Every finding on record at Sheridan County Hospital Ltcu

The facility had a census of 27 residents. The sample included 12 residents. Based on interviews and record review, the facility failed to provide Registered Nurse (RN) coverage for eight consecutive hours a day, seven days a week.Findings included:- The Payroll Based Journal (PBJ- a required detail of staffing information submitted by nursing homes, provided by the Centers for Medicare and Medicaid Services (CMS)) documented that the facility lacked RN eight-hour coverage for the following days: 04/19/25, 05/10/25, 05/17/25, and 05/24/25.On 10/21/25 at 04:00 PM, Administrative Nurse D verified on the above dates that there was no RN in the Long-Term Care Unit, but that there was an RN on call.On 10/22/25 at 07:55 AM, Administrative Staff A stated that a report was run after accounts payable received the timesheet. There had been times when they did not get the agency staff timesheets before submitting the PBJ, so that was probably the glitch. Administrative Staff A further stated they have since changed systems, and the agency staff can clock in to track their time better. Upon request, a policy for RN coverage was not provided by the facility.

The facility had a census of 27 residents. The sample included 12 residents, with seven reviewed for unnecessary drugs. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 25 was free from antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication use without an appropriate indication for use. Findings included: - R25's Electronic Medical Record documented diagnoses of anxiety disorder (mental or emotional disorder characterized by apprehension, uncertainty and irrational fear), moderate dementia (progressive mental disorder characterized by failing memory, confusion) with psychotic disturbance (gross impairment in reality perception), restlessness, and agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition).R25's Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented no delusions (untrue persistent belief or perception held by a person, although evidence shows it was untrue) or verbal behaviors. The MDS documented R25 required moderate to dependent assistance of staff for activities of daily living (ADL) and received antianxiety (class of medications that calm and relax people) and antipsychotic medications (class of medications used to treat major mental conditions causing a break from reality).R25's Psychotropic Care Area Assessment (CAA) dated 10/02/25 documented R25 had recently started olanzapine (antipsychotic medication) daily for agitation with dementia and delusional state (untrue persistent belief or perception held by a person although evidence shows it was untrue).R25's Care Plan dated 07/02/25 documented R25 started taking olanzapine 2.5 milligrams (mg) every night for agitation with dementia, initiated 10/06/25. The care plan directed staff to monitor/document/report any changes in cognitive function. R25 did best when a family member tried to provide reassurance when R25 became anxious. The care plan initiated 10/20/25 directed staff to contact her son or granddaughter as needed. The Physician Order dated 09/09/25 directed staff to administer clonazepam (used to prevent and treat anxiety disorders, seizures, bipolar mania, agitation associated with psychosis), 0.5 mg, by mouth one time a day for a diagnosis of sedative (promoting calm or inducing sleep) or a diagnosis of intoxication (being under the influence of a sedative).The Physician Order dated 09/30/25 directed staff to administer olanzapine, 2.5 mg by mouth one time a day for agitation with dementia. On 10/21/25 at 08:33 AM, R25 was seated in her wheelchair at a dining table with staff present. She sat quietly, closing her eyes at times. On 10/20/25 at 04:15 PM, Administrative Nurse D stated R25 was having some off-and-on gradual dementia signs and some delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), which the family stated she had before her admission. On 10/22/25 at 09:05 AM, Administrative Nurse D stated the diagnosis of sedation for the use of clonazepam was not an approved diagnosis, and the olanzapine was a new order. She stated the resident had agitation with paranoia (a thought process believed to be heavily influenced by anxiety or fear to the point of irrational thinking). The facility's Psychotropic Medication Use policy, dated 10/23/17, stated the indication for any psychotropic medication would be thoroughly documented in the clinical record to include an appropriate supporting diagnosis and identification of behavioral symptoms being treated. The medical record must show documentation of adequate indication and diagnosed condition. As needed (PRN) orders for psychotropic medications would be limited to 14 days unless the provider specified the duration. If the provider believed the PRN order should be extended beyond the 14 days, the provider must document the rationale in the medical record.

The facility had a census of 27 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for two residents, Resident (R) 11 and R27, who received prophylactic antibiotics for urinary tract infections (UTI- an infection in any part of the urinary system).Findings included: - R11's Electronic Medical Record (EMR) documented diagnoses of retention of urine (lack of ability to urinate and empty the bladder), Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), and paranoid schizophrenia (characterized by persistent delusions of persecution, grandeur, or jealousy, often accompanied by auditory hallucinations). R11's admission Minimum Data Set (MDS) dated [DATE] documented R11 had moderately impaired cognition. R11 was dependent upon staff assistance for toileting hygiene and was frequently incontinent of urine and always incontinent of bowel. The MDS recorded R11 had no UTIs and received an antibiotic (a class of medications used to treat infections). R11's Quarterly MDS dated 08/04/25 documented R11 had intact cognition. R11 was dependent upon staff assistance for toileting hygiene and was frequently incontinent of urine but continent of bowel. The MDS recorded R11 had no UTI and received an antibiotic medication. R11's Care Plan lacked documentation R11 had UTIs or received antibiotic medication. The Physician's Order dated 02/05/25 directed staff to administer Bactrim (an antibiotic) DS (double strength) 800-160 milligrams (mg), one tablet, by mouth, daily, prophylactic for the bladder. R11's ER lacked documentation R11 had a UTI since admission on [DATE]. The Consultant Pharmacist (CP) monthly medication reviews did not note the long-term antibiotic use and risks associated with ongoing administration from 03/2025 to 10/2025. On 10/22/25 at 01:25 PM, R11 sat in a wheelchair in his room. On 10/21/25 at 02:10 PM, Administrative Nurse E stated she did not monitor prophylactic antibiotics with her antibiotic stewardship program and would contact the physician for direction on the antibiotic use and if he would like R11 to continue the medication. At 03:00 PM, Administrative Nurse E stated that the CP verified that she did not monitor the use of the prophylactic antibiotic, only the renal function and dosage. On 10/21/25 at 03:36 PM, Certified Nurse Aide (CNA) M stated staff assisted R11 with toileting and personal care. On 10/22/25 at 03:59 PM, Licensed Nurse (LN) G stated R11 had not had any UTIs since he had been admitted and did not have any symptoms. On 10/22/25 at 10:35 AM, Administrative Nurse D stated the use of the antibiotic and what symptoms staff should be aware of should be on R11's care plan. The facility's Minimum Data Set (MDS) and Comprehensive Care Plans policy dated 09/26/19, documented that the facility shall prepare an interdisciplinary comprehensive assessment of the resident's needs, strengths, goals, life history, and preferences, and information required by the Resident Assessment Instrument (RAI) using the Minimum Data Set (MDS). The information would be used to develop, with the input and participation and the resident representative would participate in the assessment process to the extent practicable. Each discipline's assessment would include the relevant resident's needs, strengths, life history, goals, and preferences as they related to the topic or area being assessed. - R27's Electronic Medical Record (EMR) included diagnoses of personal history of urinary tract infections (UTI- an infection in any part of the urinary system), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), chronic pain, congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder. R27's Quarterly Minimum Data Set (MDS), dated [DATE], documented that R27 had intact cognition, no delirium (sudden severe confusion, disorientation, and restlessness) or psychosis (any major mental disorder characterized by a gross impairment in reality perception), and did not exhibit behaviors. R27 had impaired functional range of motion of upper and lower extremities on both sides, and was dependent on staff for oral care, toileting, personal hygiene, bathing, and upper and lower body dressing. R27 was also dependent on staff for bed mobility and transfers. The MDS further documented that R27 was on a toileting program and was frequently incontinent of urine and occasionally incontinent of bowel and had no UTIs in 30 days. R27 received insulin (a hormone that lowers the level of glucose in the blood) injections, an antianxiety (a class of medications that calm and relax people), an anticoagulant (a class of medications used to prevent the blood from clotting), an antibiotic (a class of medications used to treat infectious processes), a diuretic (a medication to promote the formation and excretion of urine), an opioid, and hypoglycemic (medication to lower the amount of glucose in the blood). The Urinary Incontinence Care Area Assessment (CAA) dated 01/20/25 documented that R27 was frequently incontinent of urine and bowel, did not always feel the urge to void, or know once she had gone. The CAA further documented that R27 was on a toileting schedule of every three hours during the day and checked once at 04:00 AM. R27's Care Plan dated 10/16/25 documented that R27 required assistance to perform most activities of daily living (ADL) and had a toileting schedule every three hours during the daytime and during the night at 04:00 AM. The care plan lacked including R27's history of UTIs or long-term use of antibiotics. The Physician Order dated 01/07/25, directed staff to administer Macrobid Oral Capsule (an antibiotic) 100 milligrams (mg) by mouth one time for the history of UTIs. The Progress Note dated 02/05/25 at 10:29 AM documented a urinary analysis (UA- lab analysis of urine). The Progress Note dated 02/05/25 at 06:11 PM documented that the staff received a physician order to hold the Macrobid (an antibiotic) and administer Cipro (an antibiotic) 500 mg by mouth twice a day for five days, repeat a UA when the Cipro was completed, and restart Macrobid 100 mg by mouth daily. The Progress Note dated 07/21/25 at 04:31 PM documented a urine culture (lab test to determine specific microorganisms and antibiotic treatment) from 07/18/25 showing that the bacteria were resistant to Macrobid. The physician ordered to administer Cipro 500 mg twice a day for five days and then resume Macrobid. On 10/21/25 at 08:58 AM, staff assisted R27 from her wheelchair to her recliner using a sit-to-stand lift. Certified Nurse Aide (CNA) P asked the resident if she needed to use the bathroom prior to being placed in the recliner. R27 declined the offer. On 10/22/25 at 09:28 AM, Licensed Nurse (LN) I stated that she believed R27's prophylactic antibiotic was for the pressure ulcer on R27's heel, which was positive for Methicillin-resistant Staphylococcus Aureus (MRSA- a type of bacteria resistant to many antibiotics). On 10/22/25 at 10:40 AM, Administrative Nurse D verified that R27 received ongoing Macrobid for the history of UTIs and would discuss the matter with R27's physician. Administrative Nurse D verified R27's care plan lacked the ongoing use of antibiotic therapy related to R27's history of UTIs, which should have been included. The facility's Minimum Data Set (MDS) and Comprehensive Care Plans policy dated 09/26/19, documented that the facility shall prepare an interdisciplinary comprehensive assessment of the resident's needs, strengths, goals, life history, preferences, and information required by the Resident Assessment Instrument (RAI) using the Minimum Data Set (MDS). The information would be used to develop, with the input and participation and the resident representative would participate in the assessment process to the extent practicable. Each discipline's assessment would include the relevant resident's needs, strengths, life history, goals, and preferences as they related to the topic or area being assessed.

The facility had a census of 27 residents. The sample included 12 residents, with seven reviewed for unnecessary medications. Based on observation, interview, and record review, the facility's Consultant Pharmacist (CP) failed to address with the facility the ongoing prophylactic (a medicine or course of action used to prevent disease) antibiotic (a class of medications used to treat infections) use for Resident (R) 11 and R27.Findings included: - R11's Electronic Medical Record (EMR) documented diagnoses of retention of urine (lack of ability to urinate and empty the bladder), Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), and paranoid schizophrenia (characterized by persistent delusions of persecution, grandeur, or jealousy, often accompanied by auditory hallucinations). R11's admission Minimum Data Set (MDS) dated [DATE] documented R11 had moderately impaired cognition. R11 was dependent upon staff assistance for toileting hygiene and was frequently incontinent of urine and always incontinent of bowel. The MDS recorded R11 had no urinary tract infection (UTI- an infection in any part of the urinary system) and received an antibiotic. R11's Quarterly MDS dated 08/04/25 documented R11 had intact cognition. R11 was dependent upon staff assistance for toileting hygiene and was frequently incontinent of urine and continent of bowel. The MDS recorded R11 had no UTI and received an antibiotic medication. R11's Care Plan lacked documentation R11 had UTIs or received antibiotic medication. The Physician's Order dated 02/05/25 directed staff to administer Bactrim (an antibiotic) DS (double strength) 800-160 milligrams (mg), one tablet, by mouth, daily, prophylactic for bladder. R11's EMR lacked documentation R11 had a UTI since admission on [DATE]. The Consultant Pharmacist (CP) monthly medication reviews did not note the long-term antibiotic use or the risks associated with ongoing administration from 03/2025 to 10/2025. On 10/22/25 at 01:25 PM, R11 sat in a wheelchair in his room. On 10/21/25 at 02:10 PM, Administrative Nurse E stated she did not monitor prophylactic antibiotics with her antibiotic stewardship program and would contact the physician for direction on the antibiotic use and if he would like R11 to continue the medication. At 03:00 PM, Administrative Nurse E stated that the CP verified that she did not monitor the use of the prophylactic antibiotic, only the renal function and dosage. On 10/22/25 at 03:59 PM, Licensed Nurse (LN) G stated R11 had not had any UTIs since he had been admitted and did not have any symptoms. On 10/22/25 at 10:35 AM, Administrative Nurse D stated the use of the antibiotic and what symptoms staff should be aware of should be on R11's care plan. Administrative Nurse D verified she was unable to find any physician notes regarding the use of the Bactrim medication and would discuss the matter with the physician. Administrative Nurse D stated the CP did not alert the facility of the antibiotic use due to the facility had a different program, and she did not have it on her radar to watch out for long-term antibiotic use. The facility's Consultant Pharmacist policy dated 10/15/17, documented that the pharmacy consultant would review antibiotic and psychotropic medication utilization and collaborate on the development of an action plan consistent with the best practices and regulatory requirements. The pharmacist would report any irregularities in a written report and give it to the Provider, the facility's medical director, and the director of nursing. The CP reports must be acted upon. Irregularities included, but not limited to: any unnecessary drug when used (1) in excessive dose (including duplicate therapy: or (2) for excessive duration: or (3) without adequate monitoring: or (4) without adequate indications for its use: or (5) in the presence of adverse consequences which indicate the dose should be reduced or discontinued: or (6) any combinations of the foregoing reasons. - R27's Electronic Medical Record (EMR) included diagnoses of personal history of urinary tract infections (UTI- an infection in any part of the urinary system), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), chronic pain, congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder. R27's Quarterly Minimum Data Set (MDS) dated [DATE] documented that R27 had intact cognition, no delirium (sudden severe confusion, disorientation, and restlessness) or psychosis (any major mental disorder characterized by a gross impairment in reality perception), and did not exhibit behaviors. R27 had impaired functional range of motion of upper and lower extremities on both sides, and was dependent on staff for oral care, toileting, personal hygiene, bathing, and upper and lower body dressing. R27 was also dependent on staff for bed mobility and transfers. The MDS further documented that R27 was on a toileting program and was frequently incontinent of urine and occasionally of bowel, and had no UTIs in 30 days. R27 received insulin (a hormone that lowers the level of glucose in the blood) injections, an antianxiety (a class of medications that calm and relax people), an anticoagulant (a class of medications used to prevent the blood from clotting), an antibiotic (a class of medications used to treat infectious processes), a diuretic (a medication to promote the formation and excretion of urine), an opioid (a class of medication to alleviate pain), and hypoglycemic (medication to lower the amount of glucose in the blood). The Urinary Incontinence Care Area Assessment (CAA) dated 01/20/25 documented that R27 was frequently incontinent of urine and bowel, did not always feel the urge to void, or know once she had gone. The CAA further documented that R27 was on a toileting schedule of every three hours during the day and checked once at 04:00 AM. R27's Care Plan dated 10/16/25 documented that R27 required assistance to perform most activities of daily living (ADL) and had a toileting schedule every three hours during the daytime and during the night at 04:00 AM. The Physician Order dated 01/07/25 directed staff to administer Macrobid Oral Capsule (an antibiotic) 100 milligrams (mg) by mouth one time for the history of UTIs. The Progress Note dated 02/05/25 at 10:29 AM documented a urinary analysis (UA- lab analysis of urine). The Progress Note dated 02/05/25 at 06:11 PM documented that the staff received a physician order to hold the Macrobid (an antibiotic) and administer Cipro (an antibiotic) 500 mg by mouth twice a day for five days, repeat a UA when the Cipro was completed, and to restart Macrobid 100 mg by mouth daily. The Progress Note dated 07/21/25 at 04:31 PM documented a urine culture (lab test to determine specific microorganisms and antibiotic treatment) from 07/18/25 showing that the bacteria were resistant to Macrobid. The physician ordered to administer Cipro 500 mg twice a day for five days and then resume Macrobid. On 10/21/25 at 08:58 AM, staff assisted R27 from her wheelchair to her recliner using a sit-to-stand lift. Certified Nurse Aide (CNA) P asked R27 if she needed to use the bathroom prior to being placed in the recliner. R27 declined the offer. On 10/21/25 at 02:15 PM, Administrative Nurse E, the Infection Preventionist (IP), reported not monitoring the prophylactic antibiotics use with the antibiotic stewardship surveillance. Administrative Nurse E reported she was not aware whether the Consultant Pharmacist (CP) reviewed the prophylactic (preventative in nature) antibiotic use, either. On 10/22/25 at 09:28 AM, Licensed Nurse (LN) I stated that she believed R27's prophylactic antibiotic was for the pressure ulcer on R27's heel, which was positive for Methicillin-resistant Staphylococcus Aureus (MRSA- a type of bacteria resistant to many antibiotics). On 10/22/25 at 10:40 AM, Administrative Nurse D verified that R27 received ongoing Macrobid for the history of UTIs and would discuss the matter with R27's physician and the CP. Administrative Nurse D reported the CP had not alerted the facility to the prophylactic antibiotic used on the monthly medication reviews, and the CP did not have it on her radar to watch for long-term antibiotic use. The facility's Consultant Pharmacist policy dated 10/15/17, documented that the pharmacy consultant would review antibiotic and psychotropic medication utilization and collaborate on the development of an action plan consistent with the best practices and regulatory requirements. The pharmacist would report any irregularities in a written report and give it to the Provider, the facility's medical director, and the director of nursing. The CP reports must be acted upon. Irregularities included, but not limited to: any unnecessary drug when used (1) in excessive dose (including duplicate therapy: or (2) for excessive duration: or (3) without adequate monitoring: or (4) without adequate indications for its use: or (5) in the presence of adverse consequences which indicate the dose should be reduced or discontinued: or (6) any combinations of the foregoing reasons.

