 sitter. The resident made no attempts to get out of bed. Further review of the nurse's note, dated 2/25/19 at 5:10 A.M., showed the resident had a 1:1 sitter and had no unusual behaviors. Further review of the nurse's note, dated 2/25/19 at 11:03 A.M., showed the nurse spoke with the resident and his/her family member, regarding the resident's visual hallucinations during the night. Further review of the nurse's note, dated 2/25/19 at 11:06 A.M., showed the nurse placed a call to the resident's primary care physician to report, when he called back, that the resident had visual hallucinations during the night. The nurse then spoke with the resident's spouse and another family member, about the likelihood the new [MEDICATION NAME] medication had caused the hallucinations. The family members said the resident was resting well with the medication and did not want it to be discontinued. Further review of the nurse's note, dated 2/25/19 at 11:29 P.M., showed the resident made no attempts to get out of bed and his/her 1:1 sitter started at 7:00 P.M. Further review of the nurse's note, dated 2/26/19 at 9:58 A.M., showed the resident was alert times two, pleasant with no behaviors, only needed one staff to assist with transfers and activities of daily living (ADLs), and was attending therapy for strengthening and mobility. Further review of the nurse's note, dated 2/26/19 at 10:37 A.M., showed the nurse called the primary care physician's office to report the resident's behaviors. There was no documentation describing these behaviors. Further review of the nurse's note, dated 2/27/19 at 10:43 P.M., showed the resident, at 6:30 P.M., wanted to know where his/her spouse had gone and if he/she was returning. The resident then started propelling him/herself back to his/her bedroom and became very agitated when the staff would not let him/her go there. The resident did not want to wait in the Great Room until the 1:1 sitter arrived. The resident started yelling help, kicked at staff, hitting staff and held onto the wheels of his/her wheelchair so the staff could not move him/her. The 1:1 sitter arrived at 7:15 P.M. and took the resident to his/her room. Further review of the nurse's note, dated 2/28/19 at 9:42 A.M., showed the resident had no coughing or choking with breakfast, only needed one staff to assist with transfers, and was able to propel him/herself in wheelchair. Further review of the nurse's note, dated 2/28/19 at 11:16 P.M., showed at 10:00 P.M., the resident became agitated, before the 1:1 sitter arrived, but quickly calmed down when staff started asking him/her about his/her earlier life. Further review of the nurse's note, dated 3/1/19 at 11:55 P.M., showed the resident had no adverse behaviors that shift. Further review of the nurse's note, dated 3/2/19 at 1:29 A.M., showed the resident was fully reclined in the Great Room, with the 1:1 sitter at arm's length. Further review of the nurse's note, dated 3/2/19 at 12:30 P.M., showed the resident was alert, oriented times two, able to make his/her needs known, needed assistance of one staff for ADLs and transfers and was attending therapy for strengthening. Further review of the nurse's note, dated 3/3/19 at 1:20 A.M., showed the resident was in his/her bed, with a family member at his/her bedside. There was no documentation a 1:1 sitter was with the resident. Review of Nurse A's nurse's note, dated 3/4/19 at 6:23 A.M., showed Nurse A was on the 400 hall (Assisted Living Unit) at 5:00 A.M., passing medications, when Certified Nurse Aide (CNA) B, the resident's 1:1 sitter from 300 hall, showed up to report the resident had fallen out of the recliner and was on the floor. The resident denied he/she had an injury, but there was a red, raised area, on his/her right forehead. The resident had full range of motion (ROM, joints in arms and legs moved without problems) and his/her neurological checks were unremarkable. Review of Nurse A's electronic Safety Event Entry form (Incident Report form), dated 3/4/19 at 7:32 A.M., showed the following: -At 5:00 A.M., on 3/4/19, CNA A, who was providing 1:1 supervision for the resident, came to him/her, who was passing medications on 400 hall, and said the resident had fallen out of the recliner in the day room (Great Room). The CNA said he/she left the resident alone, when he/she went to use the bathroom and was only gone for a couple of minutes. CNA E, who was assigned to all the other residents on 300 hall, was in another resident's room at the time. Nurse A and CNA B lifted the resident off the floor, using a gait belt and put the resident back into the recliner. Nurse A saw a raised, red area on the right side of the resident's forehead. The resident had full ROM and his/her neurological checks were unremarkable; -The fall was unwitnessed; -The cause of the fall was listed as accidental; -The resident was on [MEDICATION NAME], which is a medication known to increase the risk of falls; -The resident's blood pressure was 160/70 at the time of the fall; -Prior to the fall, fall prevention interventions were listed as personal items were within reach, on fall alert, non-slip footwear, resident education, resident situated close to the nurse's station and had a sitter; -The resident fell from a chair; -Unknown what resident was doing prior to the fall; -The floor was carpeted; -The final fall event severity was listed as a 4 (major severity); -The type of injury sustained was a major intracranial injury; -Injury to skin was a contusion (bruise), or ecchymosis (subcutaneous discoloration resulting from seepage of blood, within the contused tissue, pulled down by gravity) and hematoma; -Severity of the event was classified as a G (Severe-event caused severe harm and required significant intervention); -Actions taken immediately following the event were listed as, notification of physician, assessed/monitored resident, increased vital signs or nursing observation frequency. Further review of Nurse A's next nurse's note, dated 3/4/19 at 7:53 A.M., showed Physician C, who was on call for the resident's primary care physician, was notified of the resident's fall and there were no new orders given. A message was left on the spouse's telephone. (The specific information told to the physician was not documented.) Review of Nurse D's nurse's note, dated 3/4/19 at 11:30 A.M., showed the following: -8:30 A.M., a call was made to Physician C, regarding the resident's fall, a large hematoma on the right side of his/her forehead, and the spouse's concern about the resident needing further evaluation. Physician C gave orders to sent the resident to the hospital for evaluation; -9:40 A.M., emergency medical services (EMS) there to transport the resident to the hospital. (No further information, regarding the resident's condition was documented.); -Within this same nurse's note section was a late entry, dated 3/5/19 at 11:30 A.M., for events on 3/4/19 (no time noted). The added note, by Nurse D, said when Nurse D spoke to Physician C, he/she informed the physician of the resident's [DIAGNOSES REDACTED] and craniotomy history, which had been performed on 1/28/19. Review of Nurse D's nurse's note, dated 3/5/19 at 11:15 A.M., was a late entry for 3/4/19 (no time noted), which showed the following (observation/event times not given): -The resident had his/her head on the dining room table; -The resident appeared to have a large hematoma to the right side of his/her forehead; -The resident was alert, oriented (knew person, place and time) and awake; -Nurse D asked the resident if he/she was in pain, but the resident did not speak; -The resident's lower extremities were weak; -The resident was unable to keep his/her eyes open to check pupil size and reactivity; -The resident's temperature was 97.2 degrees F, blood oxygen saturation was 96%, blood pressure was 142/88, and his/her pulse was 100 beats per minute; -The resident's spouse arrived and was concerned about the resident's fall; -Nurse D told the spouse what he/she was told, about the fall, from Nurse A; -Nurse D told the spouse he/she could not provide exact details of the fall, because Nurse D was not present at the time of the fall; -Nurse D asked the spouse if it was normal behavior for the resident to have his/her head resting on the table, but the spouse was unable to provide the resident's baseline behavior; -The spouse told Nurse D the resident needed an x-ray, a CT scan (computed tomography is an imaging method that uses x-rays to create cross-sectional pictures of the body), or something; -Nurse D told the spouse he/she would call Physician C and get the resident sent out to the hospital for further evaluation; -A call was placed to Physician C. Review of the resident's hospital records, dated 3/4/19, showed the resident arrived at 10:16 A.M., via EMS, with a C-collar (neck brace) in place and a hematoma on his/her right forehead. The resident was somnolent (abnormal drowsiness) and non-verbal, his/her blood pressure was elevated at 158/97 and his/her heart rate was 103 beats per minute. A CT of the head, without contrast, was done at 12:23 P.M., and results showed the following: -A right subdural hematoma (bleeding under the skull and not in the brain itself, but as blood accumulates, pressure on the brain increases and this pressure causes a subdural hematoma's symptoms, and if the pressure inside the skull rises to a very high level, a subdural hematoma can lead to unconsciousness and death) with 12 millimeters (mm) of midline shift (a shift of the brain past its center line and is commonly associated with a distortion of the [DIAGNOSES REDACTED] that can cause serious dysfunction, evidenced by abnormal posturing and failure of the pupils to constrict in response to light. It is caused by high intracranial pressure, from a [MEDICAL CONDITION], which can be deadly. Immediate surgery may be indicated when there is a midline shift over 5 mm.); -Scant collection of subarachnoid hemorrhage (bleeding into the space between the arachnoid and the pia mater, the innermost membrane surrounding the brain, that is filled with cerebrospinal fluid, blood vessels and cranial nerves, typically caused when an artery breaks open in the brain) in the right sylvian (a canal between the third and fourth ventricles in the brain); -Right frontal scalp hematoma. Further review of the resident's hospital record, showed the emergency department physician, after review of the resident's CT results, called the resident's neurosurgeon at 1:16 P.M., who came to the emergency department to do an emergency craniotomy. The resident's neurosurgeon's consult, dated 3/4/19 at 1:54 P.M., showed the resident's CT revealed a large acute right side subdural hematoma with a significant mass-effect (the effect of a growing mass causing pathological effects by pushing on or displacing surrounding tissue, causing a deadly brain herniation), including midline shift. The resident was intubated (tube inserted through the mouth and into the lungs so the person can be placed on a ventilator to assist with breathing) and comatose. The resident had minimal pupillary reaction to light, his/her right pupil was 4 mm in size, and the left pupil was 3 mm in size. The surgeon met with the resident's family regarding the medical findings, treatment options and made certain the family was aware the resident's prognosis (outcome) was very poor. The family decided on brain surgery, so a right-sided craniectomy with hematoma evacuation was immediately scheduled. Further review of the resident's hospital records, showed the right sided craniectomy with hematoma evacuation started at 2:45 P.M., on 3/4/19, and ended at 5:09 P.M. On 3/4/19, at 9:02 P.M., the resident's neurological status had not improved and a repeat CT of the head showed a re-accumulation of the right-sided subdural hematoma, causing more mass-effect and more midline shift, including uncal herniation (downward brain herniation). These findings were discussed with the resident's spouse, along with the resident's poor prognosis with or without repeat brain surgery. The spouse chose comfort care for the resident. The resident passed away on 3/5/19. During an interview on 3/8/19 at 10:54 A.M., CNA B said he/she worked for the facility on an as-needed basis and had worked two or three, 1:1 sitter shifts before, for a resident several months earlier. CNA B said he/she called the on-call nurse that morning, on 3/3/19, to see what shifts were available to pick up. He/she was told about the 1:1 sitter shift, that was open from 7:00 P.M. to 7:00 A.M., and he/she picked it up. He/she spoke with the 100 hall nurse, because that is where everyone looks at the assignment schedule. The 100 hall nurse told him/her to ask the 300 hall nurse or aide, about the resident. CNA B spoke to both of the evening shift aides on the 300 hall. He/she found out who the resident was, was told he/she was an assist of one, and he/she needed to be watched because he/she gets up and down when no one is around and when he/she is awake. The resident was in the recliner chair, in front of the TV, behind the sofa and near the fireplace. CNA B said 1:1 supervision meant that the resident needed to be supervised at all times; around the clock supervision. The resident was to be watched, to make sure he/she is safe and redirect if needed. This resident was 1:1 because he/she had a fall before, and he/she tended to get up and down without asking for assistance. CNA B said he/she asked Nurse F, maybe around 8:00 P.M., if it was okay to put the resident in bed and the nurse said okay and nothing else. The resident lay in bed for about an hour, then he/she kept moving and said something about the wheelchair. CNA B could not understand what he/she was saying. The resident grabbed the bed rail and tried to get up. CNA B told the resident to wait a minute, until he/she talked to the nurse. This was around 9:00 P.M. or so. CNA B left the resident's bedroom, went to the nursing station, and told the nurse the resident wanted to get up. They went back to the resident's ro

Based on observation, interview and record review, the facility failed to assess, monitor and treat open and/or abnormal skin coloring, prior to the development of an open wound for two of two sampled residents with open areas. This failure resulted in the amputation of a toe and the worsening of an open area. (Residents #25 and #7). The census was 137 with 73 residents in certified beds. 1. Review of Resident #25's admission skin assessment completed by the facility's admission Registered Nurse (RN) dated 12/9/14, showed the following: -Left foot: -All toes [MEDICAL CONDITION] (affected with [MEDICAL CONDITION], abnormal excess accumulation of serous fluid in connective tissue or in a serous cavity) and red cracked, tough skin. Fourth toe discolored, with black tip; -Treatment: monitor, elevate, apply moisturizer every shift and as needed (PRN); -"Alligator" skin with cracks 4+ [MEDICAL CONDITION] (swelling measured on scale of 1+ to 4+); -Treatment: moisturizer every shift and PRN, float heels; -Right foot: -All toes [MEDICAL CONDITION] and red cracked, tough skin. Fourth toe discolored red "dusky", with black tip; -Treatment: apply moisturizer every shift and PRN, elevate and monitor; -"Alligator" skin with cracks 4+ [MEDICAL CONDITION]; -Treatment: moisturizer every shift and PRN, float heels; -Groin, left and right groin red, with minor breakdown at creases; -Treatment: [MEDICATION NAME] cream (skin protectant), every shift and PRN; -Right calf, lateral calf skin tear prior to admission, red, with no signs and symptoms of infection; -Treatment: monitor area, mepelex (foam dressing) every three days and PRN; -Buttocks, red, with minor breakdown at crease; -Treatment: [MEDICATION NAME] cream every shift and PRN; -Left abdomen fold, skin to skin red, with peeling -Treatment: [MEDICATION NAME] cream every shift and PRN; -General skin, [MEDICAL CONDITION] 1+ bilateral upper extremities (BUE), 4+ bilateral lower extremities (BLE) and dry. General poor turgor and condition of skin; -Treatment, required moisturizer cream to bony surfaces every shift and as needed. Keep creases clean and dry, turn resident every two hours. Review of the admission RN's initial nurse's note dated 12/9/14 at 8:53 P.M., showed the resident arrived at the facility from the hospital at 5:15 P.M. The resident was treated at the hospital for [MEDICAL CONDITION] and weakness. Resident required maximum assistance