The facility had a census of 27 residents. The sample included 12 residents, with one reviewed for Hospice (specialized end-of-life) services. Based on observation, interview, and record review, the facility failed to provide thorough care planning instruction for Resident (R) 7, who received Hospice services. Findings included:- R7's Electronic Medical Record documented a diagnosis of Huntington's disease (rare abnormal hereditary condition characterized by progressive mental deterioration, a disabling central nervous system movement disorder).R7's Quarterly Minimum Data Set (MDS) dated [DATE] documented the Brief Interview for Mental Status (BIMS) without a score and documented R7 had severely impaired cognition. The MDS documented R7 was dependent on staff for all activities of daily living and received Hospice services. R7's Care Plan dated 10/13/25 stated his family had elected Hospice services. R7's weight would be obtained monthly for Hospice to monitor. The care plan included the hospice phone number but lacked the name of the hospice. The care plan directed staff to work cooperatively with the hospice team, initiated 07/14/25.The care plan lacked the name of the Hospice company, what supplies would be provided, and how often Hospice staff would assess and provide care for R7. On 10/21/25 at 07:40 AM, R7 sat in a specialized wheelchair in the commons area. R7 was awake, alert, and looking around. He displayed some involuntary movements.On 10/21/25 at 03:00 PM, Certified Nurse Aide (CNA) O verified R7 received Hospice services, but she did not know the name. She thought the nurse came to see R7 twice weekly. She was unsure if any hospice aides came. CNA O stated hospice staff brought in briefs, but she did not know what else they might have supplied. On 10/22/25 at 09:20 AM, Administrative Nurse D stated the facility only used one Hospice. She stated the hospice nurse came one to two times per week and the visits depended on the resident's needs, family questions, or if there were any changes. She verified the care plan lacked the Hospice name, visit frequency, and supplies. Upon request, 10/22/25, the facility did not provide a Hospice policy.

The facility had a census of 27 residents. The sample included 12 residents, with seven reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to implement antibiotic use protocols to avoid unnecessary and/or inappropriate antibiotic use to reduce the risk of adverse effects, including antibiotic resistance, when the facility failed to monitor effectiveness and evaluate appropriateness for the extended administration of prophylactic (preventative in nature) antibiotics for Residents (R) 11 and R27.Findings included:- R11's Electronic Medical Record (EMR) documented diagnoses of retention of urine (lack of ability to urinate and empty the bladder), Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), and paranoid schizophrenia (characterized by persistent delusions of persecution, grandeur, or jealousy, often accompanied by auditory hallucinations). R11's admission Minimum Data Set (MDS), dated [DATE], documented R11 had moderately impaired cognition. R11 was dependent upon staff assistance for toileting hygiene and was frequently incontinent of urine and always incontinent of bowel. The MDS recorded R11 had no urinary tract infection (UTI- an infection in any part of the urinary system) and received an antibiotic (a class of medications used to treat infections). R11's Quarterly MDS, dated 08/04/25, documented R11 had intact cognition. R11 was dependent upon staff assistance for toileting hygiene and was frequently incontinent of urine and continent of bowel. The MDS recorded R11 had no UTI and received an antibiotic medication. R11's Care Plan lacked documentation R11 had UTIs or received antibiotic medication. The Physician's Order, dated 02/05/25, directed staff to administer Bactrim (an antibiotic) DS (double strength) 800-160 milligrams (mg), one tablet, by mouth, daily, prophylactic for bladder. R11's ER lacked documentation R11 had a UTI since admission on [DATE]. The Consultant Pharmacist (CP) monthly medication reviews did not note the long-term antibiotic use and risks associated with ongoing administration from 03/2025 to 10/2025. On 10/22/25 at 01:25 PM, R11 sat in a wheelchair in his room. On 10/21/25 at 02:10 PM, Administrative Nurse E stated she did not monitor prophylactic antibiotics with her antibiotic stewardship program and would contact the physician for direction on the antibiotic use and if he would like R11 to continue the medication. At 03:00 PM, Administrative Nurse E stated that the CP verified that she did not monitor the use of the prophylactic antibiotic, only the renal function and dosage. On 10/21/25 at 03:36 PM, Certified Nurse Aide (CNA) M stated staff assisted R11 with toileting and personal care. On 10/22/25 at 03:59 PM, Licensed Nurse (LN) G stated R11 had not had any UTIs since he had been admitted and did not have any symptoms. On 10/22/25 at 10:35 AM, Administrative Nurse D stated the use of the antibiotic and what symptoms staff should be aware of should be on R11's care plan. Administrative Nurse D verified she was unable to find any physician notes regarding the use of the Bactrim medication and would discuss the matter with the physician. Administrative Nurse D stated the CP did not alert the facility of the antibiotic use due to the facility had a different program, and she did not have it on her radar to watch out for long-term antibiotic use. The facility's Antimicrobial Stewardship policy, reviewed on 11/25/24, documented that all antimicrobials would be evaluated for appropriateness of therapy as soon as possible. The committee would comply with all state, federal, and local laws and regulations to follow evidence-based practice regarding antimicrobial use. The committee would provide reliable, consistent methods of surveillance and documentation regarding appropriate antibiotic usage for patients. The antimicrobial stewardship committee ensured that patients received the appropriate antibiotic therapy needed based on laboratory results and post-visit follow-ups on findings. - Resident (R) 27's Electronic Medical Record (EMR) included diagnoses of personal history of urinary tract infections (UTI- an infection in any part of the urinary system), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), chronic pain, congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder. R27's Quarterly Minimum Data Set (MDS) dated [DATE] documented that R27 had intact cognition, no delirium (sudden severe confusion, disorientation, and restlessness) or psychosis (any major mental disorder characterized by a gross impairment in reality perception), and did not exhibit behaviors. R27 had impaired functional range of motion of upper and lower extremities on both sides, and was dependent on staff for oral care, toileting, personal hygiene, bathing, and upper and lower body dressing. R27 was also dependent on staff for bed mobility and transfers. The MDS further documented that R27 was on a toileting program and was frequently incontinent of urine and occasionally of bowel and had no UTIs in 30 days. R27 received insulin (a hormone that lowers the level of glucose in the blood) injections, an antianxiety (a class of medications that calm and relax people), an anticoagulant (a class of medications used to prevent the blood from clotting), an antibiotic (a class of medications used to treat infectious processes), a diuretic (a medication to promote the formation and excretion of urine), an opioid, and hypoglycemic (medication to lower the amount of glucose in the blood). The Urinary Incontinence Care Area Assessment (CAA) dated 01/20/25 documented that R27 was frequently incontinent of urine and bowel, did not always feel the urge to void, or know once she had gone. The CAA further documented that R27 was on a toileting schedule of every three hours during the day and checked once at 04:00 AM. R27's Care Plan dated 10/16/25 documented that R27 required assistance to perform most Activities of Daily Living (ADL) and had a toileting schedule every three hours during the daytime and during the night at 04:00 AM. The Physician Order dated 01/07/25 directed staff to administer Macrobid Oral Capsule (an antibiotic) 100 milligrams (mg) by mouth one time for the history of UTIs. The Progress Note dated 02/05/25 at 10:29 AM documented a urinary analysis (UA- lab analysis of urine). The Progress Note dated 02/05/25 at 06:11 PM documented that the staff received a physician order to hold the Macrobid (an antibiotic) and administer Cipro (an antibiotic) 500 mg by mouth twice a day for five days, repeat a UA when Cipro was completed, and to restart Macrobid 100 mg by mouth daily. The Progress Note dated 07/21/25 at 04:31 PM documented a urine culture (lab test to determine specific microorganisms and antibiotic treatment) from 07/18/25 showing that the bacteria were resistant to Macrobid. The physician ordered to administer Cipro 500 mg twice a day for five days and then resume Macrobid. On 10/21/25 at 08:58 AM, staff assisted R27 from her wheelchair to her recliner using a sit-to-stand lift. Certified Nurse Aide (CNA) P asked the resident if she needed to use the bathroom prior to being placed in the recliner. R27 declined the offer. On 10/21/25 at 02:15 PM, Administrative Nurse E, the Infection Preventionist (IP), reported not monitoring the prophylactic antibiotics use with the antibiotic stewardship surveillance. Administrative Nurse E reported she was not aware whether the Consultant Pharmacist (CP) reviewed the prophylactic (preventative in nature) antibiotic use, either. On 10/22/25 at 09:28 AM, Licensed Nurse (LN) I stated that she believed R27's prophylactic antibiotic was for the pressure ulcer on R27's heel, which was positive for Methicillin-resistant Staphylococcus aureus (MRSA- a type of bacteria resistant to many antibiotics). On 10/22/25 at 10:40 AM, Administrative Nurse D verified that R27 received ongoing Macrobid for the history of UTIs and would discuss the matter with R27's physician. Administrative Nurse D reported the CP had not alerted the facility to the prophylactic antibiotic used on the monthly medication reviews, and the CP did not have it on her radar to watch for long-term antibiotic use. The facility's Antimicrobial Stewardship policy, reviewed on 11/25/24, documented that all antimicrobials would be evaluated for appropriateness of therapy as soon as possible. The committee would comply with all state, federal, and local laws and regulations to follow evidence-based practice regarding antimicrobial use. The committee would provide reliable, consistent methods of surveillance and documentation regarding appropriate antibiotic usage for patients. The antimicrobial stewardship committee ensured that patients received the appropriate antibiotic therapy needed based on laboratory results and post-visit follow-ups on findings.

The facility had a census of 27 residents. Based on observation, interview, and record review, the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ- a required detail of staffing information submitted by nursing homes, provided by the Centers for Medicare and Medicaid Services (CMS)).Findings included:- The PBJ report provided by the Centers for Medicare and Medicaid Services (CMS) for Medicare & Medicaid Services (CMS) Fiscal (YR) 2025, Quarter (Q) 2, indicated no licensed nurse coverage for four dates: 01/04/25, 02/08/25, 03/01/25, and 03/22/25.The PBJ for FY Q3 recorded no licensed nurse coverage on three dates: 04/12/25, 05/03/25, and 05/24/25.Review of the facility's licensed nurse payroll data for the dates listed above revealed a licensed nurse was on duty for 24 hours a day, seven days a week.On 10/21/25 at 04:00 PM, Administrative Nurse D stated they would never be without a licensed nurse in the facility. The Nurses were scheduled for 12-hour shifts and had the availability of agency nurses also.On 10/22/25 at 07:55 AM, Administrative Staff A stated a report was run after accounts payable received the timesheet. There had been times when they did not get the agency staff timesheets before submitting the PBJ, so that was probably the glitch. Administrative Staff A further stated they have since changed systems, and the agency staff can clock in to track their time better.Upon request, a policy for PBJ was not provided by the facility.

The facility identified a census of 26 residents, with three residents reviewed for falls and accidents. Based on record review, observation, and interview, the facility failed to transfer Resident (R) 1 safely with a gait belt, and in the process of the transfer staff lifted R1 by both of her arms and R1 sustained a broken left humerus (upper arm bone). This deficient practice placed R1 at risk for injury, pain, and delayed healing. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), major depressive disorder (major mood disorder which causes persistent feelings of sadness), and lymphedema (swelling caused by accumulation of lymph). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status score of four which indicated severely impaired cognition. The MDS documented R1 had impairment on one side of her upper extremity and lower extremity. The MDS documented R1 required moderate assistance with eating, and maximum assistance with oral hygiene, dressing, and bed mobility. The MDS documented R1 was dependent on staff for toileting, bathing, and transfer. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 01/14/24, documented R1 had a diagnosis of dementia. She was oriented to herself but would get confused about situations, times, and dates. The CAA documented that R1 became anxious and would yell at staff to compensate. The Urinary Incontinence/Indwelling Catheter CAA, dated 01/14/24, documented R1 was mostly continent of bladder, was on a toileting schedule during the day and as needed at night. She required extensive assistance with toileting transfers and hygiene from two staff. The Falls CAA, dated 01/14/24, documented R1 was a high risk for falls due to vision loss, weakness, and the non-use of her left arm. The CAA documented R1 required one to two person assist with activities of daily living and transfers for safety. R1's Care Plan documented R1 required extensive assistance from two staff members for transfers (03/23/23). R1 no longer used a walker and relied on a pivot transfer with a gait belt for transfers (03/23/23). The care plan documented R1 complained of pain when a regular gait belt was used so R1 had a green Posey gait belt in her room (01/22/24). The care plan documented R1 was dependent on two staff for toileting transfers and peri care and was not to be left alone in the bathroom (03/10/23). The Incident Note, dated 10/20/24 at 07:50 PM, documented Certified Nurse Aide (CNA) M stepped out into the hallway and called Licensed Nurse (LN) G for assistance. R1 sat on the toilet, barely on the toilet, sideways with her head forward and her body flaccid (limp). R1 was unresponsive and her skin was clammy. She had a slight purple discoloration on her face. LN G lifted R1 off ofoff the toilet and into the wheelchair. R1 had her eyes closed but was making mumbling noises. LN G and CNA M transferred R1 into bed from the wheelchair and LN G heard and felt a loud pop in R1's left arm when they lifted R1 for the transfer. LN G removed R1's shirt and noted R1's left deltoid (upper arm) area bulging out and the left shoulder appeared to be higher than the right. R1 showed no signs and symptoms of discomfort with palpation of the area. The Communication Note, dated 10/20/24 at 07:51 PM, documented staff notified R1's responsible party of the two to three minutes of unresponsiveness, the popping noise heard with the transfer, and the resulting abnormalities of the left upper arm. R1's responsible party agreed to monitor R1 throughout the night unless signs and symptoms of pain and discomfort presented and then wanted R1 to transfer to the emergency room . The Health Status Note, dated 10/20/24 at 08:01 PM, documented that staff notified the on-call administrative staff of R1's unresponsive episode and the popping noise with transfer and subsequent abnormality to the left upper arm. The note documented a plan to monitor the resident throughout the night and send a SBAR (Situation, Background, Assessment, and Recommendation) a structured communication tool used to share information about a patient's condition to the clinic. The Health Status Note, dated 10/20/24 at 09:50 PM, documented R1 rested with her eyes closed. The note documented R1 had no signs and symptoms of discomfort in her upper left arm. The Health Status Note, dated 10/20/24 at 11:43 PM, documented an SBAR with information about the incident to R1's left arm was faxed to the on-call provider at the clinic. CNA M's Witness Statement, dated 10/20/24, documented CNA M put R1 on the toilet. CNA M left the bathroom and came back into the bathroom after pulling down R1's covers. CNA M found R1 unresponsive. CNA M looked out the door and yelled for LN G to come down and help. CNA M and LN G got R1 off the toilet. As CNA M and LN G transferred R1 to bed there was a loud pop. CNA M and LN G got R1's shirt off and R1's arm was swollen. LN G's Witness Statement, dated 10/20/24, documented on 10/20/24 at approximately 07:45 PM CNA M hollered out in the hallway for LN G to come and assist her in R1's room. Upon entering R1's bathroom, R1 was on the toilet. Her face had a slight purple discoloration, and her skin was clammy. R1 was unresponsive and her body was flaccid; she was barely sitting on the toilet. CNA M pushed the wheelchair underneath R1 and LN G lifted R1 off the toilet and into the chair. R1 remained unresponsive. R1 mumbled a few things while being pushed from the bathroom in the wheelchair but still had not opened her eyes. After getting to R1's bed, R1's body was still flaccid. LN G and CNA M assisted R1 with a two-person lift from the wheelchair to the bed. CNA M stood on R1's right side and LN G was on R1's left side. When staff lifted R1, there was a loud popping noise and LN G felt a slight pressure in R1's left upper arm. LN G immediately pulled down R1's shirt and sleeve and noted R1's left deltoid area had slight swelling and R1's left shoulder was slightly raised compared to the right shoulder. R1 did not demonstrate any signs or symptoms of pain or discomfort. R1 slowly became more responsive. The facility's undated Incident Report documented Administrative Nurse D contacted LN G about the incident. LN G explained that CMA M had called for assistance from the hallway and LN G responded. When LN G got to the bathroom, CNA M was in the bathroom with R1 and R1 was unconscious, seated on the toilet. LN G assisted CMA M in transferring R1 to the wheelchair. Administrative Nurse D asked LN G if a gait belt was used and LN G admitted a gait belt had not been used. R1 was taken from the restroom to her bed. R1 still did not respond appropriately so LN G and CNA M transferred R1 to the bed. During the transfer, staff heard a popping noise and LN G felt R1's arm move against her body. After completing the transfer, LN G assessed R1's arm and it had begun to swell. R1 did not appear to be in any pain. LN G and CNA M both admitted they did not use a gait belt when they transferred R1. CNA M stated she was concerned for R1's immediate safety when R1 was unconscious on the toilet and therefore did not apply the gait belt for that transfer and then when they transferred R1 to the bed from the wheelchair, CNA M did not think to use the gait belt. She said she was just thinking of R1's safety. LN G stated she felt like it was an emergent situation and responded to R1's immediate needs which was getting her to a safe position. Administrative Nurse D counseled LN G and CNA M on gait belt use and ensured they were aware of the resident's care-planned need for gait belts and where to find this information. The facility will continue random audits for appropriate gait belt use. The Plan of Care Note, dated 10/21/24 at 08:24, documented that R1's left arm was swollen and discolored. R1 stated she had slight tenderness in her shoulder area but not in the rest of her arm. R1 rested in bed. The Order Note, dated 10/21/24 at 08:26 AM, documented R1's primary care physician, ordered a two-view left shoulder x-ray for pain. The Plan of Care Note, dated 10/21/24 at 10:00 AM, documented staff were able to get R1 up and transferred to her recliner to eat breakfast. R1 continued to have no complaints of pain or discomfort. The Plan of Care Note, dated 10/21/24 at 11:14 AM, documented the facility received a call from the nurse practitioner and she requested to see R1 in the emergency room to splint her left arm which had a fracture. The emergency room Discharge Paperwork, dated 10/21/24, documented R1 had a left humerus fracture. Orthopedics (bone specialist) was consulted and advised R1 was not a surgical candidate and recommended a posterior (backside) or sugar-tongue splint to the left arm. Orthopedics wanted R1 to follow up in the clinic with repeat X-rays on Wednesday. The plan of care was discussed with R1's primary care physician and an appointment was made for R1 to see him on Wednesday, 10/23/24 at 02:00 PM for repeat x-rays to be done prior to the appointment and sent to orthopedics. The left posterior arm splint and sling were to remain in place at all times. R1 was non-weight bearing to her left upper extremity. The Order Note, dated 10/21/24 at 01:36 PM, documented R1 was back from the emergency room and would have another x-ray on Wednesday. R1 presented with a left posterior arm splint and sling that was to remain in place at all times. R1 could use over-the-counter Tylenol or ibuprofen (pain medications) as needed for pain or swelling. The note ordered to apply ice to the affected area three to four times daily for thirty minutes for three days, then discontinue. The Radiology Report, dated 10/23/24, documented R1 had sustained a displaced overlapping proximal humerus fracture with some improved alignment. The Health Status Note, dated 10/23/24, documented R1's left humerus x-ray report showed a proximal humerus fracture with some improved alignment with interval splinting. The Health Status Note, dated 11/06/24, documented R1 complained of pain in her left forearm. The CNAs reported R1 had consistently pointed to that area and complained of pain. The nurse pulled pack the ace wrap and encountered cast padding with a sleeve under it. The nurse contacted the on-call provider for advice on how to position and maneuver the left arm for assessment so as not to move the fracture to the left humerus and was advised to bend the elbow like a bicep curl. Upon assessment, a bruise was found on R1's left forearm with black spots in the middle and reddened areas towards the outside which measured 3 centimeters (cm) by 2.6 cm. The findings were reported to the on-call provider, and he advised to return the casting as it had been and loosely wrap the ACE bandage back around the splint. R1's primary care physician will see R1 tomorrow and address the area of concern. The Order Note, dated 11/07/24, documented R1 had a follow-up appointment with her primary care physician regarding her left arm and the pressure area from the splint; padding was placed on the splint. On 11/14/24 at 10:00 AM, observation revealed, R1 sat in her wheelchair with a left splint and sling to her left arm. On 11/14/24 at 10:00 AM, R1 stated she had pain in her left arm and pointed to her left arm with her right hand. On 11/14/24 at 10:15 AM, CNA N stated she never transferred R1 or any other resident without using a gait belt. CNA N stated R1 had complained of pain in her left arm numerous times since breaking it. CNA N stated R1 had just got done showering and the left splint and sling never came off but was wrapped up in a bag to keep it dry. On 11/14/24 at 10:30 AM, LN H stated she expected all staff to use a gait belt with all transfers because it was the only way to ensure resident and staff safety. On 11/14/24 at 01:00 PM, Administrative Nurse D stated she had talked to CNA M and LN G and they admitted they had not used a gait belt for any of R1's transfers the day of the incident. Administrative Nurse D stated there were other ways R1 could have been transferred besides the way staff had transferred her that day. Administrative Nurse D verified she educated all facility staff regarding gait belt use with transfers and following resident care plans on 10/21/24 and was performing gait belt audits randomly throughout varying shifts for four weeks. The facility's Gait Belts and Transfer Policy, revised 03/19/07, documented that gait belts are provided to assist staff in safely transferring or ambulating residents. Note the use of a gait belt in the resident care plan. The facility failed to transfer R1 safely with a gait belt which resulted in a broken left humerus. This deficient practice placed R1 at risk for injury, pain, and delayed healing. On 10/21/24, the facility identified and completed all corrective actions including staff education on following residents' plan of care, use of gait belt use with transfers, and completed gait belt audits randomly for four weeks. All actions were completed before the onsite survey therefore the deficient practice was deemed past noncompliance and remained at a G scope and severity.