and was unable to roll from side to side while in bed without assistance from two staff members. Resident's skin dry, [MEDICAL CONDITION], cracked, thick and in general poor condition. The resident's fourth toe on each foot discolored and dark. Review of the resident's physician's order sheet (POS) dated 12/9/14 through 12/31/14, showed the following: -admitted [DATE]; -[DIAGNOSES REDACTED]. -Medications included [MEDICATION NAME] (used to treat fluid retention such as [MEDICAL CONDITION]), 40 mg daily; -Skin treatments per facility protocols, see skin assessment for details; -Braden scale (used for predicting pressure sore risk) completed upon admission and then weekly for four weeks, every Monday; -[MEDICATION NAME] cream to buttocks every shift and PRN; -Mepelex 4 inches (in.) by 4 in., to right calf skin tear every three days and PRN; -[MEDICATION NAME] cream (used to treat the itching, redness, dryness, crusting, scaling, inflammation, and discomfort of various skin conditions), 0.05% back, legs and abdominal rash twice a day (BID); -Full weight bearing as tolerated. Review of the treatment administration record (TAR), showed the order for weekly Braden scale assessments. The space for 12/15 was initialed, but there was no documentation of the score. Staff left the space for 12/22 blank. The resident went to the hospital on [DATE]. Review of the resident's TAR and POS, dated 12/9/14 through 12/31/14, showed the following: -[MEDICATION NAME] treatment to buttocks and groin administered eight times out of 54 opportunities, with two lines written through order with order changed 12/14, written in on TAR with no initials; -No documentation of a physician's order to change the treatment, no new treatment order and no new treatments documented on the TAR; -Mepelex dressing to skin tear on right calf, applied two of six opportunities; -Moisturizer cream to BLE, feet and heels, every shift and PRN, applied 28 of 54 opportunities; -[MEDICATION NAME] cream to abdomen fold every shift and PRN., applied seven of 54 opportunities, with two lines written through order, order changed 12/14, written in on TAR with no initials; -POS showed order for [MEDICATION NAME] cream to abdominal rash, no documentation of a physician's order to change the treatment; -No new treatment order or no new treatments documented on the TAR; -[MEDICATION NAME] cream 0.05% to back, legs and abdominal rash BID, first treatment not administered until 12/11/14. Staff administered it 15 of 36 administration opportunities. Review of the resident's care plan dated 12/9/14, showed the following: -Required assistance with activities of daily living (ADLs), which included maximum assistance from two staff with bathing/showering and dressing; -Braden Scale, completed upon admission, with a score of 15 (Mild risk: Total score 15 through 18). Staff to inspect resident for signs and symptoms of skin breakdown, frequent turning, float heels and weekly skin checks. Review of the resident's records from 12/9 through 12/29/14, showed no documentation of weekly skin checks completed. Review of the resident's physician's progress note dated 12/12/14, showed Nurse Practitioner U documented the following: -Musculoskeletal, [MEDICAL CONDITION]; -Skin, one small blister upper extremity; -Impression/plan included, weakness and BLE [MEDICAL CONDITION] (swelling of tissues, usually in the lower limbs), resident currently on [MEDICATION NAME], continue to elevate legs. Review of the resident's nurse's notes, showed the following: -12/13/14 at 1:04 P.M., staff documented anasarca (extreme [MEDICAL CONDITION]) noted, with pitting and hardness of skin; -12/14/14 at 9:53 A.M., resident initially refused a shower twice, the previous evening on 12/13/14. Finally agreed with certified nurse aide (CNA) day staff, to shower. During an interview on 1/14/15 at 1:35 P.M., the Director of Nurses (DON) said she was unable to provide the resident's shower sheets used by staff to document any abnormalities noticed on the resident during bathing/showers. Review of the resident's physician's progress note dated 12/15/14, showed Nurse Practitioner U documented the following: -Musculoskeletal, [MEDICAL CONDITION]; -Impression/plan included, weakness and BLE [MEDICAL CONDITION]. [MEDICAL CONDITION] stable, increase [MEDICATION NAME] to 80 mg for three days, continue to elevate legs. Further review of the resident's POS dated 12/9/14 through 12/31/14, showed an order dated 12/15/14 at 10:00 A.M., for [MEDICATION NAME] 40 mg. BID for three days. Review of the resident's Medication Administration Record [REDACTED]. [MEDICATION NAME] 40 mg. daily, not administered again until 12/20/14 (no documentation [MEDICATION NAME] administered on 12/19/14). Further review of the resident's nurse's notes, showed the following: -12/16/14 at 4:37 P.M., staff documented the resident's spouse soaked the resident's feet and brought it to the nurse's attention, the toenail on the fourth toe of the left foot lose. Nurse applied Band-Aid and documented the podiatrist would come to the facility on [DATE] and the resident placed on the list to see him; -12/17/14 at 4:44 P.M., lower extremities (LE) remain [MEDICAL CONDITION] and resident completing three days of [MEDICATION NAME]; -No documentation the resident saw the podiatrist on 12/17/14. During an interview on 1/14/15 at 10:00 A.M., the DON said she did not know if the resident was on the list to see the podiatrist and if he/she saw him, but said she would find out. She could not provide documentation of the residents listed to see the podiatrist on 12/18/14. Review of an email correspondence between the DON and the Social Service/facility's transitional coach dated 1/14/15, showed: -The resident recognized as wanting/needing to see podiatry when she put out the sign up sheet one week prior to the appointment; -When the podiatrist came to the facility on [DATE], the Social Service/facility transitional coach was informed by nursing the resident refused. Review of the resident's medical record, showed no documentation the resident was offered to see the podiatrist on 12/18/14 and refused. Review of the resident's physician's progress note dated 12/18/14, showed the physician documented the following: -Musculoskeletal, [MEDICAL CONDITION]; -Impression/plan included, weakness and LE [MEDICAL CONDITION], ace wrap, physical and occupational therapy; -No mention of the toes. Further review of the resident's nurse's note dated 12/18/14 at 6:58 P.M., showed staff documented the resident's physician visited and ordered ace wraps to LE. Further review of the resident's TAR, showed ace wraps to both legs, on in the A.M. and off in the P.M. Review of the resident's 14-day admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/19/14, showed the following: -No cognitive impairments; -Extensive assistance of two to transfer; -Extensive assistance of one for all other ADLs; -No impairment to upper or lower extremities; -At risk for pressure ulcers with no ulcers present; -No venous and/or arterial ulcers (ulcers caused by decreased blood circulation) present; -No documentation of any infection in the resident's feet. Review of the resident's physician's progress note dated 12/22/14, showed Nurse Practitioner U documented the following: -Musculoskeletal, BLE [MEDICAL CONDITION] stable; -Skin, mild [DIAGNOSES REDACTED] (skin condition characterized by redness or rash, in response to medicines, infections, or illness), on BLE [MEDICATION NAME] layer, chronic; -Impression/plan included, BLE [MEDICAL CONDITION] stable, weakness, resident doing well. Continue therapy, ace wraps/elevate legs, monitor mild [DIAGNOSES REDACTED] on BLE; -No mention of the toes. Further review of the resident's nurse's notes dated 12/26/14, showed the following: -8:18 A.M., BLE [MEDICAL CONDITION] 4+, left leg slightly more red and tight than the right. Tightness extended up into the thigh area bilaterally. Open, draining area to the left fourth toe, dry gauze wrapped around this area to protect clothing; -10:06 A.M., Nurse Practitioner U doing rounds. Resident with a change in condition to the right foot fourth toe. Toe swollen, skin broken and serosanguinous drainage (consisting of both blood and serous