The facility had a census of 23 residents. The sample included 13 residents with eight reviewed for falls. Based on observation, record review, and interview the facility failed to ensure an environment free from accidents when staff placed Resident (R) 4's electric lift chair remote in reach, despite a safety evaluation which indicated it was not safe. As a result, R4 fell and required sutures to her head laceration. The facility continued to leave the lift control within R4's reach, which placed her at continued risk for falls, injuries, and associated pain. Findings included: - R4's Electronic Medical Record (EMR) recorded diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, atrial fibrillation (rapid, irregular heartbeat), hypertension (HTN-elevated blood pressure) with heart failure, Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), weakness, and repeated falls. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R4 had moderately impaired cognition. R4 had a functional range of motion impairment on both sides upper and lower extremities. R4 was dependent with toileting hygiene and showering and required substantial to maximal assistance with mobility. R4 had a toileting program and was frequently incontinent of urine and occasionally incontinent of bowel. R4 had one non-injury fall. The MDS further documented R4 received an antianxiety (class of medications that calm and relax people), antidepressant (a class of medications used to treat mood disorders), anticoagulant (medication used to prolong blood from clotting), diuretic (medication to promote the formation and excretion of urine), and opioid (medication used to treat pain) medication; R4 used a bed and chair alarm daily. The Annual Fall Care Area Assessment (CAA), dated 08/08/23, documented R4 had multiple back surgeries, mobility, and pain issues, and was at high risk for falls. R4 walked with a walker and one to two-person assistance for short distances. The CAA further documented R4 had not always called for assistance or wait for staff to help her so an alarm pad in her chair and bed. R4's Care Plan dated 02/09/24 documented R4 had multiple back surgeries with mobility and pain issues related to her back. R4 reported her left leg did not work well. She had multiple falls prior to moving into long term care and she had several since. The care plan instructed R4 had her lift chair from home but could no longer safely operate the chair. R4's Durable Power of Attorney (DPOA) was aware of this and the safety risk of falling. R4's DPOA would like staff to operate the chair for her, and if needed, the DPOA would provide a mechanical recliner in the future. The plan documented an assessment would be done quarterly to evaluate for safety. The Quarterly Lift Chair Safety assessment dated [DATE], 01/29/24, and 04/29/24, documented R4 had not met the safety requirements for a lift chair unless under supervision. The Progress Note dated 05/18/24 at 07:20 PM documented a Certified Medication Aide (CMA) requested immediate assistance to R4's room. Upon entering the room, R4 was laying prone (lying face down) on the floor and shifted more onto the left side. There was a large amount of blood present related to a head laceration (wound to the skin) to R4's left forehead and bruising noted to R4's left eyebrow. R4 stated she was trying to get to the bathroom. R4 was transferred to the emergency room at 07:31 PM. The Progress Note dated 05/18/24 at 07:34 PM documented upon further discussion with the CMA, the resident's chair alarm started going off and staff ran to the room where R4 was found lying on the floor. There were non-slip socks were present, and the lift chair was lifted all the way up. The Progress Note dated 05/18/24 at 11:30 PM, documented R4 returned from the emergency room , and had six sutures to the left forehead laceration. A head and cervical spine (neck/spine) computed tomography scan (CT-imaging to obtain detailed internal images of the body) resulted with no negative findings from the trauma. The Progress Note dated 05/20/24 at 10:39 PM, documented R4 had her call light on but was trying to get out of her easy chair independently at 09:45 PM when staff responded. R4 had dark purple bruising to left side of her face and around her left eye. On 05/21/24 at 02:53 PM, observation revealed R4 sat in her recliner with the footrest elevated. The call light was fastened to the right arm rest of the recliner. The remote controls to the recliner sat on the top of a nightstand to the right of the recliner. R4 reported she was blind in her right eye and that is why she had a dark lens in her glasses. R4 reported she fell the other day trying to go upstairs. She said she fell and hit her head and it bled everywhere. On 05/23/24 at 09:00 AM, observation revealed R4 sat in her recliner with her eyes closed, covered with blankets. The footrest of the lift chair was elevated. The call light and the lift chair control were resting on the right arm rest within her reach. There were no staff present supervising. On 05/22/24 at 11:07 AM, Certified Nurse Aide (CNA) M reported staff keep R4's call light within reach, and staff position themselves close to the resident's room. CNA M said staff place appropriate footwear on R4, elevate her feet due to swelling, and place a walker or wheelchair within her reach in case she tries to get up on her own. CNA M reported the chair remote for the electric lift chair should be placed on the nightstand next to the chair to the right side of the resident due to R4 being blind in her right eye. On 05/22/24 at 11:45 PM, Licensed Nurse (LN) J reported staff try to check R4 frequently to make sure things R4 would want are kept withing reach and where she could see them. LN J stated R4 would get impatient with staff and try to get up and only sometimes used the call light. On 05/23/24 at 09:02 AM, CNA O reported R4 had an alarm because she would try to stand up on her own and required two staff for transfers. CNA O stated R4's last fall was due to the resident trying to get up and she fell into the dresser. CNA O verified at this time the call light and lift chair control were located on the right arm rest of the recliner in reach, while the resident sat in it. 05/23/24 at 09:07 AM, Administrative Nurse D stated R4's DPOA was aware she could no longer safely operate the lift chair and knew the safety risk of falling. Administrative Nurse D said R4's DPOA would like staff to operate the chair. Administrative Nurse D verified the call light and lift chair control was present on the right arm rest of the recliner, and stated staff may have to unplug the electric lift chair to prevent R4 from operating the chair without staff present. The facility's Fall Prevention Guidelines policy, dated 09/26/19, documented the facility to provide a safe environment for residents while helping them maintain an optimal level of independence. To assess to residents and implement interventions to keep them safe and independent. The facility failed to ensure an environment free from accidents when staff placed R4's electric lift chair remote in reach despite a safety evaluation which indicated it was not safe. As a result, R4 fell and required sutures to a head laceration. The facility continued to leave the lift control within R4's reach, which placed her at continued risk for falls, injuries, and associated pain.

The facility had a census of 23 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to implement a water management program for the Legionella disease (Legionella is a bacterium spread through mist, such as from air-conditioning units for large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease, or heavy tobacco use are most at risk of developing pneumonia caused by legionella) and other waterborne pathogens. The facility staff failed to change gloves while providing incontinent care for R23. This placed the residents in the facility at risk for infectious disease. Findings Included: - On 05/22/24 at 08:51 AM, Administrative Nurse D stated she was unaware of what the facility's measures were to prevent the growth of Legionella and other waterborne pathogens in building water systems. Administrative Nurse D said the emergency preparedness manager at the hospital might be in charge of the plan but would be gone all week. Administrative Nurse D stated the maintenance supervisor would know more about it. On 05/22/24 at 11:11 AM, Maintenance Staff (MS) U stated he had started the program but was unaware of what to do regarding Legionella prevention. The facility's Water Management Program Legionella Policy, revised 03/23, documented the water management program should identify areas or devices in the building where Legionella might grow or spread to people to reduce the risk. The facility would control legionella hazards by identifying and managing conditions that support the spread of legionella. The facility failed to develop a water management plan for detecting and mitigating Legionella and other waterborne pathogens in the facility water system. This placed the 23 residents at risk of developing an infection. - R23's Electronic Medical Record (EMR) documented R23 had diagnoses of prostatic hyperplasia (a noncancerous enlargement of the prostate gland (below the bladder in men and surrounds the top portion of the tube that drains urine from the bladder) R23's Admission Minimum Data Set (MDS), dated [DATE], documented R23 was frequently incontinent of urine and bowel. R23 required partial to moderate staff assistance with toilet hygiene. The Urinary Incontinence/Indwelling Catheter Care Area Assessment (CAA ), dated 04/11/24, documented R23 was frequently incontinent of bowel and bladder. He wore pull-ups and required staff assistance to ensure hygiene was done well. The CAA documented R23 had a check and change schedule of 05:00 AM and 12:00 PM. R23's Care Plan, revised 04/05/24, documented R23 required staff assistance with toilet hygiene. On 05/22/24 at 10:30 AM, observation revealed Certified Nurse Aide (CNA) N propelled R23 in a Geri-chair (a recliner on wheels that can be pushed around like a wheelchair, usually with a removable tray) to his room. CNA P assisted CNA N and transferred R23 to his bed. Both staff applied gloves. CNA N removed R23's incontinent brief which was saturated with urine. Then, wearing the same soiled gloves, CNA N assisted R23 in turning on his right side, touching his clothing. CNA N provided perineal (private area) care to R23's buttocks, then with the same soiled gloves, assisted CNA P in repositioning R23 on his back. CNA N provided perineal care to R23's genitals and wearing the same soiled gloves, took off the resident's jogging pants, placed new jogging pants on R23, placed net stockings on R23's feet, and put R23's shoes on. With the same soiled gloves, CNA N assisted R23 to sit on the side of the bed touching his shirt, and placed a gait belt on R23, then assisted CNA P to pivot transfer R23 to a Geri-chair. Ongoing observation revealed CNA N, wearing the same soiled gloves, removed R23's sweatshirt, went to the closet, retrieved a new button-down shirt, took a clean t-shirt from R23's drawer, and assisted CNA P in putting the shirts on R23. CNA N, with the same soiled gloves, retrieved a wet washcloth, washed R23's face, placed a hearing aid in his left ear, placed eyeglasses on R23's eyes, placed foot pedals on the chair, picked up R23's dirty clothes from the floor, and placed them in a trash bag. CNA N then removed and discarded his gloves, tied up the trash bag, and left the room without washing his hands. On 05/22/24 at 10:56 AM, CNA N verified he had not changed his gloves or washed his hands after providing perineal care to the resident and stated he should have. CNA N stated sometimes he gets busy with the procedures and forgets to change his gloves. On 05/23/24 at 08:53 AM, Administrative Nurse D stated she expected staff to change gloves and wash hands after they removed a soiled brief and complete perineal care. Upon request, the facility did not provide a policy regarding changing gloves and washing hands during incontinence care. The facility staff failed to change gloves and wash hands when providing R23 incontinent care and continued to provide care with the same soiled gloves. This placed the resident at risk for infection.

The facility had a census of 23 residents. The sample included 13 residents with one reviewed for dignity. Based on observation, record review, and interviews, the facility staff failed to treat Resident (R) 17 with dignity when staff failed to close the window curtain during personal care of a gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach). This placed the resident at risk for an undignified experience and embarrassment. Findings included: - R17's Electronic Medical Record (EMR) documented R17 had a diagnosis of multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord) R17's Quarterly Minimum Data Set (MDS), dated [DATE], documented R17 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R17 was dependent on staff for most activities of daily living (ADLs). R17 had a feeding tube. R17's Care Plan, revised 02/26/24, instructed staff to administer all of R17's medications per her G-tube. On 05/22/24 at 09:15 AM, Licensed Nurse (LN) H entered R17's room and shut the door. R17 was in an electric wheelchair and faced the window. With the window blinds wide open, LN H pulled R17's shirt up revealing her abdomen and G-tube, and administered R17's medications through her tube while R17 was visible to other residents and family members through the window. On 05/22/24 at 09:23 AM, LN H verified she had not closed the resident's window blinds and stated she should have. On 05/23/24 at 08:54 AM, Administrative Nurse D stated she expected staff to provide R17 dignity by ensuring privacy during G-tube administration by closing the room door and offering to close the blinds. The facility's Dignity and Respect of Individuality Policy, revised 09/26/19, documented the facility would honor each resident's dignity and respect of individuality. The facility failed to treat R17 with dignity when staff left the window blinds wide open, with R17 facing the window while administering medications per R17's G-tube. This placed the resident at risk for an undignified experience and embarrassment.