fluid) noted. Resident denied feeling pain in the area. New order to send resident to hospital for treatment of [REDACTED]. Review of the resident's physician's progress note dated 12/26/14, showed Nurse Practitioner U documented the following: -Musculoskeletal, BLE worsening BLE, in thigh now; -Skin, toe LE, with severe [MEDICAL CONDITION]/toe infection; -Impression/plan included, BLE [MEDICAL CONDITION] worsening, weakness, lower left extremity toe infection, send to emergency room (ER). Review of the ER nurse's note dated 12/26/14 at 10:42 A.M., showed the following; -Arrived to ER with complaint of LE swelling; -Large ulcer noted to fourth toe left foot; -Small open area noted on fourth toe on right foot; -Per facility nurse, feet ulcers just noticed. Review of the ER physician's note dated 12/26/14, showed the following: -Musculoskeletal, fourth toe [MEDICAL CONDITION], white with distal necrotic portion and bleeding. [DIAGNOSES REDACTED] of left foot extended into lower leg, right lower leg, with milder [DIAGNOSES REDACTED]. BL, with stasis [MEDICAL CONDITION] (blood pools in the veins of the lower leg); -Swelling, bleeding of the fourth left toe, diffuse soft tissue swelling present, with soft tissue defect consistent with an ulcer present at the tip; -Impression, left fourth toe ulcer, swelling consistent with [MEDICAL CONDITION], possible erosive changes at the "tuft" (tip) of the distal phalanx of the fourth toe suggestive of osteo[DIAGNOSES REDACTED] (infection in the bone); -BLE swelling and redness, redness from left fourth toe, extended up foot and lower leg. Right leg, with stasis changes; -Surgical consult ordered. During an interview on 12/26/14 at 3:30 P.M., the ER RN said the resident was previously a patient at the same hospital for a stomach ulcer and sent to the facility for rehabilitation. She said the resident had a history of [REDACTED]. The resident arrived at the hospital on [DATE] around 10:30 A.M. The emergency medical team (EMT) informed the ER RN, the facility reported to them they were sending the resident out for lower extremity [MEDICAL CONDITION] and possible [MEDICAL CONDITION] in both lower extremities. The ER RN said when the resident presented at the ER, his/her left sock was very dirty and full of blood. With the EMT present, they removed the sock. The resident's fourth toe, on the left foot, had the skin detaching and the toe barely attached to the foot. The ER RN said the resident had extreme dark redness and swelling from the foot up into the resident's groin and thigh area. The resident's lymph nodes in the groin area very swollen from possible infection. The resident, fully cognitive, reported to the ER RN the foot and leg started to swell the week prior to the point the detached toe lost its toenail. The resident said the facility was wrapping his/her legs, but they were not treating the toe. The resident had been running a low grade fever, since arriving at the ER. The ER RN said she did not think the resident's toe could be saved and was worried the lower part of the resident's leg may also have to be amputated. Review of the pathology record dated 12/27/14 at 9:40 A.M., showed the following: -Amputation of the fourth left toe, specimen 6 cm; -Gangrenous necrosis (potentially life-threatening condition that arises when a considerable mass of body tissue dies), lesion 3.2 cm by 3.4 cm. with underlying acute osteo[DIAGNOSES REDACTED]. During an interview on 1/14/14 at 12:01 P.M., the facility's wound nurse said she should have documented the resident's skin issues on his/her admission skin assessment on the skin report. She should have ensured the description of the resident's fourth right and left toes were on the resident's TAR. The wound nurse said she did not assess the resident as she should have. Review of a written statement from the admission RN submitted by the facility on 1/14/14, showed the admission RN did not recall informing or not informing the nurse practitioner of skin issues when she notified the nurse practitioner for admission orders [REDACTED] During an interview on 1/14/14 at 1:35 P.M., the DON said she would have expected nursing staff and treatment nurse to document weekly about the resident's toes and other skin areas. The DON said the resident did have a history of venous and arterial [MEDICAL CONDITION] (blood clots) when he/she was admitted , which contributed to his/her [MEDICAL CONDITION] and skin issues. During an interview on 1/14/15 at 12:10 A.M., Nurse Practitioner U said she does a head to toe assessment of residents every time she visited the facility. She had not been informed of, or noticed anything in particular about the resident's fourth left toe until 12/26/14. When she visited the resident on 12/26/14, she noticed the left leg much more swollen all the way up to the resident's groin area. When she removed the resident's sock she discovered the infected toe. The facility nurse present, explained they had just noticed the toe the previous night after the resident was out on leave with his/her family for a couple hours on 12/25/14. Nurse Practitioner U said the facility did not notify her specifically in regards to the resident having black toes upon admission to the facility. The resident always had very red, dry, cracked and swollen skin. Staff had informed her before, the resident did not like them to remove his/her socks and was resistant to showers. Nurse Practitioner U said the facility should have definitely informed the physician's office immediately, upon discovery of the black tips of both the resident's fourth right and left toe. She said if nursing staff did notice those skin issues when the resident was first admitted to the facility, they should have been charting and assessing the areas on a constant basis. During an interview on 1/27/15 at 10:47 A.M., the ER physician who initially assessed the resident on 12/26/14, said if the facility documented dark areas anywhere on the feet, they should have been monitoring them on a consistent basis. The surgeon's finding showed acute osteo[DIAGNOSES REDACTED], which would of had to develop over weeks, for the infection to get into the bone. The ER physician said upon admission, after the facility assessed the resident's skin and documented black discoloration on the fourth toe of both his/her left and right foot, he would have expected them to notify the resident's physician of their findings. Especially with the resident's history of of diabetes and [MEDICAL CONDITION]. The ER physician said not monitoring the area from 12/9/14 through 12/26/14, was too long and a problem. 2. Review of Resident #7's quarterly MDS dated [DATE], showed the following: -Alert; -Frequently incontinent of bladder; -Continent of bowel; -Required extensive assistance from staff for ADLs, -At risk for pressure ulcers; -One, Stage II (Stage II-Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue). May also present as an intact or open/ruptured blister) pressure ulcer; -No venous/arterial ulcers. Review of facility's wound report, dated December 2014, showed staff documented an assessment of the resident's wounds on his/her left lower extremity and left lateral foot (side of foot) on the following dates: -On 12/17/14: Date of onset 10/14/14, location/site left lower extremity, classification of wound erosive [MEDICAL CONDITION] (deep inflammation of the tissues just under the skin, caused by infection). Staff documented the wound measured 12.0 cm length by 12.0 cm width by 0.1 cm depth with wound bed pale. Staff documented the status of the wound "stable"; -On 12/17/14: Date of onset 10/14/14, location/site left lateral foot, classification of wound arterial stasis ulcer. Staff documented the wound measured 2.5 cm length by 2.5 cm width with black eschar. Staff documented the wound had improved; -On 12/24/14, no documentation regarding measurements of the wound on the left lower extremity. Staff documented the wound bed, dark with slough (dead tissue) in the center of the wound. Staff documented the status of the wound had declined; -On 12/24/14, no documentation regarding measurements of the wound on the left lateral foot. Staff documented the wound had increased slough with tan, black eschar. Staff documented the wound had declined. Review of the POS [REDACTED] -An order dated 10/23/14, wash left lower extremity with Dial (antibacterial soap) and water, pat dry, apply Santyl ([MEDICATION NAME] ointment) and mupirocin (antibiotic ointment) to wound bed, apply [MEDICATION NAME] (brand name, non-adhesive type dressing) wound dressing and Kerlix (gauze wrap) change dressing daily; -An order dated 11/23/14, apply Santyl and mupirocin ointment to left lateral foot and cover with dry dressing and wrap with Kerlix daily; -An order dated 1/5/15, obtain wound culture and sensitivity (C&S, diagnostic laboratory test used to identify types of bacteria and to determine types of antibiotic that can be used to treat the bacteria); -An order dated 1/5/15, for [MEDICATION NAME] (antibiotic) 100 milligrams (mg) one tablet twice daily for ten days; -An order dated 1/5/15, for [MEDICATION NAME] (antibiotic) 250 mg one tablet twice daily for ten days; -No physician's orders documented after 1/5/15. Review of the facility's wound report, dated January 2015, showed: -On 1/1/15, the wound on the left lower extremity measured 12.0 cm length by 12.0 cm width by 0.2 cm depth with dry, pink wound bed. No documentation regarding the status of the wound on the left lower extremity. The wound on the left lateral foot measured 2.0 cm length by 1.0 cm width with dry, dark eschar. No documentation regarding the status of the wound on the left lateral foot; -On 1/7/15, the wound on the left lower extremity measured 10.0 cm length by 15.0 cm width with wound bed dark, red and black. Staff documented the status of the wound on the left lower extremity had declined. The wound on the left lateral foot measured 3.0 cm in length by 2.0 cm in width by 1.0 cm, open area with yellow slough. Staff documented the status of the wound on the left lateral foot had declined. Review of the TAR dated 1/1 through 1/31/15, showed the following: -An order dated 10/23/14, wash left lower extremity with Dial soap and water, pat dry, apply Santyl and mupirocin to wound bed, apply [MEDICATION NAME] wound dressing and Kerlix daily; -From 1/1 through 1/12/15, staff initialed and documented the treatment with dressing application was administered; -An order dated 11/23/14, apply Santyl and mupirocin ointment to left lateral foot and cover with dry dressing and wrap with Kerlix daily; -From 1/1 through 1/12/15, staff initialed and documented the treatment with dressing application was administered; -No other physician orders regarding treatments to the resident's left lower extremity and left lateral foot were documented on the TAR. Review of the resident's medical record, showed the following: -A laboratory test for left foot wound culture dated 1/6/15, showed gram positive cocci (bacteria that causes infection) with heavy growth; -A laboratory test for left foot wound culture obtained 1/6/15 with final report dated 1/10/15, showed Staphylococcus Auricularis (gram-positive bacteria that cause infection) heavy growth; -A hospital wound center report dated 1/9/15, showed an order for [REDACTED]. -Nurse's note dated 1/9/15 at 7:03 P.M., showed the resident had returned to the facility from the wound center. The resident's attending physician was notified of the resident's wound center report. Observation and interview on 1/13/15 at 10:00 A.M., showed the resident lay in the bed. Nurse P said the resident returned from the wound clinic on 1/9/15, without new orders regarding treatments. He/she said the only new physician's order from the wound clinic was [MEDICATION NAME] (elastic tubular support bandage) to the resident's left lower extremity. Nurse P said the wound on the resident's left lower extremity was due to [MEDICAL CONDITION] and the wound on the left lateral foot was an arterial stasis ulcer. Nurse P removed the soiled dressing dated 1/12/15, from the resident's left lower extremity and left lateral foot. The wound on the resident's left lower extremity measured approximately 10.0 cm in length by 20.0 cm in width with bright red tissue that covered the wound bed. The wound on the left lateral foot measured approximately 3.0 cm in length by 3.0 cm in width with scant amount of brown eschar that covered the wound bed. Nurse P cleansed the wounds on the resident's left lower extremity and left lateral foot with Dial soap/water, applied Santyl and mupirocin ointment to both wounds on the left lower extremity and left lateral foot. Nurse P covered the wounds with dry dressing and Kerlix wrap. Observation of the treatment carts on 1/13/15 at 11:00 A.M., showed no tube of [MEDICATION NAME] ointment for the resident on either cart. During an interview on 1/13/15 at 12:30 P.M., the pharmacist said [MEDICATION NAME] and mupirocin ointments were not the same medication. He/she said both were antibiotic ointments, but made with different types of antibiotic. The pharmacist said he/she had not received a physician's order for [MEDICATION NAME] ointment from the facility for the resident. He/she said the pharmacy received a re-fill order from the facility for Santyl and mupirocin ointments for the resident on 1/8/15. Observation of the treatment carts on 1/14/15 at 6:15 A.M., showed no tube of [MEDICATION NAME] ointment for the resident on either cart. Further review on 1/14/15 at 6:20 A.M., of the resident's POS and TAR dated 1/1 through 1/31/15, showed no order written for the administration of [MEDICATION NAME] ointment. During an interview on 1/14/15 at 11:15 A.M., the wound center nurse said the resident was examined and treated by the wound center physician on 1/9/15. The new treatment orders for the resident's wounds to his/her left lower extremity and left lateral foot were for [MEDICATION NAME] and Santyl ointment to be administered daily. The wound physician discontinued the mupirocin ointment because the resident's wound culture showed gram-positive cocci bacteria. He/she said the wound physician expected the [MEDICATION NAME] ointment to be administered as ordered. During an interview on 1/14/15 at 1:30 P.M., the DON said mupirocin and [MEDICATION NAME] ointments were not the same. The charge nurse was responsible for taking off the physician's orders from the wound center, faxed the order to the pharmacy and transcribed the treatment orders onto the TAR. The physician's order from the wound center should be transcribed onto the POS and filed under the section for physician's orders and not under the laboratory section in the resident's medical record. She expected the [MEDICATION NAME] ointment to be administered as ordered. Review of the facility's faxed information received 1/16/15 at 4:15 A.M., showed the resident was seen at the wound center on 1/9/15. The facility had contacted the resident's attending physician and wound physician regarding the wound center physician's orders dated 1/9/15, which were found under the laboratory section in the resident's medical record and reported the staff did not address the 1/9/15 orders, until 1/14/15. MO 902

For examples, see the revisit survey dated January 16, 2015, at Event ID#94UR12.