The facility had a census of 23 residents. The sample included 13 residents, of which five were reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 9's as needed (PRN) Xanax (an antianxiety medication that calms and relaxes people with excessive restlessness, nervousness, and tension) had a 14-day stop date and or a rationale for extended use with a specified stop date. This placed R9 at risk of receiving unnecessary psychotropic medications (medications that affect the chemical makeup of the brain). Findings included: - R9's Electronic Medical Record (EMR) recorded a diagnosis of bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R9's Annual Minimum Data Set (MDS), dated [DATE], recorded R9 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. The MDS recorded the resident required limited staff assistance with activities of daily living. The MDS documented R9 received an antianxiety medication. R9's Care Plan, dated 04/22/24, directed staff to observe R9 to monitor the resident for any signs and symptoms of feeling down due to her husband's passing and feeling her kids placed her in the facility and abandoned her. R9's Care Plan directed the staff to monitor for medication effectiveness or decline in her mood and worsening behaviors including hopelessness, anxiety, sadness, insomnia, negative statements, repetitive anxiety, or health-related complaints. The Physician's Order, dated 04/18/24, directed staff to administer Xanax, 0.25 milligrams (mg), one tablet as needed, every eight hours PRN for anxiety. The order lacked a stop date. The Pharmacist Recommendation, dated 12/2023, documented the resident received PRN Xanax and per Centers for Medicare and Medicaid Services (CMS) regulation all psychoactive medications that are ordered as needed or PRN would be automatically discontinued after 14 days. The medication can be written to extend beyond 14 days if the prescriber provides proper rationale and a designated period of use. On 12/19/23 the physician documented to continue for six months but only recorded that the benefits in relieving the symptoms outweighed potential risk. Record review revealed the facility did not enter the physician's order for a stop date six months from the order in the resident's EMR or Medication Administration Record. On 05/22/24 at 08:00 AM, R9 sat in a recliner in her room. Licensed Nurse (LN) H administered the resident her morning medications. On 05/22/24 at 10:00 AM, Administrative Nurse D verified R9 received the PRN Xanax for anxiety. Administrative Nurse D verified the PRN Xanax had no stop date. The facility's Psychotropic Medication Use policy, dated 10/01/19 recorded that residents would not receive psychotropic medications unless behavioral programming and/or environment changes or other non-pharmacological intervention shave failed to sufficiently address the resident's target behavioral goals. The policy documented PRN orders for psychotropic medications are limited to 14 days unless the provider specifies the duration. If the provider believes that the PRN order should be extended beyond 14 days, the provider must document the rationale in the medical record. PRN orders for antipsychotic drugs are limited to 14 days and cannot be renewed unless the provider evaluates the resident for the appropriateness of the medication. The facility failed to ensure R9's PRN antianxiety medication had a stop date. This placed the resident at risk for adverse medication side effects and unnecessary psychotropic medications.

The facility identified a census of 29 residents with three reviewed for accidents. Based on record review, observation, and interview, the facility failed to update Resident (R) 1's Care Plan to include staff using a gait belt to assist R1 when standing from a seated to a standing position after Certified Nurse's Aide (CNA) M did not use a gait belt causing bruises and pain. This deficient practice placed R1 at risk for unsafe transfers due to uncommunicated care needs. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of dementia (progressive mental disorder characterized by failing memory, and confusion), repeated falls, and chronic respiratory failure. The Annual Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. The MDS documented R1 had impairment on one side of her body of both the upper and lower extremities and utilized a walker and a wheelchair. The Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 12/27/23 documented R1 had been weaker after having COVID-19 (highly contagious respiratory virus). The CAA documented R1 was requiring staff assistance for transfers, toileting, dressing, and ambulating. The CAA documented R1 needed reminders and cues due to poor safety awareness. R1's Care Plan, dated 01/05/23, documented R1 had limited physical mobility related to generalized weakness. The plan directed staff R1 was dependent with bathtub transfers, required limited assistance of staff for safe transfers into and out of bed, and required one to two staff assistants for toileting depending on her level of strength for the day. The care plan lacked any intervention for staff to use a gait belt when assisting R1 from a seated to a standing position. The Skin Lesion Assessment, dated 01/24/24, documented R1 had a bruise on her left forearm that was purple/dark blue and measured 13 cm by 11 cm. The Skin Lesion Assessment, documented a dark blue bruise on R1's left forearm which measured 4 cm by 4.1 cm. The Facility Incident Report, dated 01/25/24, documented Licensed Nurse (LN) G performed R1's skin assessment and noted a large dark purple/blue bruise on R1's left forearm and elbow. The bruise on R1's forearm measured 13 centimeters (cm) by 11 cm and the bruise on R1's elbow measured 4 cm by 4.1 cm. When asked what happened, R1 stated, It was that black girl. She grabbed me here to help me up. She didn't mean anything by it. She is not here anymore anyway so there is nothing to be done. R1 referred to CNA M who worked at the facility as a contracted agency CNA. Changes to the care plan included staff utilizing a gait belt to assist R1 when standing from a seated position. The Skin Lesion Assessment, dated 01/28/24, documented R1 had a bruise to her left forearm that was purple/dark pink and measured 20 cm by 14 cm, the bruise was resolving. The assessment documented a pink/light purple bruise on R1's left forearm which measured 5 cm by 6.5 cm. The Skin Lesion Assessment, dated 02/04/24, documented R1's bruising to her left forearm had resolved. On 02/06/24 at 10:15 AM, observation revealed R1 sat in her recliner watching television. R1's left forearm was reddish/pink. On 02/06/24 at 10:15 AM, R1 stated CNA M pulled on her left arm to get her out of the chair. R1 stated CNA M had not used a gait belt. R1 stated it hurt when R1 pulled on her arm, and she yelled out but CNA M did not say anything or stop pulling on her arm. On 02/06/24 at 10:30 AM, Administrative Nurse D stated when she had talked with R1 about the situation R1 had told her CNA M had not used a gait belt. Administrative Nurse D verified it was the facility's policy to use a gait belt during transfers for safety. The facility's Gait Belts and Transfer Policy, revised 03/19/07, documented gait belts are provided to assist staff to safely transfer or ambulate residents. The policy documented to note the use of gait belts in the resident's care plan. The facility failed to update R1's care plan to include staff using a gait belt to assist R1 when standing from a seated to a standing position after staff did not use a gait belt causing bruises and pain. This deficient practice placed R1 at risk for unsafe transfers due to uncommunicated care needs.

The facility identified a census of 29 residents with three reviewed for accidents. Based on record review, observation, and interview, the facility failed to provide Resident (R) 1 a safe environment when Certified Nurse's Aide (CNA) M did not use a gait belt and pulled on R1's left arm causing bruises and pain. This deficient practice placed R1 at risk for pain, bruising, altered skin integrity, and falls. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), repeated falls, and chronic respiratory failure. The Annual Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. The MDS documented R1 had impairment on one side of her body of both the upper and lower extremities and utilized a walker and a wheelchair. The Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 12/27/23 documented R1 had been weaker after having COVID-19 (highly contagious respiratory virus). The CAA documented R1 was requiring staff assistance for transfers, toileting, dressing, and ambulating. The CAA documented R1 needed reminders and cues due to poor safety awareness. R1's Care Plan, dated 01/05/23, documented R1 had limited physical mobility related to generalized weakness. The plan directed staff R1 was dependent with bathtub transfer, required limited assistance of staff for safe transfers into and out of bed, and required one to two staff assistants for toileting depending on her level of strength for the day. The care plan lacked any intervention for staff to use a gait belt when assisting R1 from a seated to a standing position. The Skin Lesion Assessment, dated 01/24/24, documented R1 had a bruise on her left forearm that was purple/dark blue and measured 13 cm by 11 cm. The Skin Lesion Assessment, documented a dark blue bruise on R1's left forearm which measured 4 cm by 4.1 cm. The Facility Incident Report, dated 01/25/24, documented Licensed Nurse (LN) G performed R1's skin assessment and noted a large dark purple/blue bruise on R1's left forearm and elbow. The bruise on R1's forearm measured 13 centimeters (cm) by 11 cm and the bruise on R1's elbow measured 4 cm by 4.1 cm. When asked what happened, R1 stated, it was that black girl. She grabbed me here to help me up. She didn't mean anything by it. She is not here anymore anyway so there is nothing to be done. R1 referred to CNA M who worked at the facility as a contracted agency CNA. Changes to the care plan includedstaff were to utilize a gait belt to assist R1 when standing from a seated position. The Skin Lesion Assessment, dated 01/28/24, documented R1 had a bruise on her left forearm that was purple/dark pink and measured 20 cm by 14 cm, the bruise was resolving. The assessment documented a pink/light purple bruise on R1's left forearm which measured 5 cm by 6.5 cm. The Skin Lesion Assessment, dated 02/04/24, documented R1's bruising to her left forearm had resolved. On 02/06/24 at 10:15 AM, observation revealed R1 sat in her recliner watching television. R1's left forearm was reddish/pink. On 02/06/24 at 10:15 AM, R1 stated CNA M pulled on her left arm to get her out of the chair. R1 stated CNA M had not used a gait belt. R1 stated it hurt when R1 pulled on her arm, and she yelled out but CNA M did not say anything or stop pulling on her arm. On 02/06/24 at 10:30 AM, Administrative Nurse D stated when she had talked with R1 about the situation R1 told her CNA M had not used a gait belt. Administrative Nurse D stated she saw CNA M use a gait belt during her time employed as a CNA at the facility. Administrative Nurse D stated all staff had pulled on a resident's arm at some time or other. Administrative Nurse D verified it was the facility's policy to use a gait belt during transfers for safety. The facility's Gait Belts and Transfer Policy, revised 03/19/07, documented gait belts are provided to assist staff to safely transfer or ambulate residents. The policy documented to note the use of gait belts in the resident's care plan. The facility failed to provide R1 a safe environment. This deficient practice placed R1 at risk for pain, bruising, altered skin integrity, and falls.

The facility identified a census of 31 residents with three residents reviewed for pressure ulcers. Based on record review, observation, and interview, the facility failed to provide a comprehensive care plan regarding R1's a palm protector, removeable splint/brace, and restorative nursing care to avoid a pressure ulcer from developing for Resident (R) 1. This deficient practice placed R1 at risk for pressure ulcers, wound complications, and pain. Findings included: - The Electronic Medical Record (EMR) documented R1 had the diagnoses of Huntington's Disease (rare abnormal hereditary condition characterized by progressive mental deterioration; a disabling central nervous system movement disorder), contractures (abnormal permanent fixation of joints or muscles) of the muscles, and major depressive disorder (major mood disorder). The Quarterly Minimum Data Set (MDS), dated [DATE], documented the Brief Interview for Mental Status (BIMS) was not completed because R1 was rarely/never understood. The MDS documented R1 required extensive assistance to total dependence of two staff for all activities of daily living. The MDS documented R1 had two days of occupational therapy for a total of forty-one minutes during the look back period. The MDS documented restorative therapy had seen R1 for two days for passive range of motion but zero days for splint or brace assistance. The Pressure Ulcer/Injury Care Area Assessment (CAA), dated 03/15/23, documented R1 was a high risk for skin breakdown. R1 required two personal assistance for transfer and was frequently incontinent of bladder and bowel, followed a toileting schedule of every two hours, and sat on a pressure relieving cushion in his geri-chair. The Restorative Nursing Care Plan, dated 04/06/22, directed the restorative aide to assist R1 to perform range of motion to his upper and lower extremities each time she worked with him, the restorative aide would focus on R1's contracted right hand by opening his hand, extending his fingers and washing all surfaces, and the restorative aide would work with R1 three to five times a week. The intervention dated 06/14/23, documented occupational therapy was working with R1 weekly regarding R1's right wrist/hand contracture. The Activity of Daily Living Care Plan, dated 04/07/22, documented R1 had contractures of his right arm and hand. The care plan directed staff to provide skin care daily and as needed to keep the skin clean and prevent skin breakdown. The care plan documented R1 had a palm protector that needed placed in his right hand to prevent his nails from digging into his skin. The care plan failed to document what staff was to place the palm protector, when the palm protector was to be placed on, or for how long the palm protector was to be on. The Disease Process Care Plan, dated 04/07/22, documented R1 had an occupational therapy evaluation and was recommended to wear a progressive hand/wrist orthosis (splint). Occupational therapy was currently utilizing a palm protector. The care plan lacked any direction regarding placement of the palm protector. The Occupational Therapy Initial Evaluation, dated 05/23/23, documented R1 presented with right wrist and digit contracture. The occupational therapy goal documented R1 would tolerate a palm protector for two hours with no increase in pain or redness. The Occupational Therapy Daily Note, dated 06/22/23, documented due to the complexity of R1's hand position the registered occupational therapist would need to devise some type of splint that R1 could tolerate, until the registered occupational therapist became available, the plan was for the Certified Nurse Aide (CNA) to keep the palm protector in place. The EMR lacked documentation directing placement of the palm protector directions or assessment of the skin underneath the palm protector. The Skin Lesion Assessment Form, dated 07/17/23, documented an open wound was found to R1's right hand in the webbing between the thumb and the index finger measured 1.2 centimeters (cm) in length, 0.5 cm in width, and 0.3 cm in depth. The assessment form documented the wound nurse would be consulted to decide the treatment for the open wound. The Skin Lesion Assessment Form, dated 07/18/23, documented the treatment for R1's open wound to R1's right hand would be medi-honey with polymer (an occlusive or semi-occlusive dressing which provides a barrier against bacterial penetration into the wound). The Skin Lesion Assessment Form, dated 07/24/23, documented the wound to R1's right hand in the webbing between R1's thumb and index finger measured 0.9 cm in length, 0.5 cm in width, and 0.2 cm in depth. The wound bed was pink in the center, light pink around the edges, with white exudate (drainage). The Skin Lesion Assessment Form, dated 08/01/23, documented the open wound to R1's right hand in the webbing between R1's thumb and index finger measured 0.2 cm in length, 0.3 cm in width, and 0.05 cm in depth. The wound bed was pink. The Skin Lesion Assessment Form, dated 08/10/23, documented the open area to R1's right hand was resolved. No further monitoring needed. On 08/16/23 at 10:00 AM, observation revealed R1 sat in a recliner in the day room. R1 had a contracted right wrist and fingers. R1 did not have a palm protector or splint to his right hand. On 08/16/23 at 10:05 AM, CNA M stated that she thought R1 was supposed to have some sort of a splint to his right hand but did not know whose responsibility it was to apply the splint or monitor the skin under R1's splint. On 08/16/23 at 10:15 AM, CNA N stated she thought R1's palm protector or splint was discontinued because he got a wound to his right hand from the splint. CNA N stated she did not know whose responsibility it was to apply the splint to R1's hand or monitor the skin underneath the splint. On 08/16/23 at 10:30 AM, Licensed Nurse (LN) G verified in the EMR that there were no orders to apply a palm protector or splint to R1's right hand. LN G stated the palm protector had been discontinued because of the wound to R1's right hand and that gauze was to be placed in R1's right hand to protect his hand. LN G verified that R1 did not have any gauze, palm protector, or splint to his right hand. On 08/16/23 at 11:00 AM, Administrative Nurse E stated that she could not find any documentation from occupational therapy regarding directions for placement of R1's palm protector or splint to prevent further contracture of R1's right wrist and hand and to protect R1's right palm from R1's nails digging into his palm. On 08/16/23 12:30 PM, Administrative Nurse D stated that after the wound to R1's right hand had been found, nursing was putting a gauze roll in R1's right hand. This surveyor told Administrative Nurse D that there was nothing in R1's hand at that time. Administrative Nurse D went and assessed R1's right hand and verified that there was nothing in R1's right hand to protect it. Administrative Nurse D stated R1 had a shower that morning and no gauze roll had been placed in R1's right hand. Administrative Nurse D placed a gauze roll in R1's right hand. Administrative Nurse D stated there was obviously a lack of communication between occupational therapy and nursing regarding the directions for applying a palm protector or splint to R1's contracted right wrist/hand. Administrative Nurse D verified R1's care plan had interventions regarding palm protector placement, skin assessment by restorative nursing, but lacked any directions regarding the placement of a palm protector. Administrative Nurse D stated R1 would require another evaluation by occupational therapy. The facility's Care Plan Policy, revised 09/26/19, documented the care plan would ensure all issues related to falls, skin breakdown, psychotropic medications, and weight loss or gain would be discussed at care plan meetings and effective interventions would be implemented and documented. New entries and changes to the care plan would be updated in the electronic health record. Care plans wound be updated on the computer and printed quarterly or as needed and all issues requiring follow up would be addressed by the appropriate team member immediately following the care plan meeting. The facility failed to provide a comprehensive care plan regarding R1's a palm protector, removeable splint/brace, and restorative nursing care to avoid a pressure ulcer from developing for R1. This deficient practice placed R1 at risk for pressure ulcers, wound complications, and pain.

The facility identified a census of 31 residents with three residents reviewed for pressure ulcers. Based on record review, observation, and interview, the facility failed to assess the skin under the removeable splint/brace to avoid a pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) from developing for Resident (R) 1. This deficient practice placed R1 at risk for pressure ulcers, wound complications, and pain. Findings included: - The Electronic Medical Record (EMR) documented R1 had the diagnoses of Huntington's Disease (rare abnormal hereditary condition characterized by progressive mental deterioration; a disabling central nervous system movement disorder), contractures (abnormal permanent fixation of joints or muscles) of the muscles, and major depressive disorder (major mood disorder). The Quarterly Minimum Data Set (MDS), dated [DATE], documented the Brief Interview for Mental Status (BIMS) was not completed because R1 was rarely/never understood. The MDS documented R1 required extensive assistance to total dependence of two staff for all activities of daily living. The MDS documented R1 had two days of occupational therapy for a total of forty-one minutes during the look back period. The MDS documented restorative therapy had seen R1 for two days for passive range of motion but zero days for splint or brace assistance. The Pressure Ulcer/Injury Care Area Assessment (CAA), dated 03/15/23, documented R1 was a high risk for skin breakdown. R1 required two personal assistance for transfer and was frequently incontinent of bladder and bowel, followed a toileting schedule of every two hours, and sat on a pressure relieving cushion in his geri-chair. The Restorative Nursing Care Plan, dated 04/06/22, directed the restorative aide to assist R1 to perform range of motion to his upper and lower extremities each time she worked with him, the restorative aide would focus on R1's contracted right hand by opening his hand, extending his fingers and washing all surfaces, and the restorative aide would work with R1 three to five times a week. The intervention dated 06/14/23, documented occupational therapy was working with R1 weekly regarding R1's right wrist/hand contracture. The Activity of Daily Living Care Plan, dated 04/07/22, documented R1 had contractures of his right arm and hand. The care plan directed staff to provide skin care daily and as needed to keep the skin clean and prevent skin breakdown. The care plan documented R1 had a palm protector that needed placed in his right hand to prevent his nails from digging into his skin. The care plan failed to document what staff was to place the palm protector, when the palm protector was to be placed on, or for how long the palm protector was to be on. The Disease Process Care Plan, dated 04/07/22, documented R1 had an occupational therapy evaluation and was recommended to wear a progressive hand/wrist orthosis (splint). Occupational therapy was currently utilizing a palm protector. The care plan lacked any direction regarding placement of the palm protector. The Occupational Therapy Initial Evaluation, dated 05/23/23, documented R1 presented with right wrist and digit contracture. The occupational therapy goal documented R1 would tolerate a palm protector for two hours with no increase in pain or redness. The Occupational Therapy Daily Note, dated 06/22/23, documented due to the complexity of R1's hand position the registered occupational therapist would need to devise some type of splint that R1 could tolerate, until the registered occupational therapist became available, the plan was for the Certified Nurse Aide (CNA) to keep the palm protector in place. The EMR lacked documentation directing placement of the palm protector directions or assessment of the skin underneath the palm protector. The Skin Lesion Assessment Form, dated 07/17/23, documented an open wound was found to R1's right hand in the webbing between the thumb and the index finger measured 1.2 centimeters (cm) in length, 0.5 cm in width, and 0.3 cm in depth. The assessment form documented the wound nurse would be consulted to decide the treatment for the open wound. The Skin Lesion Assessment Form, dated 07/18/23, documented the treatment for R1's open wound to R1's right hand would be medi-honey with polymer (an occlusive or semi-occlusive dressing which provides a barrier against bacterial penetration into the wound). The Skin Lesion Assessment Form, dated 07/24/23, documented the wound to R1's right hand in the webbing between R1's thumb and index finger measured 0.9 cm in length, 0.5 cm in width, and 0.2 cm in depth. The wound bed was pink in the center, light pink around the edges, with white exudate (drainage). The Skin Lesion Assessment Form, dated 08/01/23, documented the open wound to R1's right hand in the webbing between R1's thumb and index finger measured 0.2 cm in length, 0.3 cm in width, and 0.05 cm in depth. The wound bed was pink. The Skin Lesion Assessment Form, dated 08/10/23, documented the open area to R1's right hand was resolved. No further monitoring needed. On 08/16/23 at 10:00 AM, observation revealed R1 sat in a recliner in the day room. R1 had a contracted right wrist and fingers. R1 did not have a palm protector or splint to his right hand. On 08/16/23 at 10:05 AM, CNA M stated that she thought R1 was supposed to have some sort of a splint to his right hand but did not know whose responsibility it was to apply the splint or monitor the skin under R1's splint. On 08/16/23 at 10:15 AM, CNA N stated she thought R1's palm protector or splint was discontinued because he got a wound to his right hand from the splint. CNA N stated she did not know whose responsibility it was to apply the splint to R1's hand or monitor the skin underneath the splint. On 08/16/23 at 10:30 AM, Licensed Nurse (LN) G verified in the EMR that there were no orders to apply a palm protector or splint to R1's right hand. LN G stated the palm protector had been discontinued because of the wound to R1's right hand and that gauze was to be placed in R1's right hand to protect his hand. LN G verified that R1 did not have any gauze, palm protector, or splint to his right hand. On 08/16/23 at 11:00 AM, Administrative Nurse E stated that she could not find any documentation from occupational therapy regarding directions for placement of R1's palm protector or splint to prevent further contracture of R1's right wrist and hand and to protect R1's right palm from R1's nails digging into his palm. On 08/16/23 12:30 PM, Administrative Nurse D stated that after the wound to R1's right hand had been found, nursing was putting a gauze roll in R1's right hand. This surveyor told Administrative Nurse D that there was nothing in R1's hand at that time. Administrative Nurse D went and assessed R1's right hand and verified that there was nothing in R1's right hand to protect it. Administrative Nurse D stated R1 had a shower that morning and no gauze roll had been placed in R1's right hand. Administrative Nurse D placed a gauze roll in R1's right hand. Administrative Nurse D stated there was obviously a lack of communication between occupational therapy and nursing regarding the directions for applying a palm protector or splint to R1's contracted right wrist/hand. Administrative Nurse D verified R1's care plan had interventions regarding palm protector placement, skin assessment by restorative nursing, but lacked any directions regarding the placement of a palm protector. Administrative Nurse D stated R1 would require another evaluation by occupational therapy. The facility's Pressure Ulcer Prevention and Treatment Policy, revised 02/03/21, documented a program of prevention, care and treatment of pressure ulcers is carried out for all residents to prevent skin breakdown and promote healing. The responsibility of all caregivers is to prevent, care for, and provide treatment for pressure ulcers. Nursing judgement may be used to determine what preventative measures are to be used for each resident. These measures are included in the Resident Care Plan. The facility failed to assess the skin under the removeable splint/brace to avoid a pressure ulcer from developing for R1. This deficient practice placed R1 at risk for pressure ulcers, wound complications, and pain.

The facility identified a census of 31 residents with three residents sampled. Based on record review, observation, and interview, the facility failed to provide Resident (R) 1, who had limited mobility, with the necessary restorative services, equipment, and assistance to maintain or improve mobility. This deficient practice placed R1 at risk for pressure ulcers, increased contracture (abnormal permanent fixation of joints or muscles) to R1's right wrist/hand, and decreased mobility to R1's right wrist and hand. Findings included: - The Electronic Medical Record (EMR) documented R1 had the diagnoses of Huntington's Disease (rare abnormal hereditary condition characterized by progressive mental deterioration; a disabling central nervous system movement disorder), contractures of the muscles, and major depressive disorder (major mood disorder). The Quarterly Minimum Data Set (MDS), dated [DATE], documented the Brief Interview for Mental Status (BIMS) was not completed because R1 was rarely/never understood. The MDS documented R1 required extensive assistance to total dependence of two staff for all activities of daily living. The MDS documented R1 had two days of occupational therapy for a total of forty-one minutes during the look back period. The MDS documented restorative therapy had seen R1 for two days for passive range of motion but zero days for splint or brace assistance. The Pressure Ulcer/Injury Care Area Assessment (CAA), dated 03/15/23, documented R1 was a high risk for skin breakdown. R1 required two personal assistance for transfer and was frequently incontinent of bladder and bowel, followed a toileting schedule of every two hours, and sat on a pressure relieving cushion in his geri-chair. The Restorative Nursing Care Plan, dated 04/06/22, directed the restorative aide to assist R1 to perform range of motion to his upper and lower extremities each time she worked with him, the restorative aide would focus on R1's contracted right hand by opening his hand, extending his fingers and washing all surfaces, and the restorative aide would work with R1 three to five times a week. The intervention dated 06/14/23, documented occupational therapy was working with R1 weekly regarding R1's right wrist/hand contracture. The Activity of Daily Living Care Plan, dated 04/07/22, documented R1 had contractures of his right arm and hand. The care plan directed staff to provide skin care daily and as needed to keep the skin clean and prevent skin breakdown. The care plan documented R1 had a palm protector that needed placed in his right hand to prevent his nails from digging into his skin. The care plan failed to document what staff was to place the palm protector, when the palm protector was to be placed on, or for how long the palm protector was to be on. The Disease Process Care Plan, dated 04/07/22, documented R1 had an occupational therapy evaluation and was recommended to wear a progressive hand/wrist orthosis (splint). Occupational therapy was currently utilizing a palm protector. The care plan lacked any direction regarding placement of the palm protector. The Occupational Therapy Initial Evaluation, dated 05/23/23, documented R1 presented with right wrist and digit contracture. The occupational therapy goal documented R1 would tolerate a palm protector for two hours with no increase in pain or redness. The Occupational Therapy Daily Note, dated 06/22/23, documented due to the complexity of R1's hand position the registered occupational therapist would need to devise some type of splint that R1 could tolerate, until the registered occupational therapist became available, the plan was for the Certified Nurse Aide (CNA) to keep the palm protector in place. The EMR lacked documentation directing placement of the palm protector directions or assessment of the skin underneath the palm protector. The Skin Lesion Assessment Form, dated 07/17/23, documented an open wound was found to R1's right hand in the webbing between the thumb and the index finger measured 1.2 centimeters (cm) in length, 0.5 cm in width, and 0.3 cm in depth. The assessment form documented the wound nurse would be consulted to decide the treatment for the open wound. The Skin Lesion Assessment Form, dated 07/18/23, documented the treatment for R1's open wound to R1's right hand would be medi-honey with polymer (an occlusive or semi-occlusive dressing which provides a barrier against bacterial penetration into the wound). The Skin Lesion Assessment Form, dated 07/24/23, documented the wound to R1's right hand in the webbing between R1's thumb and index finger measured 0.9 cm in length, 0.5 cm in width, and 0.2 cm in depth. The wound bed was pink in the center, light pink around the edges, with white exudate (drainage). The Skin Lesion Assessment Form, dated 08/01/23, documented the open wound to R1's right hand in the webbing between R1's thumb and index finger measured 0.2 cm in length, 0.3 cm in width, and 0.05 cm in depth. The wound bed was pink. The Skin Lesion Assessment Form, dated 08/10/23, documented the open area to R1's right hand was resolved. No further monitoring needed. On 08/16/23 at 10:00 AM, observation revealed R1 sat in a recliner in the day room. R1 had a contracted right wrist and fingers. R1 did not have a palm protector or splint to his right hand. On 08/16/23 at 10:05 AM, CNA M stated that she thought R1 was supposed to have some sort of a splint to his right hand but did not know whose responsibility it was to apply the splint or monitor the skin under R1's splint. On 08/16/23 at 10:15 AM, CNA N stated she thought R1's palm protector or splint was discontinued because he got a wound to his right hand from the splint. CNA N stated she did not know whose responsibility it was to apply the splint to R1's hand or monitor the skin underneath the splint. On 08/16/23 at 10:30 AM, Licensed Nurse (LN) G verified in the EMR that there were no orders to apply a palm protector or splint to R1's right hand. LN G stated the palm protector had been discontinued because of the wound to R1's right hand and that gauze was to be placed in R1's right hand to protect his hand. LN G verified that R1 did not have any gauze, palm protector, or splint to his right hand. On 08/16/23 at 11:00 AM, Administrative Nurse E stated that she could not find any documentation from occupational therapy regarding directions for placement of R1's palm protector or splint to prevent further contracture of R1's right wrist and hand and to protect R1's right palm from R1's nails digging into his palm. On 08/16/23 12:30 PM, Administrative Nurse D stated that after the wound to R1's right hand had been found, nursing was putting a gauze roll in R1's right hand. This surveyor told Administrative Nurse D that there was nothing in R1's hand at that time. Administrative Nurse D went and assessed R1's right hand and verified that there was nothing in R1's right hand to protect it. Administrative Nurse D stated R1 had a shower that morning and no gauze roll had been placed in R1's right hand. Administrative Nurse D placed a gauze roll in R1's right hand. Administrative Nurse D stated there was obviously a lack of communication between occupational therapy and nursing regarding the directions for applying a palm protector or splint to R1's contracted right wrist/hand. Administrative Nurse D verified R1's care plan had interventions regarding palm protector placement, skin assessment by restorative nursing, but lacked any directions regarding the placement of a palm protector. Administrative Nurse D stated R1 would require another evaluation by occupational therapy. The facility's Range of Motion Exercises Nursing Intervention Policy, revised 03/19/07, documented a regiment of individualized range of motion exercises is available to all residents of the long-term care facility. Range of motion exercises are used to: maintain joint mobility, prevent deformities that limit function, and stimulate circulation. Nursing services and rehab perform range of motion exercises. A Physical Therapist assesses joint mobility on each resident before establishing a range or motion regimen that defines joints to be ranged and frequency of exercise. A nursing assistant may carry out range of motion exercises after instruction and demonstrated competency under the supervision of a registered nurse. Nursing services and rehab aides participates with rehabilitation in providing restorative exercises as appropriate. The facility failed to provide R1, who had limited mobility, with the necessary restorative services, equipment, and assistance to maintain or improve mobility. This deficient practice placed R1 at risk for pressure ulcers, increased contracture to R1's right wrist/hand, and decreased mobility to R1's right wrist and hand.