2 Based on observation, interview and record review, the facility failed to assess, monitor and treat open and/or abnormal skin coloring, prior to the development of an open wound for two of two sampled residents with open areas. This failure resulted in the amputation of a toe and the worsening of an open area. (Residents #25 and #7). The census was 137 with 73 residents in certified beds. 1. Review of Resident #25's admission skin assessment completed by the facility's admission Registered Nurse (RN) dated 12/9/14, showed the following: -Left foot: -All toes [MEDICAL CONDITION] (affected with [MEDICAL CONDITION], abnormal excess accumulation of serous fluid in connective tissue or in a serous cavity) and red cracked, tough skin. Fourth toe discolored, with black tip; -Treatment: monitor, elevate, apply moisturizer every shift and as needed (PRN); -Alligator skin with cracks 4+ [MEDICAL CONDITION] (swelling measured on scale of 1+ to 4+); -Treatment: moisturizer every shift and PRN, float heels; -Right foot: -All toes [MEDICAL CONDITION] and red cracked, tough skin. Fourth toe discolored red dusky, with black tip; -Treatment: apply moisturizer every shift and PRN, elevate and monitor; -Alligator skin with cracks 4+ [MEDICAL CONDITION]; -Treatment: moisturizer every shift and PRN, float heels; -Groin, left and right groin red, with minor breakdown at creases; -Treatment: [MEDICATION NAME] cream (skin protectant), every shift and PRN; -Right calf, lateral calf skin tear prior to admission, red, with no signs and symptoms of infection; -Treatment: monitor area, mepelex (foam dressing) every three days and PRN; -Buttocks, red, with minor breakdown at crease; -Treatment: [MEDICATION NAME] cream every shift and PRN; -Left abdomen fold, skin to skin red, with peeling -Treatment: [MEDICATION NAME] cream every shift and PRN; -General skin, [MEDICAL CONDITION] 1+ bilateral upper extremities (BUE), 4+ bilateral lower extremities (BLE) and dry. General poor turgor and condition of skin; -Treatment, required moisturizer cream to bony surfaces every shift and as needed. Keep creases clean and dry, turn resident every two hours. Review of the admission RN's initial nurse's note dated 12/9/14 at 8:53 P.M., showed the resident arrived at the facility from the hospital at 5:15 P.M. The resident was treated at the hospital for [MEDICAL CONDITION] and weakness. Resident required maximum assistance and was unable to roll from side to side while in bed without assistance from two staff members. Resident's skin dry, [MEDICAL CONDITION], cracked, thick and in general poor condition. The resident's fourth toe on each foot discolored and dark. Review of the resident's physician's order sheet (POS) dated 12/9/14 through 12/31/14, showed the following: -admitted [DATE]; -[DIAGNOSES REDACTED]. -Medications included [MEDICATION NAME] (used to treat fluid retention such as [MEDICAL CONDITION]), 40 mg daily; -Skin treatments per facility protocols, see skin assessment for details; -Braden scale (used for predicting pressure sore risk) completed upon admission and then weekly for four weeks, every Monday; -[MEDICATION NAME] cream to buttocks every shift and PRN; -Mepelex 4 inches (in.) by 4 in., to right calf skin tear every three days and PRN; -[MEDICATION NAME] cream (used to treat the itching, redness, dryness, crusting, scaling, inflammation, and discomfort of various skin conditions), 0.05% back, legs and abdominal rash twice a day (BID); -Full weight bearing as tolerated. Review of the treatment administration record (TAR), showed the order for weekly Braden scale assessments. The space for 12/15 was initialed, but there was no documentation of the score. Staff left the space for 12/22 blank. The resident went to the hospital on [DATE]. Review of the resident's TAR and POS, dated 12/9/14 through 12/31/14, showed the following: -[MEDICATION NAME] treatment to buttocks and groin administered eight times out of 54 opportunities, with two lines written through order with order changed 12/14, written in on TAR with no initials; -No documentation of a physician's order to change the treatment, no new treatment order and no new treatments documented on the TAR; -Mepelex dressing to skin tear on right calf, applied two of six opportunities; -Moisturizer cream to BLE, feet and heels, every shift and PRN, applied 28 of 54 opportunities; -[MEDICATION NAME] cream to abdomen fold every shift and PRN., applied seven of 54 opportunities, with two lines written through order, order changed 12/14, written in on TAR with no initials; -POS showed order for [MEDICATION NAME] cream to abdominal rash, no documentation of a physician's order to change the treatment; -No new treatment order or no new treatments documented on the TAR; -[MEDICATION NAME] cream 0.05% to back, legs and abdominal rash BID, first treatment not administered until 12/11/14. Staff administered it 15 of 36 administration opportunities. Review of the resident's care plan dated 12/9/14, showed the following: -Required assistance with activities of daily living (ADLs), which included maximum assistance from two staff with bathing/showering and dressing; -Braden Scale, completed upon admission, with a score of 15 (Mild risk: Total score 15 through 18). Staff to inspect resident for signs and symptoms of skin breakdown, frequent turning, float heels and weekly skin checks. Review of the resident's records from 12/9 through 12/29/14, showed no documentation of weekly skin checks completed. Review of the resident's physician's progress note dated 12/12/14, showed Nurse Practitioner U documented the following: -Musculoskeletal, [MEDICAL CONDITION]; -Skin, one small blister upper extremity; -Impression/plan included, weakness and BLE [MEDICAL CONDITION] (swelling of tissues, usually in the lower limbs), resident currently on [MEDICATION NAME], continue to elevate legs. Review of the resident's nurse's notes, showed the following: -12/13/14 at 1:04 P.M., staff documented anasarca (extreme [MEDICAL CONDITION]) noted, with pitting and hardness of skin; -12/14/14 at 9:53 A.M., resident initially refused a shower twice, the previous evening on 12/13/14. Finally agreed with certified nurse aide (CNA) day staff, to shower. During an interview on 1/14/15 at 1:35 P.M., the Director of Nurses (DON) said she was unable to provide the resident's shower sheets used by staff to document any abnormalities noticed on the resident during bathing/showers. Review of the resident's physician's progress note dated 12/15/14, showed Nurse Practitioner U documented the following: -Musculoskeletal, [MEDICAL CONDITION]; -Impression/plan included, weakness and BLE [MEDICAL CONDITION]. [MEDICAL CONDITION] stable, increase [MEDICATION NAME] to 80 mg for three days, continue to elevate legs. Further review of the resident's POS dated 12/9/14 through 12/31/14, showed an order dated 12/15/14 at 10:00 A.M., for [MEDICATION NAME] 40 mg. BID for three days. Review of the resident's Medication Administration Record [REDACTED]. [MEDICATION NAME] 40 mg. daily, not administered again until 12/20/14 (no documentation [MEDICATION NAME] administered on 12/19/14). Further review of the resident's nurse's notes, showed the following: -12/16/14 at 4:37 P.M., staff documented the resident's spouse soaked the resident's feet and brought it to the nurse's attention, the toenail on the fourth toe of the left foot lose. Nurse applied Band-Aid and documented the podiatrist would come to the facility on [DATE] and the resident placed on the list to see him; -12/17/14 at 4:44 P.M., lower extremities (LE) remain [MEDICAL CONDITION] and resident completing three days of [MEDICATION NAME]; -No documentation the resident saw the podiatrist on 12/17/14. During an interview on 1/14/15 at 10:00 A.M., the DON said she did not know if the resident was on the list to see the podiatrist and if he/she saw him, but said she would find out. She could not provide documentation of the residents listed to see the podiatrist on 12/18/14. Review of an email correspondence between the DON and the Social Service/facility's transitional coach dated 1/14/15, showed: -The resident recognized as wanting/needing to see podiatry when she put out the sign up sheet one week prior to the appointment; -When the podiatrist came to the facility on [DATE], the Social Service/facility transitional coach was informed by nursing the resident refused. Review of the resident's medical record, showed no documentation the resident was offered to see the podiatrist on 12/18/14 and refused. Review of the resident's physician's progress note dated 12/18/14, showed the physician documented the following: -Musculoskeletal, [MEDICAL CONDITION]; -Impression/plan included, weakness and LE [MEDICAL CONDITION], ace wrap, physical and occupational therapy; -No mention of the toes. Further review of the resident's nurse's note dated 12/18/14 at 6:58 P.M., showed staff documented the resident's physician visited and ordered ace wraps to LE. Further review of the resident's TAR, showed ace wraps to both legs, on in the A.M. and off in the P.M. Review of the resident's 14-day admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/19/14, showed the following: -No cognitive impairments; -Extensive assistance of two to transfer; -Extensive assistance of one for all other ADLs; -No impairment to upper or lower extremities; -At risk for pressure ulcers with