The facility had a census of 28 residents. The sample included 12 residents with one resident reviewed for foot care. Based on observation, record review, and interview the facility staff failed to provide appropriate foot care in accordance with professional standards of practice, to prevent complications from conditions such as diabetes, when a Certified Nurse Aide (CNA) filed Resident (R) 15's callous on her right big toe, which caused a wound. As a result. R15's wound became infected, required medical treatment including antibiotics, and continued to cause R15 pain. Findings included: - R15's Electronic Medical Record documented the resident had diagnose of type II diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). R15's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score 14, which indicted intact cognition. The MDS documented R15 required supervision with transfers, was independent with the rest of her activities of daily living (ADLs) and had an infection of her foot. R15's Diabetes Mellitus Care Plan, revised 05/25/22, instructed staff to provide diabetic foot checks on the resident twice weekly on Tuesdays and Fridays. The care plan documented the resident received added protein in her meals three times daily for wound healing, and multivitamin and vitamin C daily for wound healing. The care plan documented R15's right great toe was scabbed over, with signs of healing, and pink skin around area. The plan of care recorded the toe had no dressing and instructed nurses to monitor the wound twice weekly with baths. The Skin/Wound Notes, dated 01/14/22 at 09:23 AM documented R15's skin was intact and both feet had dry skin. The note documented R15 complained of right great toe pain around the callous (thick and hardened area of skin), and had some purple discoloration. The note documented the resident stated CNA M filed it on the resident's last bath day, and R15 had discomfort since then. The Skin Assessment Sheet, dated 01/28/22, documented the wound on the tip or R15's great toe measured 1.2 centimeters (cm) long (l) by 0.9 cm wide (w) with 0.2 cm depth. The area had a pink, soft, mushy pinpoint open area, and a wound dressing identified as Duoderm (wafer type moisture-retentive wound dressing used for partial and full-thickness wounds leaking fluids) to be changed every three days and as needed and instructed the wound nurse to follow and treat the wound. The Skin/Wound Note, dated 01/28/22, documented R15 had a pinpoint open and the resident complained of discomfort to the affected area. Administrative Nurse D discussed wound treatment, applied Duoderm dressing to the affected area and would change and monitor area every three days and as needed. The Skin/Wound Note, dated 01/31/22 documented the area on the tip of R15's right great toe was dried, slightly crusty, tender, and slightly boggy underneath. The dressing was changed to include a small amount of [MEDICATION(S)] (wound gel used for [MEDICATION(S)] (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue) on the area, cover with a corn pad, and secure with tape. The note documented the resident would receive a bath the next day. At that time, Administrative Nurse D would see if the area could be debrided (mechanical removal of dead tissue) by scrubbing it, and the physician was notified regarding the wound. A Skin/Wound Note, dated 02/01/22 documented R15 had a stage three (broken completely through the top two layers of the skin and into the fatty tissue below) pressure ulcer on her tip of right great toe, measured 0.4 cm (L) x 0.5 cm (W) x 0.1 cm (D), which was red and granulating (regrowth of tissue). The note recorded a [MEDICATION(S)] (a medicated dressing used for exudation (fluid that leaks out of body vessels and tissues]) dressing was placed on the wound, covered with [MEDICATION(S)], and secured with tape. A Skin/Wound Note, dated 02/08/22, documented staff completed the diabetic foot check on R15's feet and toes. The treatment was changed to cleanse area, apply [MEDICATION(S)], Polymen (breathable yet tough, protective, water-resistant dressing), and secure with tape. The open wound area measured 0.5 cm (L) by0.6 cm (W). A Skin/Wound Note, dated 02/11/22, documented R15 complained of pain to right great toe wound when walking or pressure applied to end of toe. A Skin/Wound Note, dated 02/11/22, documented R15 had a 0.3 by 0.3 cm wound on the tip of her right great toe, which was dark pink, R15 reported the wound hurt when she walked. The dressing was changed to place a corn pad to protect, Polymen, then secure with tape. A Nurse's Note, dated 02/21/22, documented R15 had appointment the next day with the physician for the wound on her right great toe. The Physician Office Visit Note documented on 02/22/22 at 01:30 PM R15 presented to the clinic for a painful big toe. The note documented Administrative Nurse D reported a certified nurse aide filed a callous too close and irritated R15's toe. The note further stated Administrative Nurse D initially treated the wound like a pressure wound and placed some triple antibiotic ointment with band-aide; R15 had irritation with the toe for approximately six weeks. The note documented the resident had a skin ulcer of the toe on the right foot with the fat layer exposed. The Skin Assessment Sheet, dated 02/28/22, documented R15's tip of the great toe measured 0.5 cm by 0.6 cm, had no depth, was pink, and improving. The Physician Office Visit Note documented on 03/23/22 at 10:30 AM recorded the wound on the end of R15's right great toe had a callous on it that had been filed down and created an open area. The treatment was [MEDICATION(S)], and cover with foam. The note documented R15's toe was red, swollen, and painful with pressure or palpation. There was no drainage from the area, though the area had increased warmth and the physician diagnosed it with [CONDITION(S)] (skin infection caused by bacteria characterized by heat, redness and swelling). The physician ordered staff to administer [MEDICATION(S)] (antibiotic) ,100 milligrams (mg), twice daily for seven days and to call for any new, worsening, or changing symptoms. A Skin/Wound Note, dated 04/08/22, documented R15 had wound trauma, measured 0.5 (L) by 0.5 (W) and 0.1 cm (D) and the treatment was changed to Aqucel (sterile post-operative dressing made of an inner (wound contact) non-woven pad) dressing apply to fit wound bed, cover with Polymen, and secure with tube gauze. The Wound Culture Report, dated 05/02/22, documented R15's tip of the right great toe wound had staphylococcus (bacterial infection) and enterococcus (bacterial infection). A Nurse's Note, dated 05/11/22, documented the nurse received a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A Hospital Wound Care Evaluation /Re-evaluation Sheet, dated 05/17/22 at 08:15 AM, documented the same dressing was applied to R15's tip of the right great toe wound. The sheet documented R15 continued to receive [MEDICATION(S)] IV daily for an infection to the right great toe through a peripherally inserted central catheter (PICC-long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart). A Hospital Wound Care Evaluation/Re-Evaluation Sheet, dated 05/20/22 at 01:14 PM, documented R15 received treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The sheet noted the physician wanted to perform a procedure to clean out the infection. Administrative Nurse D visited with R15's Durable Power of Attorney (DPOA-appointed person to handle certain matters, such as finances or health care) about the procedure, and the DPOA would schedule an appointment with a different physician. The note documented R15 received [MEDICATION(S)] through outpatient at the hospital for the wound culture results. The note documented the resident had a lot of callous build up on her toe which Administrative Nurse D peeled off easily, and the plan of care to the wound was to moisturize her toe and leave the dressing off. A Nurse's Note, dated 06/06/22, documented R15 had part of the bone in her infected great toe wound removed by the podiatrist (foot doctor) that day. The note further stated the wound began to ache really bad that afternoon, and the nurse received a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nurse's Note, dated 06/06/22, documented R15 reported right great toe wound pain rated at a 7 (0-10 scale with 0 being no pain and 10 being the worst pain imaginable) at 06:50 PM. The nurse administered [MEDICATION(S)] to the resident at 07:15 PM and the resident rated her pain at an 8. The note documented the nurse changed the gauze dressing due to bloody drainage leaking through the dressing, wrapped it with coban, and placed a cool compress over the dressing to alleviate some pain. A Nurse's Note, dated 06/08/22, documented the resident continued to report pain in her right great toe wound and the pain medication she received was enough to help with pain. A Nurse's Note, dated 06/10/22, documented R15 complained of discomfort to right great toe during the night and upon rising in the morning and the right great toe wound had purple discoloration. A Physician Office Visit Note documented on 06/14/22 at 02:30 PM recorded R15 reported that her right great toe still hurt. The note documented R15 had a bone biopsy (sample of tissue is removed from the body to examine more closely) and debridement with podiatry the previous week. R15's incision was healing well, and sutures were to be removed the following week. The bone biopsy showed no [CONDITION(S)] (bone infection) so [MEDICATION(S)] was discontinued. On 07/13/22 at 09:00 AM, observation revealed Licensed Nurse (LN) G applied gloves, removed the R15's gripper sock on her right foot to reveal an uncovered wound area at the tip of the resident's great toe. The indented wound had pink surrounding tissue, with a pinpoint scab in the middle, no odor or drainage noted. R15 stated it was tender to touch but was finally healing. On 07/13/22 at 09:00 AM, R15 stated she went through hell the last six months with the pain from the wound on the tip of her great toe. R15 stated she felt the wound was a result of the CNA filing the callous. On 07/13/22 at 11:30 AM, CNA N stated the facility did not have a designated bath aide. She said when she came to work, the nurse provided her with a list of residents she was responsible for providing baths on that day. CNA N stated all CNAs could provide foot care on all residents' bath days. CNA N further stated the only training she had was two years ago when she was first employed; she watched another aide provide foot care. On 07/13/22 at 08:59 AM, LN G stated CNAs provided resident foot care, including diabetic residents, on their bath day. LN G stated if the CNA was not comfortable providing it to diabetics, the CNAs would get the nurse. On 07/12/22 08:57 AM, Administrative Nurse D stated she heard that CNA M had filed R15's callous too close, but when she asked CAN M, CNA M responded she did not file R15's callous. Administrative Nurse D stated R15 had a spot on the tip of her great toe, which ended up being an ingrown toenail. Administrative Nurse D stated the podiatrist fixed the ingrown toenail (condition where the corners or edges of a toenail grow into the skin) and the wound was now open to air and was healing. 07/14/22 at 11:20 AM, Administrative Nurse D stated she preferred a nurse to provide residents footcare, but CNAs were permitted to provide foot care. Administrative Nurse D stated if a resident was diabetic, the CNA can only file, not clip, the resident's toenails. On 07/13/22 at 03:24 PM, Consultant GG stated he was unaware R15 had a wound on her tip of right great toe. Consultant GG stated if a resident was diabetic, CNAs should not provide foot care on that resident prior to consulting with the facility wound care nurse. The facility's Bathing Policy, revised on 09/26/19, instructed staff to call the charge nurse to trim calluses and toenails on diabetic residents. The facility failed to ensure R15 received appropriate footcare in accordance with professional standards of practice, when a CNA filed R15's callous, causing her pain, infection and surgery.

The facility had a census of 28 residents. The sample included 12 residents. Based on record review and interview, the facility Quality Assessment and Assurance Committee (QA&A) failed to include the Medical Director's (Consultant GG) presence at the quarterly meetings. This placed the residents at risk for lack of input from Consultant GG towards issues discussed in quarterly QA&A meetings. Findings included: - The Quarterly QA&A Meeting Sign in Sheet, dated 08/17/21, 11/16/21 (did not meet in person reports were e-mailed to quality assurance director), 02/15/22, and 05/17/22, lacked documentation Consultant GG attended the meetings. The Quality Assurance Performance Improvement Plan, revised on 12/22/2, documented although QA&A meetings were not attended by the Chief Medical Officer (CMO), reports were presented, reviewed and discussed with Consultant GG. On 07/13/22 at 12:55 PM, Administrative Staff B verified Consultant GG did not attend the facility quarterly QA&A meetings. The information discussed at the meetings was documented and delivered to the medical staff meeting the next day for Consultant GG to review. On 07/14/22 at 11:20 AM, Administrative Nurse D stated Consultant GG did not attend the facility QA&A meetings; the information discussed was typed up and delivered to Consultant GG the next day for review. Upon request the facility failed to provide a policy regarding QA&A. The facility failed to ensure Consultant GG attended the quarterly QA&A meetings. This placed the residents at risk for lack of input from Consultant GG regarding QA&A issues.

The facility had a census of 28 residents. The sample included 12 residents with no residents positive for Covid-19 (potentially fatal, highly contagious respiratory virus). The facility was located in a county with substantial county trasmission. Based on observation, record review, and interview the facility failed to monitor and adhere to the use of facial masks as directed in the core principles of infection control to mitigate the spread of Covid-19. This placed the residents at increased risk for Covid-19 infection. Findings included: - On 07/11/22 at 10:15 AM, observation revealed a desk set up inside the facility entrance with a plastic covered sheet which read Long Term Care (LTC) visitors please wear a mask while in the facility. Further observation revealed a box on the desk with surgical masks. On 07/11/22 12:15 PM, observation revealed Social Service X walked down the hall by the main dining room without a mask. On 07/11/22 at 12:15 PM Social Service X verified she had no mask on and stated she was headed to get her lunch and continued walking down the hallway. On 07/12/22 at 09:00 AM, Administrative Nurse D reported the facility had a nurse test positive that morning for COVID -19, when she reported to work. On 07/12/22 at 11:30 AM observation revealed Licensed Nurse (LN) H administered medications to residents with her surgical mask below her nose. On 07/12/22 at 01:00 PM, observation revealed an unidentified dietary staff in the main dining room with a surgical mask below the chin. On 07/12/22 at 01:00 PM, observation revealed a housekeeping staff in the main dining room sweeping the floor with a surgical mask below his chin. On 07/12/22 at 01:58 PM, observation revealed a family visitor passed the screening desk, without screening in, and went to the dining area where the halls met without a mask. Another family member yelled out to her that she needed to wear a mask, and she replied oh really. They both went back to the screening desk at the front entrance door; she came back with a surgical mask on. On 07/12/22 at 02:12 PM, observation revealed LN H verified her mask was below her nose and stated it should not be, it just slides down. On 07/12/22 at 02:33 PM, observation revealed several residents in the main dining room at a resident's birthday party with outside singers. Further observation revealed Administrative Staff A had his surgical mask in his lap and two family visitors were also present without a mask. On 07/13/22 at 08:21 AM, LN I stated visitors self-screen at the front entrance and were to wear a mask when in the facility. LN I stated if staff saw a visitor without a mask, facility staff encouraged them to wear one. On 07/13/22 at 08:37 AM, LN I stated long term care staff were to wear a surgical mask in the dining room if a resident was present. LN I stated kitchen staff had to wear a mask if serving a resident or in contact with a resident. On 07/14/22 at 10:57 AM, Administrative Nurse D stated she expected staff to wear a surgical mask when providing cares or around a resident, but staff could take it off in nurses station if a resident was not present. The facility's Implementation Guidelines for Self Screening,revised 06/22/22, instructed visitors to please wear a mask while in the facility. The facility failed to enforce infection control measures to mitigate the spread of Covid-19 by allowing visitors and staff not to wear a mask or to wear their facial mask inappropriately. This palced the residents at increased risk for Covid-19.

The facility had a census of 25 residents. The sample included three residents reviewed for abuse. Based on observation, record review, and interview, the facility failed to prevent an incident of abuse for Resident (R) 1, when in September 2020 a staff member recorded a video on her cell phone of staff providing personal care to Resident (R) 1 with his private area exposed and visible on the video, while attached to a mechanical lift. The resident told the staff to stop it, but the staff member continued to record the video. Staff then posted the video on a social media site and shared it with multiple staff. This deficient practice placed R1 in immediate jeopardy. Findings included: - R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of nine. R1 had physical and verbal behaviors one to three days in the seven day look back period that significantly interfered with the resident's care. The resident required two-person physical assistance with transfers, bed mobility, and toileting. The Activities of Daily Living (ADL) Care Area Assessment (CAA), dated 09/08/20, documented R1 required assistance with most ADL's with cueing. The CAA documented R1 had occasional behaviors of yelling at staff and required use of the sit-to-stand lift (a mechanical device used to assist a person from a sitting to standing position) for all transfers. The ADL Care Plan, dated 09/10/20, documented R1 required extensive staff assistance for toileting and directed staff to toilet the resident every two hours. The care plan directed staff to use the sit-to-stand mechanical lift to transfer R1. The Facility Investigation, dated 03/31/21, documented on 03/15/21 a family member of a local high school student who did not work at the facility notified Administrative Nurse F about a social media video of facility staff performing peri-care (washing the genitals and anal area) on a male resident with dementia. The reporter stated staff recorded the video because he makes funny noises and says funny thing when you are doing peri-care on him. The reporter did not know the name of the resident but knew he had passed away since staff recorded the video. The reporter did not have a timeframe for when staff recorded the video. On 03/30/21 at 10:22 AM, observation revealed Certified Nurse Aide (CNA) P entered the resident shower room and retrieved her cellular telephone out of her purse. CNA P stated she used her cellular telephone to play music while she gave residents baths. On 03/29/21 at 11:32 AM, Administrative Nurse F stated she received a telephone call from a concerned citizen informing the facility a staff member recorded a video of a resident then posted the video on social media, so the facility started an investigation. CNA Q told Administrative Nurse F that CNA N showed her a video on CNA N's cellular telephone of an unidentified staff member spraying R1 with periwash (a gentle hygienic cleanser in a spray bottle easily applied directly onto soiled areas or onto toilet paper before wiping) while R1 was raised up in the [sit-to-stand] lift, naked from the waist down, with his genitals completely exposed, and R1 hollered at staff to stop. During the facility investigation, CNA M and CNA R both admitted to providing peri care to R1, but said they did not know they were being recorded. Also, the facility investigation revealed CNA N also had involvement in the incident or at least knew the incident occurred. Administrative Nurse F stated during their investigation there were several CNA staff who reported knowing about the video, but did not report the video to management staff for fear they would get their friends in trouble and/or CNA M contacted and threatened them to delete the pictures or videos of R1 off their cellular telephones. On 03/29/21 at 11:44 AM, Administrative Staff B stated during the facility's investigation CNA N admitted she had the video on her social media account and used her cellular telephone to show the video to CNA Q. On 03/29/21 at 03:29 PM, R4 stated the previous week she observed some of the young female staff sneak and held their cellular telephones down by their side and texted. R4 stated she did not see staff take pictures or record videos of residents. R4 stated if a staff member tried to take pictures or record her, she would tell the nurse because it wouldn't be proper for them to do that. On 03/29/21 at 04:55 PM, CNA M stated a long time ago a video was made of her performing pericare on R1 while he sat on the toilet hooked up to the sit-to-stand lift. R1 screamed because his groin was red and sore, and it hurt to spray his groin with the cleaning spray. CNA N worked with CNA M and thought it was funny that R1 screamed. CNA N pulled her cellular telephone out of her pocket and recorded the resident. CNA M did not tell anyone in management about the video. She stated she knew the facility's Abuse, Neglect, and Exploitation policy along with the Cellular Telephone policy and should have reported it at that time. CNA M stated she had not heard about the video again until 03/16/21 when Administrative Staff B questioned her about it. On 03/29/21 at 05:51 PM, CNA N stated sometime in September of 2020 she answered R1's call light, when she entered the room she saw CNA M spraying R1's genitals while he sat on the toilet hooked up to the sit-to-stand lift. CNA N stated she saw CNA O videotaping CNA M spraying R1's genitals on her cellular telephone with a social media filter to distort R1's face. CNA N walked out of the room. CNA M sent the video to CNA N through social media and she saved it in the social media app on her cellular telephone, but did not tell management about the video. CNA N stated a while later she was at CNA Q's house and showed CNA Q the video she had stored on her cellular telephone. On 03/30/21 at 11:47 AM, CNA O stated she did not know the month or the day, but she walked into R1's room and saw CNA M spray R1's genitals multiple times. R1 was up on the sit-to-stand lift and was very mad at CNA O. CNA N was behind the door and the three of them assisted R1 to sit in his recliner. CNA O did not tell anyone about the incident because she did not know if CNA N videotaped the incident. CNA O stated other staff knew about the video before the facility found out on 03/15/21. On 03/30/21 at 02:58 PM, Social Services Staff (SS) X stated a few months ago CNA Q informed her of a video her daughter, CNA M, was in and involved a resident. This video was recorded a few months prior to the conversation between SS X and CNA Q. SS X told CNA Q if she thought the video needed to be reported then CNA Q should report it to management staff. SS X then talked with CNA M and CNA R about the video and told them they needed to get rid of the video. SS X stated she was trained on the facilities Abuse, Neglect, and Exploitation/Social Media/Cellular Telephone policy and she should have reported knowing about the video when CNA Q told her about it. On 03/31/21 at 05:04 PM, CNA Q stated in December of 2020, after R1's death, CNA N came to her house and showed her a video CNA N said she received over social media on her cellular telephone. In the video she saw CNA M spray R1's genitals while R1 was hooked in the sit-to-stand lift. She could hear R1 screaming and say, stop that, stop that, and staff laughed. CNA Q stated she talked to CNA M, CNA N, CNA P, and SS X about the video. CNA Q stated she was trained on the facilities Abuse, Neglect, and Exploitation/Social Media/Cellular Telephone policies. On 03/29/21 at 05:27 PM, Administrative Nurse D stated all staff should treat residents with respect and dignity, and did not expect any of her staff to be involved in this incident. Administrative Nurse D stated staff did not follow multiple facility policies that included the Abuse Neglect and Exploitation policy, the Social Media policy, and the Cellular Telephone policy, to name a few. The facility's revised Abuse Prevention policy, dated 02/02/17, defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. The policy defined mental abuse to include but not limited to humiliation, harassment, and threats of punishment or deprivation. The policy documented residents had the right to be free from abuse. The Administrator would be notified immediately of any suspected abuse between residents, staff-to-resident, or visitor-to-resident. The facility's revised Personal Technology Devices policy, dated 01/28/19, documented the use of personal technology devices could be disrupting to the user and others and appear unprofessional. Employees could use personal devices when prudent for work related activities only, with the express permission of their supervisor and not in view of patients/residents, families, or visitors .All technological devices, for personal reasons, were to be used during breaks and meal periods. The facility's Social Media Usage policy, dated 02/27/18, documented the purpose was to assure there is not misuse of time and inappropriate information in the field of social networking. The policy defined Social Media to include but not limited to on-line collaborative information and publishing systems that are accessible to internal and external audiences, video sharing, and social networks. Employees were prohibited from posting any content that is patient health information including patient images on any Social Media Site. Even if an individual is not identified by the name within the information you wish to use or disclose, if there is a reasonable basis to believe that the person could still be identified from that information, then its use or disclosure could constitute a violation of Health Insurance Portability and Accountability Act (HIPAA). The facility failed to protect R1 from abuse when staff recorded a video and posted the inappropriate video of the resident to a social media site, placing the resident at risk for humiliation and embarrassment. This deficient practice placed R1 in immediate jeopardy. The facility removed the immediate jeopardy on 04/01/21, when they required all long term care staff to have their cellular telephones locked in the medication room while on shift, and educated all staff on the following policies: the Abuse Prevention policy, the Personal Technology Devices policy, the Social Media Usage policy, and the Confidential Information Policy. This deficient practice remained at a scope and severity of a G.

The facility had a census of 31 residents. The sample included 19 residents. Based on observation, record review and interview the facility failed to provide quality care and services for 3 of 19 sampled residents. Staff failed to thoroughly assess/reassess Resident #10, after he/she had a choking episode in the dining room, Resident #34 had low oxygen saturations without a thorough assessment or reassessment, and the facility failed to follow physician's orders [REDACTED].#28 with multiple skin tears. Findings included: - Resident #28's (POS) Physician order [REDACTED]. The admission (MDS) Minimum Data Set assessment, dated 7/4/16, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 2 which indicated severely impaired cognition. The assessment revealed the resident required limited assistance of 1 staff for all activities of daily living except for dressing and personal hygiene which required extensive assistance. The assessment further revealed the resident did not have any skin issues. The 7/14/16 care plan stated the resident had an infected skin tear on his/her shin and directed staff to administer medications and treatments as ordered, assist with frequent position changes, and staff to only provide showers for the resident and no baths. The care plan lacked interventions to prevent skin tears. The 6/28/16 admission skin assessment revealed the resident had a 5 (cm) centimeter x 0.5 cm sutured skin tear on his/her right shin. The skin assessment further revealed the skin around the wound was pink. The 6/28/16 physician's orders [REDACTED]. The resident's skin assessments revealed the following: On 7/1/16, right shin steri-striped On 7/5/16, right shin 5 cm x 0.5 cm pink with slight drainage. On 7/8/16, right shin steri-strip with moderate yellow drainage On 7/19/16, right shin 2 cm x 2.4 cm with yellow drainage (the day after he/she received a whirlpool bath) On 7/22/16, right shin 2 cm x 1.5 cm with yellow drainage On 7/26/16, right shin 1.7 cm x 0.7 cm x 0.4 cm with yellow drainage (the day after he/she received a whirlpool bath) The 7/8/16 physician progress notes [REDACTED]. The note further stated the resident's family member stated the resident had been given 2 baths at the facility and the wound was oozing and gaping. The note stated the steri-strips were still in place on the right shin, 1/3 of the skin tear was open with yellow exudate (a mass of cells and fluid that has seeped out of blood vessels or an organ, especially in inflammation) noted and mid 1/3 of wound had clear serous (thin water fluid) drainage proximal (situated nearer to the point of attachment) end of the wound was closed. Staff cleansed the wound, obtained a culture and covered the wound with a [MEDICATION NAME] (a transparent medical dressing used to cover wounds) foam adhesive dressing. The 7/8/16 physician's orders [REDACTED]. The order further directed staff to not bath the resident until further notice. Review of the (ADL) Activities of Daily living record revealed the resident received a whirlpool bath on July 18,21, 25, and August 1, 4, and 8 although the physician orders [REDACTED]. The 7/14/16 at 8:00 AM, nurse's note stated a skin tear to the resident's left posterior (further back in position) forearm was found during the resident's bath. The resident was unable to tell staff the cause of the skin tear. The note further stated the skin tear measured 2 cm x 0.8 cm, staff cleansed the site with sterile saline and applied triple antibiotic ointment. The 7/15/16 skin assessment stated the resident had a red and open skin tear measuring 3 cm x 2 cm. The 7/15/16 physician's progress note stated to leave the resident shin open to air and the resident had a new skin tear on his/her left forearm. The note further stated the forearm skin was combed back, cleansed and then reapproximated (to bring closer together), steri-stripped and glued into place with dermabond (a topical skin adhesive that is equivalent to sutures). The note stated the resident had persistent [MEDICAL CONDITION] (swelling) in his/her lower extremities. The 7/15/16 at 6:00 PM, nurse's note stated the resident's family member had assisted him/her to the bathroom without a gaitbelt, the resident lost his/her balance and the resident's family member grabbed his/her hand and caused a skin tear. The note further stated the skin tear was on his/her left hand between the thumb and first finger, steri-stripped and a [MEDICATION NAME] (non stick dressing) and kling (used to cover dressings). The 7/15/16 physician's orders [REDACTED]. The 7/19/16 physician progress notes [REDACTED]. The note stated the 3 (cm) laceration was v shaped on the web space dorsum (upper surface) of the left hand and on the right shin and ulcer with [MEDICAL CONDITION] (inflammation of subcutaneous connective tissue) The physician inspected the wound on the shin and noted it was deeper and recommended [MEDICATION NAME] (treatment that aides in debridement and removal of necrotic, dead, tissue) in the wound. The physician cleansed the wound on the resident's left hand, reapproximated the skin, steri-stripped and placed dermabond on the wound. The note stated the resident had bilateral [MEDICAL CONDITION] in his/her lower legs and directed staff to elevate the residents legs as much as possible. The 7/20/16 at 1:32 PM, nurse's note stated the dressing to the resident's shin changed and area noted to be red and warm to the touch with a scant amount of yellow drainage. The 7/22/16 physician's orders [REDACTED]. The 8/10/16 at 10:36 AM, nurse's note stated during the dressing change to the resident's right shin, the resident's family member pulled on the [MEDICATION NAME] to assist in removing the dressing and caused a skin tear on each outer edge of the wounds The skin tears measured 1 cm x 1 cm in size, and staff cleansed the areas with saline and applied steri-strips. The 8/10/16 physician's orders [REDACTED]. On 8/11/16 at 9:02 AM, Licensed Nurse O stated the resident had a skin tear on his/her left shin prior to his/her admission that became infected and the culture grew out pseudomonas aeruginosa (a gram negative bacteria) and staphylococcus (a gram positive bacteria). Licensed Nurse O) further stated the resident should be getting showers instead of baths until further notice. Licensed Nurse O stated the resident has had skin tears since his/her admission and the staff monitor him/her more to try to prevent any more skin tears. On 8/10/16 at 11:19 AM, Nurse Aide C stated the resident was only allowed showers instead of baths due to the wound on his/her leg. On 8/11/16 at 10:24 AM, observation revealed Licensed Nurse O with gloved hands, removed the old Polymem dressing. Further observation revealed 2 steri-stripped areas, approximately the size of a penny on either side of the small dime sized circular wound. Licensed Nurse O cleansed the wound with saline, obtained clean gloves, and placed a small amount of [MEDICATION NAME] in the center of the wound. Licensed Nurse O placed a Polymem dressing over all the wounds and secured it with [MEDICATION NAME] tape. On 8/11/16 at 4:00 PM, Administrative Staff E stated he/she planned to have a conference with the resident's family members regarding safety concerns because of recent skin tears that the resident acquired when with his/her family member. On 8/19/16 at 9:30 AM, Medical Technician R stated the physician would expect the facility to follow his/her written orders to not to give the resident any baths until further notice. The 3/19/07 facility Skin Integrity Policy stated the resident's skin integrity is preserved through adequate nutrition and hydration, daily inspection of the skin, compliance with proper body alignment, positioning, and mobility. The facility failed to implement preventative measures for Resident #28 who received multiple skin tears and failed to follow physician's orders [REDACTED]. - Resident #10's annual (MDS) Minimum Data Set assessment, dated 5/27/16, indicated the resident had a (BIMS) Brief Interview of Mental Status score of 13, which indicated the resident had intact cognition. The MDS revealed the resident independent with bed mobility, transfers, walking in room/hall, eating, toileting, and personal hygiene. The MDS indicated the resident had no natural teeth, no problems chewing or swallowing, and required a mechanical soft, therapeutic diet. The 5/27/16 Nutrition (CAA) Care Area Assessment instructed staff to allow the resident to make his/her food choices, and serve the resident a regular diet with ground meat due to no teeth or dentures. The CAA indicated the resident eats independently, denies chewing/swallowing problems, has good food intake, and no weight concerns. The 6/27/16 care plan indicated the resident has no teeth but able to eat food preferences, has difficulty chewing meat, and swallowing some foods and medications. The care plan instructed staff to serve the resident ground meat and to notify the kitchen/dietary staff if the resident has difficulty chewing or swallowing so they could offer the resident an alternate food. The care plan indicated the speech therapist instructed staff not to give the resident hard or crunchy foods due to his/her chewing and swallowing difficulties. The 6/7/16 nutrition assessment, performed by the (CDM) Certified Dietary Manager, indicated the resident ate independently, had no teeth, no swallowing difficulties, and received a regular diet with ground meat. The 7/20/16 speech therapist progress note indicated the resident had completed pharyngeal (top of the throat that provides a passage for air during breathing) and laryngeal (bottom of the throat and part of the respiratory system that allows air passage) exercises to decrease coughing, choking and swallowing difficulties, and directed staff to provide the resident a regular diet with ground meat. On 8/10/16 at 12:00 PM, observation revealed the resident seated at the dining room table, independently eating lunch. Continued observation revealed the resident stopped eating, turned red, tried to cough but was unable to and continued to turn a darker red. A member of the survey team notified a nurse and (CMA) Certified Medication Aide, who were visiting with other staff in the hall and not able to see the resident. Observation revealed Medication Aide A and Nurse B went to the resident, held the resident's left arm above his/her head and patted his/her back. Further observation revealed the resident was able to expel several pieces of shredded lettuce out of his/her mouth. Further observation revealed Nurse Aide C came up to the resident and asked him/her if he/she was having difficulty chewing, and the resident replied yes. Further observation revealed Nurse B returned to the medication cart, retrieved the resident's medication, and administered them to the resident. Continued observation revealed no nursing assessment of the resident, including lung sounds or oxygen levels following the resident's choking incident. The 08/10/16 physician progress notes [REDACTED]. The progress note indicated the resident continued to have a cough with yellow sputum (mucous secretion from the lungs) and shortness of breath. The progress note further indicated the physician assessed wheezes throughout the resident's lungs and diminished sounds in the bases. On 8/11/16 at 10:27 AM Nurse F stated he/she would assess the resident, after the resident had a significant choking incident to ensure the resident was safe and not having respiratory problems. On 8/11/16 at 10:55AM, Administrative Nurse E stated staff reported the resident's choking episode in the dining room. Administrative Nurse E stated the resident had a history of [REDACTED]. Administrative Nurse E stated he/she was not aware the nurse did not assess the resident after the choking incident. The facility's undated Documentation policy stated a resident may be assessed and documented as often as deemed necessary. The facility failed to assess Resident #10 after he/she had a choking episode, which put the resident at risk for aspiration or further breathing problems. - Resident #34's admission (MDS) Minimum Data Set assessment, dated 5/25/16, indicated the resident had moderately impaired cognition, total dependence with 2 staff assist for bed mobility, transfers, toileting, did not walk and independent with eating. The MDS further indicated the resident had range of motion (ROM) impairment in one lower extremity, used a wheelchair, experienced coughing and swallowing problems while eating, and did not have shortness of breath during the review period. The 6/1/16 Fall (CAA) Care Area Assessment indicated the resident would be care planned to remain free from falls and staff would assist him/her with (ADLs) Activities of Daily Living. The 6/1/16 care plan directed staff to orient the resident during times of confusion and to encourage the resident to use his/her call light for assistance. The 6/2/16 care plan directed staff to administer medications as ordered. The 5/19/16 signed physician's orders [REDACTED]. The 6/11/16 at 3:00 PM, nurse's notes indicated the resident had a fall in his/her room and was lying on his/her left side beside the easy chair. The note further indicated the foot of the easy chair was in the up position and his/her oxygen saturations were 88% on room air. Review of the medical record revealed no documentation related to the resident's low oxygen saturations of 88% room air, including no reassessment or initiation of oxygen or physician notification as directed in the 5/19/16 physician orders. The 6/15/16 at 9:02 AM vital signs record indicated the resident's oxygen saturation was 88% room air. The 6/15/16 at 6:44 PM vital signs record indicated the resident's oxygen saturation was 87% room air. The 6/20/16 at 8:49 PM vital signs record indicated the resident's oxygen saturation was 81% room air. Review of the June 2016 (TAR) Treatment Administration Record lacked evidence staff applied as needed oxygen to the resident for oxygen saturations below 89% room air, or notified the physician as directed in the 5/19/16 physician orders. On 8/18/18 at 12:00 PM, Administrative Nurse E verified he/she would expect nursing staff to follow the physician's standing orders to apply supplemental oxygen and contact the physician for the resident's oxygen saturation below 89% room air. The facility's Vital Signs Protocol and Reporting Abnormal Values, revised 8/17/16, stated it is the responsibility of the licensed nurse to assess abnormal vital signs measurements reported to them by direct care staff. Licensed staff will report abnormal values to the resident's primary providers unless after clinic hours, then will notify the on-call provider. The policy further stated notify the provider immediately if a resident's oxygen saturation is less than 90% room air and initiate standing orders for supplemental oxygen per nasal cannula or mask as needed . The facility failed to follow physician's orders [REDACTED].#34's oxygen saturations below 89% room air, placing him/her at risk for respiratory distress.