no ulcers present; -No venous and/or arterial ulcers (ulcers caused by decreased blood circulation) present; -No documentation of any infection in the resident's feet. Review of the resident's physician's progress note dated 12/22/14, showed Nurse Practitioner U documented the following: -Musculoskeletal, BLE [MEDICAL CONDITION] stable; -Skin, mild [DIAGNOSES REDACTED] (skin condition characterized by redness or rash, in response to medicines, infections, or illness), on BLE [MEDICATION NAME] layer, chronic; -Impression/plan included, BLE [MEDICAL CONDITION] stable, weakness, resident doing well. Continue therapy, ace wraps/elevate legs, monitor mild [DIAGNOSES REDACTED] on BLE; -No mention of the toes. Further review of the resident's nurse's notes dated 12/26/14, showed the following: -8:18 A.M., BLE [MEDICAL CONDITION] 4+, left leg slightly more red and tight than the right. Tightness extended up into the thigh area bilaterally. Open, draining area to the left fourth toe, dry gauze wrapped around this area to protect clothing; -10:06 A.M., Nurse Practitioner U doing rounds. Resident with a change in condition to the right foot fourth toe. Toe swollen, skin broken and serosanguinous drainage (consisting of both blood and serous fluid) noted. Resident denied feeling pain in the area. New order to send resident to hospital for treatment of [REDACTED]. Review of the resident's physician's progress note dated 12/26/14, showed Nurse Practitioner U documented the following: -Musculoskeletal, BLE worsening BLE, in thigh now; -Skin, toe LE, with severe [MEDICAL CONDITION]/toe infection; -Impression/plan included, BLE [MEDICAL CONDITION] worsening, weakness, lower left extremity toe infection, send to emergency room (ER). Review of the ER nurse's note dated 12/26/14 at 10:42 A.M., showed the following; -Arrived to ER with complaint of LE swelling; -Large ulcer noted to fourth toe left foot; -Small open area noted on fourth toe on right foot; -Per facility nurse, feet ulcers just noticed. Review of the ER physician's note dated 12/26/14, showed the following: -Musculoskeletal, fourth toe [MEDICAL CONDITION], white with distal necrotic portion and bleeding. [DIAGNOSES REDACTED] of left foot extended into lower leg, right lower leg, with milder [DIAGNOSES REDACTED]. BL, with stasis [MEDICAL CONDITION] (blood pools in the veins of the lower leg); -Swelling, bleeding of the fourth left toe, diffuse soft tissue swelling present, with soft tissue defect consistent with an ulcer present at the tip; -Impression, left fourth toe ulcer, swelling consistent with [MEDICAL CONDITION], possible erosive changes at the tuft (tip) of the distal phalanx of the fourth toe suggestive of osteo[DIAGNOSES REDACTED] (infection in the bone); -BLE swelling and redness, redness from left fourth toe, extended up foot and lower leg. Right leg, with stasis changes; -Surgical consult ordered. During an interview on 12/26/14 at 3:30 P.M., the ER RN said the resident was previously a patient at the same hospital for a stomach ulcer and sent to the facility for rehabilitation. She said the resident had a history of [REDACTED]. The resident arrived at the hospital on [DATE] around 10:30 A.M. The emergency medical team (EMT) informed the ER RN, the facility reported to them they were sending the resident out for lower extremity [MEDICAL CONDITION] and possible [MEDICAL CONDITION] in both lower extremities. The ER RN said when the resident presented at the ER, his/her left sock was very dirty and full of blood. With the EMT present, they removed the sock. The resident's fourth toe, on the left foot, had the skin detaching and the toe barely attached to the foot. The ER RN said the resident had extreme dark redness and swelling from the foot up into the resident's groin and thigh area. The resident's lymph nodes in the groin area very swollen from possible infection. The resident, fully cognitive, reported to the ER RN the foot and leg started to swell the week prior to the point the detached toe lost its toenail. The resident said the facility was wrapping his/her legs, but they were not treating the toe. The resident had been running a low grade fever, since arriving at the ER. The ER RN said she did not think the resident's toe could be saved and was worried the lower part of the resident's leg may also have to be amputated. Review of the pathology record dated 12/27/14 at 9:40 A.M., showed the following: -Amputation of the fourth left toe, specimen 6 cm; -Gangrenous necrosis (potentially life-threatening condition that arises when a considerable mass of body tissue dies), lesion 3.2 cm by 3.4 cm. with underlying acute osteo[DIAGNOSES REDACTED]. During an interview on 1/14/14 at 12:01 P.M., the facility's wound nurse said she should have documented the resident's skin issues on his/her admission skin assessment on the skin report. She should have ensured the description of the resident's fourth right and left toes were on the resident's TAR. The wound nurse said she did not assess the resident as she should have. Review of a written statement from the admission RN submitted by the facility on 1/14/14, showed the admission RN did not recall informing or not informing the nurse practitioner of skin issues when she notified the nurse practitioner for admission orders [REDACTED] During an interview on 1/14/14 at 1:35 P.M., the DON said she would have expected nursing staff and treatment nurse to document weekly about the resident's toes and other skin areas. The DON said the resident did have a history of venous and arterial [MEDICAL CONDITION] (blood clots) when he/she was admitted , which contributed to his/her [MEDICAL CONDITION] and skin issues. During an interview on 1/14/15 at 12:10 A.M., Nurse Practitioner U said she does a head to toe assessment of residents every time she visited the facility. She had not been informed of, or noticed anything in particular about the resident's fourth left toe until 12/26/14. When she visited the resident on 12/26/14, she noticed the left leg much more swollen all the way up to the resident's groin area. When she removed the resident's sock she discovered the infected toe. The facility nurse present, explained they had just noticed the toe the previous night after the resident was out on leave with his/her family for a couple hours on 12/25/14. Nurse Practitioner U said the facility did not notify her specifically in regards to the resident having black toes upon admission to the facility. The resident always had very red, dry, cracked and swollen skin. Staff had informed her before, the resident did not like them to remove his/her socks and was resistant to showers. Nurse Practitioner U said the facility should have definitely informed the physician's office immediately, upon discovery of the black tips of both the resident's fourth right and left toe. She said if nursing staff did notice those skin issues when the resident was first admitted to the facility, they should have been charting and assessing the areas on a constant basis. During an interview on 1/27/15 at 10:47 A.M., the ER physician who initially assessed the resident on 12/26/14, said if the facility documented dark areas anywhere on the feet, they should have been monitoring them on a consistent basis. The surgeon's finding showed acute osteo[DIAGNOSES REDACTED], which would of had to develop over weeks, for the infection to get into the bone. The ER physician said upon admission, after the facility assessed the resident's skin and documented black discoloration on the fourth toe of both his/her left and right foot, he would have expected them to notify the resident's physician of their findings. Especially with the resident's history of of diabetes and [MEDICAL CONDITION]. The ER physician said not monitoring the area from 12/9/14 through 12/26/14, was too long and a problem. 2. Review of Resident #7's quarterly MDS dated [DATE], showed the following: -Alert; -Frequently incontinent of bladder; -Continent of bowel; -Required extensive assistance from staff for ADLs, -At risk for pressure ulcers; -One, Stage II (Stage II-Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue). May also present as an intact or open/ruptured blister) pressure ulcer; -No venous/arterial ulcers. Review of facility's wound report, dated December 2014, showed staff documented an assessment of the resident's wounds on his/her left lower extremity and left lateral foot (side of foot) on the following dates: -On 12/17/14: Date of onset 10/14/14, location/site left lower extremity, classification of wound erosive [MEDICAL CONDITION] (deep inflammation of the tissues just under the skin, caused by infection). Staff documented the wound measured 12.0 cm length by 12.0 cm width by 0.1 cm depth with wound bed pale. Staff documented the status of the wound stable; -On 12/17/14: Date of onset 10/14/14, location/site left lateral foot, classification of wound arterial stasis ulcer. Staff documented the wound measured 2.5 cm length by 2.5 cm width with black eschar. Staff documented the wound had improved; -On 12/24/14, no documentation regarding measurements of the wound on the left lower extremity. Staff documented the wound bed, dark with slough (dead tissue) in the center of the wound. Staff documented the status of the wound had declined; -On 12/24/14, no documentation regarding measurements of the wound on the left lateral foot. Staff documented the wound had increased slough with tan, black eschar. Staff documented the wound had declined. Review of the POS [REDACTED] -An order dated 10/23/14, wash left lower extremity with Dial (antibacterial soap) and water, pat dry, apply Santyl ([MEDICATION NAME] ointment) and mupirocin (antibiotic ointment) to wound bed, apply [MEDICATION NAME] (brand name, non-adhesive type dressing) wound dressing and Kerlix (gauze wrap) change dressing daily; -An order dated 11/23/14, apply Santyl and mupirocin ointment to left lateral foot and cover with dry dressing and wrap with Kerlix daily; -An order dated 1/5/15, obtain wound culture and sensitivity (C&S, diagnostic laboratory test used to identify types of bacteria and to determine types of antibiotic that can be used to treat the bacteria); -An order dated 1/5/15, for [MEDICATION NAME] (antibiotic) 100 milligrams (mg) one tablet twice daily for ten days; -An order dated 1/5/15, for [MEDICATION NAME] (antibiotic) 250 mg one tablet twice daily for ten days; -No physician's orders documented after 1/5/15. Review of the facility's wound report, dated January 2015, showed: -On 1/1/15, the wound on the left lower extremity measured 12.0 cm length by 12.0 cm width by 0.2 cm depth with dry, pink wound bed. No documentation regarding the status of the wound on the left lower extremity. The wound on the left lateral foot measured 2.0 cm length by 1.0 cm width with dry, dark eschar. No documentation regarding the status of the wound on the left lateral foot; -On 1/7/15, the wound on the left lower extremity measured 10.0 cm length by 15.0 cm width with wound bed dark, red and black. Staff documented the status of the wound on the left lower extremity had declined. The wound on the left lateral foot measured 3.0 cm in length by 2.0 cm in width by 1.0 cm, open area with yellow slough. Staff documented the status of the wound on the left lateral foot had declined. Review of the TAR dated 1/1 through 1/31/15, showed the following: -An order dated 10/23/14, wash left lower extremity with Dial soap and water, pat dry, apply Santyl and mupirocin to wound bed, apply [MEDICATION NAME] wound dressing and Kerlix daily; -From 1/1 through 1/12/15, staff initialed and documented the treatment with dressing application was administered; -An order dated 11/23/14, apply Santyl and mupirocin ointment to left lateral foot and cover with dry dressing and wrap with Kerlix daily; -From 1/1 through 1/12/15, staff initialed and documented the treatment with dressing application was administered; -No other physician orders regarding treatments to the resident's left lower extremity and left lateral foot were documented on the TAR. Review of the resident's medical record, showed the following: -A laboratory test for left foot wound culture dated 1/6/15, showed gram positive cocci (bacteria that causes infection) with heavy growth; -A laboratory test for left foot wound culture obtained 1/6/15 with final report dated 1/10/15, showed Staphylococcus Auricularis (gram-positive bacteria that cause infection) heavy growth; -A hospital wound center report dated 1/9/15, showed an order for [REDACTED].>-Nurse's note dated 1/9/15 at 7:03 P.M., showed the resident had returned to the facility from the wound center. The resident's attending physician was notified of the resident's wound center report. Observation and interview on 1/13/15 at 10:00 A.M., showed the resident lay in the bed. Nurse P said the resident returned from the wound clinic on 1/9/15, without new orders regarding treatments. He/she said the only new physician's order from the wound clinic was [MEDICATION NAME] (elastic tubular support bandage) to the resident's left lower extremity. Nurse P said the wound on the resident's left lower extremity was due to [MEDICAL CONDITION] and the wound on the left lateral foot was an arterial stasis ulcer. Nurse P removed the soiled dressing dated 1/12/15, from the resident's left lower extremity and left lateral foot. The wound on the resident's left lower extremity measured approximately 10.0 cm in length by 20.0 cm in width with bright red tissue that covered the wound bed. The wound on the left lateral foot measured approximately 3.0 cm in length by 3.0 cm in width with scant amount of brown eschar that covered the wound bed. Nurse P cleansed the wounds on the resident's left lower extremity and left lateral foot with Dial soap/water, applied Santyl and mupirocin ointment to both wounds on the left lower extremity and left lateral foot. Nurse P covered the wounds with dry dressing and Kerlix wrap. Observation of the treatment carts on 1/13/15 at 11:00 A.M., showed no tube of [MEDICATION NAME] ointment for the resident on either cart. During an interview on 1/13/15 at 12:30 P.M., the pharmacist said [MEDICATION NAME] and mupirocin ointments were not the same medication. He/she said both were antibiotic ointments, but made with different types of antibiotic. The pharmacist said he/she had not received a physician's order for [MEDICATION NAME] ointment from the facility for the resident. He/she said the pharmacy received a re-fill order from the facility for Santyl and mupirocin ointments for the resident on 1/8/15. Observation of the treatment carts on 1/14/15 at 6:15 A.M., showed no tube of [MEDICATION NAME] ointment for the resident on either cart. Further review on 1/14/15 at 6:20 A.M., of the resident's POS and TAR dated 1/1 through 1/31/15, showed no order written for the administration of [MEDICATION NAME] ointment. During an interview on 1/14/15 at 11:15 A.M., the wound center nurse said the resident was examined and treated by the wound center physician on 1/9/15. The new treatment orders for the resident's wounds to his/her left lower extremity and left lateral foot were for [MEDICATION NAME] and Santyl ointment to be administered daily. The wound physician discontinued the mupirocin ointment because the resident's wound culture showed gram-positive cocci bacteria. He/she said the wound physician expected the [MEDICATION NAME] ointment to be administered as ordered. During an interview on 1/14/15 at 1:30 P.M., the DON said mupirocin and [MEDICATION NAME] ointments were not the same. The charge nurse was responsible for taking off the physician's orders from the wound center, faxed the order to the pharmacy and transcribed the treatment orders onto the TAR. The physician's order from the wound center should be transcribed onto the POS and filed under the section for physician's orders and not under the laboratory section in the resident's medical record. She expected the [MEDICATION NAME] ointment to be administered as ordered. Review of the facility's faxed information received 1/16/15 at 4:15 A.M., showed the resident was seen at the wound center on 1/9/15. The facility had contacted the resident's attending physician and wound physician regarding the wound center physician's orders dated 1/9/15, which were found under the laboratory section in the resident's medical record and reported the staff did not address the 1/9/15 orders, until 1/14/15. MO 902