The facility had a census of 31 residents. The sample included 19 residents. Based on observation, record review and interview, the facility failed to ensure the resident environment remained as free of accident hazards and provided supervision to prevent accidents for 4 of 5 residents and for failure to store potentially hazardous chemicals in areas accessible to 6 cognitively impaired independently mobile residents. Resident #28, #22, #25 had loose side rails on their beds. Resident #34 sustained a burn from hot coffee and had multiple falls without preventative measures in place and fell and sustained a hip fracture. Findings included: - Resident #34's admission (MDS) Minimum Data Set assessment, dated 5/25/16, indicated the resident had moderately impaired cognition, total dependence with 2 staff assist for bed mobility, transfers, toileting, did not walk and independent with eating. The MDS further indicated the resident had range of motion (ROM) impairment in one lower extremity, used a wheelchair, experienced coughing and swallowing problems while eating, and received a mechanically altered diet. The 6/1/16 Fall (CAA) Care Area Assessment indicated the resident would be care planned to remain free from falls and staff would assist him/her with (ADLs) Activities of Daily Living. The 6/1/16 care plan for falls indicated the resident recently had surgery to repair a left hip fracture. The care plan also indicated the resident sometimes became confused and thought he/she could do things independently. The care plan directed staff to orient the resident during times of confusion and to encourage the resident to use his/her call light for assistance. The care plan did not address any other types of accidents, other than falls. The 6/2/16 care plan update indicated the resident's family member came to meals to assist him/her if needed. The care plan further directed staff to assist the resident as needed with eating if the resident's family member was not available. The resident's 5/19/16 fall risk score was 40, indicating the resident a moderate risk for falling. The 5/19/16 signed physician's orders [REDACTED]. The 6/10/16 physician's orders [REDACTED]. The 5/31/16 at 4:15 AM, nurse's notes indicated staff found the resident sitting on the side of the bed with his/her feet on the floor at 3:00 AM. The note further indicated staff found the resident this way for 3 nights in a row and staff encouraged and reminded the resident to use his/her call light and wait for staff to arrive. The 6/11/16 at 3:00 PM, nurse's notes indicated the resident had a fall in his/her room and staff found the resident lying on his/her left side beside the easy chair. The note further indicated the foot of the easy chair was in the up position. The resident's right forearm had a dark purple bruise that measured 10 (cm) centimeters long by 6 cm wide that was swollen and hard to the touch. The note further indicated the bruise had an open area below the right elbow that measured 1 cm long by 0.1 cm wide and an open area above the right wrist that measured 1 cm long by 1 cm wide, was V shaped and approximately 0.1 cm deep. The staff sent the resident to the emergency room , per his/her family member's request. The emergency room staff dressed the resident's open areas and the resident returned to the facility with no new orders. The 6/11/16 facility's Incident Summary indicated the resident was intermittently confused and his/her family requested the cushion in his/her chair be removed due to causing the resident to sit up too high in the chair. The summary further indicated staff removed the chair cushion and family did not currently want alarms to be placed in the resident's bed or wheelchair. The incident summary stated appropriate actions were taken by nursing staff and lacked information regarding the foot of the easy chair being in the up position. Review of the medical record lacked a nursing assessment for safe use of a recliner or easy chair. The 6/14/16 at 6:55 PM, nurse's notes indicated the resident was walking with 2 staff assistance and stated he/she felt like his/her knees were going to give out. The note further indicated staff lowered the resident to the floor to prevent injury. The 6/14/16 facility's Incident Summary indicated staff performed appropriately by using gait belt and assist for ambulation, avoiding injury to the resident. The summary further indicated no further actions were needed. Review of the medical record revealed no root cause analysis regarding the resident's falls. The 6/23/16 at 7:00 AM, nurse's notes indicated the resident sat at a table in the lobby area when a housekeeping employee, sweeping around and underneath the table, bumped the table where the resident sat. The note further indicated a cup of hot coffee, sitting on the table, spilled over and onto the resident's right thigh. Upon initial assessment of the burned area, a raised, warm, reddened area measured 20.5 (cm) centimeters length by 8.5 cm width. Nursing staff applied a cool washcloth to the area for 15 minutes. The note further indicated the physician assessed the resident the same day and directed staff to apply Silvadene Cream (a topical antibacterial cream used for burns) daily to the right thigh until the burn healed. The nurse's note lacked information if the resident's coffee was a nectar thick consistency as ordered by the physician on 5/19/16 or a thin consistency based on the 6/10/16 physician's orders [REDACTED]. The facility's Incident Summary from the resident's burn that occurred on 6/23/16 at 7:00 AM, indicated by 11:00 AM the burned area had developed into a large blister. The Incident Summary further indicated housekeeping staff had reported the tables in the lobby were wobbly and placed a work order to tighten the tables. The investigation findings by the facility stated the positioning of tables on the floor may cause the tables to seem more unsteady at times due to the floor being uneven and the housekeeping supervisor would continue to stress to staff the importance of safety while completing cleaning duties. The incident summary lacked information if the resident's coffee was thickened to a nectar thick consistency or if nursing staff were in the area to assist the resident as needed as directed by the plan of care. The 6/24/16 at 2:06 PM, nurse's note indicated the resident received a bath in the morning and one of the blisters to his/her right inner thigh was no longer fluid filled. The nurse's note further indicated the resident's burn site did not have signs or symptoms of infection and staff covered the burn site with Silvadene cream and a dressing. The 6/24/16 at 8:05 PM, nurse's notes indicated the resident's family member witnessed a fall at 4:05 PM. The note further indicated staff found the resident lying on his/her right side on the floor. The resident's call light was on and the sensor pad (chair alarm) was sounding. The resident reported he/she tried to stand up and fell down, and hit his/her head. The note indicated the resident had an open area to his/her right forearm that measured 7 cm long by 4 cm wide, V shaped. The resident had an open area to his/her right hand that measured 2 cm long by 2 cm wide, an open area near the right elbow that measured 2 cm long by 0.8 cm wide, a purple and dark pink area of bruising to the right upper arm measured 8 cm long by 5 cm wide, a purple and dark pink area of bruising to the right shoulder that measured 4 cm long by 5 cm wide and a 7 cm long by 9 cm wide hematoma (localized swelling, filled with blood) to his/her right side of head. The 6/24/16 at 8:32 PM, nurse's note indicated at 5:35 PM the resident complained of pain all over and became drowsy. The note further indicated staff notified the on-call physician of the fall and injuries at that time. Nursing staff did not receive any new orders from the physician regarding the fall. The 6/25/16 at 12:24 AM, nurse's note indicated on 6/24/16 at 6:15 PM the resident's family member requested nursing staff assess the resident due to the resident being very sleepy. The note further indicated the resident was lethargic (sluggish, little energy), but answered questions appropriately. The resident's oxygen saturation was 82-84% on room air, staff applied oxygen at 2 liters via nasal cannula and the resident's oxygen saturations rose to 94-96% with oxygen on. The note continues that during neurological checks, the resident's left pupil was misshapen, but the nurse was told the misshapen pupil was normal for the resident. The note did not indicate who told the nurse the resident's left pupil was normally misshapen and did not indicate the nursing staff notified the physician regarding the resident's lethargy, low oxygen saturations, application of oxygen, or his/her misshapen left pupil. The 6/25/16 at 2:16 AM, nurse's note indicated the resident hollered out and verbalized pain to his/her right hip when turned onto his/her right hip (more than 6 hours after the fall). The 6/25/16 at 6:36 AM, nurse's note indicated the nurse had a difficult time getting the resident to squeeze his/her right hand and staff placed a second call to the on-call physician (more than 10 hours after the resident's fall). The physician did not answer the phone or return the call. The 6/25/16 at 11:22 AM, nurse's note indicated the resident had seizure-like activity with shaking of his/her body and rolling of the eyes. The note further indicated staff transferred the resident to the emergency room at 10:30 AM for evaluation (more than 13 hours after the resident's fall and more than 9 hours after the resident verbalized pain in his/her right hip). The 6/25/16 emergency room report indicated the hospital admitted the resident for acute hyperkalemia (potassium levels in the blood that are higher than normal), psuedo seizure (a series of movements and behaviors that resemble a seizure, but are not caused by abnormal brain activity), and moderate dehydration. The report further indicated the resident displayed pain with movement, grabbed his/her right hip during repositioning and exhibited moderate distress. The resident had a hematoma to the right parietal area (mid-section of the skull). The resident had multiple abrasions and skin tears to upper extremities, and a blister to the right thigh from a previous coffee burn. The resident's right arm and hand was flaccid (hanging loosely or limply) and he/she was unable to grip with the right hand. The radiology report revealed a fracture of the right femur (break of the thigh bone). The facility's Incident Summary for the resident's fall on 6/24/16 at 4:05 PM indicated the resident fractured his/her right hip, transferred out of the facility and then discharged . On 8/18/16 at 12:05 PM, temperature of coffee dispensed from the facility's coffee machine read 164 degrees (F) Fahrenheit. On 8/10/16 at 5:16 PM, (CNA) Certified Nurse Aide D stated a staff member filled the resident's coffee cup up and the housekeeping staff bumped the table which caused the coffee to spill on the resident's leg. The written statement by Housekeeping Staff K, dated 6/23/16, untimed, stated he/she spoke to the housekeeping staff member present at the time of the burn incident and provided verbal education regarding making sure the staff member was not mopping around tables when residents were near the tables, so that another accident did not occur again. The statement further indicated staff placed a maintenance work order for maintenance staff to check the table to ensure that it was not wobbly. On 8/16/16 at 10:25 AM, Housekeeping Staff K stated he/she provided verbal education to the staff member involved in the burn incident. He/she further stated that all other housekeeping staff were verbally educated at a later date, but there was not any documentation to reflect the education. Housekeeping Staff K stated after the burn incident occurred, he/she had inspected the table in the lobby area and the table was found to be sturdy and he/she felt the problem with the table being wobbly was a matter of the floor being uneven. On 8/11/16 at 1:12 PM, Administrative Nurse E stated the housekeeping supervisor spoke with the employee about being safe around the residents. On 8/16/16 at 8:50 AM, Administrative Nurse E stated nursing staff received education not to fill cups with hot liquids more than halfway full and maintenance staff had planned on marking the floors in the lobby area where the tables should be placed, so the tables are secure and not wobbly. Administrative Nurse E verified that at the time of the interview, maintenance had not placed marks on the lobby floor where the tables should be placed. On 8/16/16 at 2:35 PM, Administrative Nurse E verified the resident's coffee, at the time of the burn incident, was not thickened to nectar thick, per the 5/19/16 physician's orders [REDACTED]. On 8/18/16 at 9:17 AM, Administrative Nurse E stated his/her expectation would be for nursing staff to have re-notified the physician when the resident had complaints of right hip pain on 6/25/16 at 2:16 AM. He/she further stated when staff called the on-call physician regarding abnormal neurological responses at 6:36 AM, the physician did not return the call to the facility. Administrative Nurse E stated his/her expectation would be for the nursing staff to physically take the resident to the emergency room , due to a change in condition, if the physician had not returned the call. The facility's Safety Regulations policy, dated 3/19/07, stated defective equipment should be immediately removed from the area with replacement of necessary equipment provided within a reasonable time limit and all safety issues or concerns must be reported to the immediate supervisor. The facility failed to ensure the resident's environment remained as free from accident hazards as possible, resulting in a burn with blisters to Resident #34's right thigh. The facility also failed to perform root cause analysis for falls, and failed to implement effective fall interventions after the resident experienced multiple falls. The resident fell and sustained a right hip fracture approximately 5 weeks after admission to the facility after a fall resulting in a fracture of the left hip. - Resident #22's quarterly (MDS) Minimum Data Set assessment, dated 6/12/16, indicated the resident had severely impaired cognition and required limited assistance of 1 staff for bed mobility, transfers, walking, and personal hygiene. The MDS further indicated the resident required extensive assistance of 1 staff for dressing, toileting, bathing, and no falls since the previous MDS assessment. The 12/22/15 (ADL) Activities of Daily Living (CAA) Care Area Assessment indicated the resident required minimal assistance from staff for ADLs, except for extensive assistance from staff for dressing, toileting, and bathing. The CAA further indicated the resident used a walker with ambulation and had fallen once since admission to the facility. The 6/18/15 (most current date) care plan indicated the resident required stand by assistance from staff for transfers and ambulation. The care plan lacked information regarding side rails. Review of the resident's medical record lacked a side rail assessment. On 8/9/16 at 9:58 AM, observation revealed the resident's bed had a 1/2 side rail attached to both sides of the bed, with one side rail in the raised position and the other side rail in a half raised position (positioned so the resident could use the half raised position to use as a grab bar to aide in transfers). Further observation revealed the side rails loose, with 4-5 inches of give. On 8/11/16 at 7:02 AM, observation revealed the resident, independently sitting up in bed, transferred out of bed with stand by assistance of 1 staff. Further observation revealed the siderails not loose, with the siderails attached firmly to the bedframe at the time of observation. On 8/10/16 at 5:16 PM, (CNA) Certified Nurse Aide D stated the resident required assistance of 1 with transfers and ambulation. CNA D further stated the resident always rings his/her call light for assistance. On 8/11/16 at 12:54 PM, Licensed Nurse I stated he/she didn't know about a side rail assessment. On 8/11/16 at 1:58 PM, Maintenance Staff J stated the maintenance staff performed monthly checks and logs of the siderails in the facility. He/she further stated the monthly checks have become more general over the past few years and the facility planned on making the logs more specific to catch problems with side rails. Maintenance Staff J stated he/she has checked all the beds in the facility to see if the side rails were attached firmly to the bed frame and all loose side rails have been fixed by replacing the existing handle that attached the frame to the bed, with a self-locking nut and lock screw that can only loosen with the use of a wrench. On 8/10/16 at 8:06 AM, Administrative Nurse E stated there was not a routine safety check on side rails that he/she was aware of. On 8/11/16 at 1:12 PM, Administrative Nurse E verified the facility did not perform side rail assessments for residents who utilized side rails while in bed. He/she verified the staff fixed the loose side rail and safely attached it to the bed frame after the state surveyor had brought the loose side rails to the facility's attention. The facility's 3/17/07 Beds and Siderails Policy stated beds, bedframes, siderails, and mattresses are routinely inspected by the maintenance department for possible areas of entrapment and there will be no gaps wide enough to entrap a resident's head or body between the mattress, bedframe, and/or siderail. The policy further stated staff would be oriented to, educated about, and trained in the use of siderails and the dangers of entrapment. The facility's 3/19/07 Fall Prevention Policy stated new residents will have a fall assessment and side rail assessment completed immediately upon arrival, by the admitting nurse and whenever warranted. The facility failed to ensure the siderails of Resident #22's bed were firmly attached to the bed frame, without gaps between the mattress and the siderail, and to assess his/her safety with using siderails. The facility's failure to assess for safe use of siderails places Resident #22 at risk for entrapment and at an increased risk for falls. - Resident #25's admission (MDS) Minimum Data Set assessment, dated 5/23/16, indicated the resident had severely impaired cognition and required extensive assistance of 2 staff for bed mobility, transfers, locomotion, dressing, toileting, bathing and personal hygiene. The MDS further indicated the resident did not walk, had an unknown fall history and no falls since admission to the facility. The 5/30/16 falls (CAA) Care Area Assessment indicated the resident had a fall risk score of 55, indicating a high risk for falls and required 2 staff assistance for all (ADL) activities of daily living. The CAA further indicated the resident used a mechanical lift for transfers and did not walk. The 6/2/16 fall and ADL care plan indicated the resident dependent on staff for all ADLs and directed staff to check on him/her frequently, assist with position changes in his/her wheelchair and bed, and to assist with all transfers and toileting. The care plan lacked information regarding the resident's use of side rails. Review of the resident's medical record lacked a side rail assessment. On 8/9/16 at 9:05 AM, observation revealed the resident's bed had 1/2 siderails in the up position on both sides of the bed. Further observation revealed both side rails were loose, with 4-6 inches of give (enough room for a limb to become entrapped between the mattress and the side rail). On 8/10/16 at 7:48 AM, observation revealed the resident, lying in bed, on his/her back with the lights in the room turned off. Further observation revealed both 1/2 side rails were in the up position. On 8/11/16 at 8:44 AM, observation revealed both 1/2 side rails of the resident's bed were firmly secured to the bedframe, with no gaps between the mattress and the side rail. On 8/11/16 at 12:54 PM, Licensed Nurse I stated he/she didn't know about a side rail assessment. On 8/11/16 at 1:58 PM, Maintenance Staff J stated the maintenance staff performed monthly checks and logs of the siderails in the facility. He/she further stated the monthly checks have become more general over the past few years and the facility planned on making the logs more specific to catch problems with side rails. Maintenance Staff J stated he/she has checked all the beds in the facility to see if the side rails were attached firmly to the bed frame and all loose side rails have been fixed by replacing the existing handle that attached the frame to the bed, with a self-locking nut and lock screw that can only loosen with the use of a wrench. On 8/10/16 at 8:06 AM, Administrative Nurse E stated there was not a routine safety check on side rails that he/she was aware of. On 8/11/16 at 1:12 PM, Administrative Nurse E verified the facility did not perform side rail assessments for residents who utilized side rails while in bed. He/she verified the staff fixed the loose side rail and safely attached it to the bed frame after the state surveyor had brought the loose side rails to the facility's attention. The facility's 3/17/07 Beds and Siderails Policy stated beds, bedframes, siderails, and mattresses are routinely inspected by the maintenance department for possible areas of entrapment and there will be no gaps wide enough to entrap a resident's head or body between the mattress, bedframe, and/or siderail. The policy further stated staff would be oriented to, educated about, and trained in the use of siderails and the dangers of entrapment. The facility's 3/19/07 Fall Prevention Policy stated new residents will have a fall assessment and side rail assessment completed immediately upon arrival, by the admitting nurse and whenever warranted. The facility failed to ensure Resident #25's siderails were firmly attached to the bed frame, without gaps between the mattress and the siderail, and to assess his/her safety with using siderails. The facility's failure to assess for safe use of siderails placed Resident #25 at risk for entrapment and at an increased risk for falls. - Resident #28's (POS) Physician order [REDACTED]., and chronic obstructive pulmonary disease (lung disease characterized by chronic obstruction of air flow that interferes with normal breathing) The admission (MDS) Minimum Data Set assessment, dated 7/4/16, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 2 which indicated severely impaired cognition. The assessment revealed the resident required limited assistance of 1 staff for all activities of daily living except for dressing and personal hygiene which required extensive assistance. The 7/14/16 care plan lacked any indication the resident had side rails. On 8/9/16 at 1:39 PM, observation revealed the 1/2 bed rail on the resident's bed loose and wobbly with a 4-5 inch gap between the rail and the mattress. On 8/10/16 at 11:19 AM, Nurse Aide C stated the resident used the side rails for position change when in bed. On 8/11/16 at 11:00 AM, observation revealed the 1/2 bed rail on the bed secured without wobbling. On 8/11/16 at 1:58 PM, Maintenance Staff J stated monthly checks are done on the side rails but he/she does not write down individual rooms that were checked. Maintenance Staff J further stated the loose rails have been fixed and a better checking system will be put into place. On 8/11/16 at 4:00 PM, Administrative Staff E stated the facility does not do any type of side rail assessments and do not check to see if the side rails are loose on the bed, maintenance staff do the rail checks and side rails are to be placed on the resident's care plan. The facility's Safety Regulations policy, dated 3/19/07, stated defective equipment should be immediately removed from the area with replacement of necessary equipment provided within a reasonable time limit and all safety issues or concerns must be reported to the immediate supervisor. The facility failed to ensure that the resident environment remains as free of accident hazards as is possible for Resident #28 who had a loose side rail placing him/her at risk for entrapment. - On 8/8/16 at 1:30 PM, observation during the initial tour revealed an open bathroom door in the commons area. Further observation revealed a yellow housekeeping mop bucket filled with water and disinfectant. On 8/8/16 at 1:35 PM, Licensed Nurse P verified the mop bucket had disinfectant and stated it should not be left in the bathroom. On 8/11/16 at 8:29 AM, observation revealed the whirlpool room door propped open. Further observation revealed a sign on the door stating Door must be closed at all times. Continued observation revealed a cabinet door in the room open. The following items were observed: 1 canister of Cavi wipes, with the warning label Avoid contact with eyes and Keep out of reach of children. 1 canister of Sani cloth bleach SE, with the warning label Keep out of reach of children. 2-1 Liter jugs of Cen Care shampoo, with the warning label May cause gastrointestinal irritation and Keep out of reach of children. 2-1 Liter jugs of Bath oil, with the warning label May cause allergic skin reaction and Keep out of reach of children. 2-15 (oz) ounce canister of Sunburst Aerosol Spray, with the warning label May cause skin irritation and Keep out of reach of children. 1-16 oz of Raze Crawling and Flying Insect Killer, with the warning label May cause allergic skin reaction and keep out of reach of children. 2-1 Liter jugs of Bath and Body Wash, with the warning label May cause gastrointestinal irritation and Keep out of reach of children. 4-19 oz Lysol Spray canisters, with the warning label Keep out of reach of children. 1 Liter of Cen Kleen Disinfectant, with the warning label of Can cause severe eye and skin irritation and keep out of reach of children. 1-32 oz unlabeled bottle with yellow liquid which Nurse Aide Q stated was Cen Kleen Disinfectant. On 8/11/16 at 8:52 AM, observation revealed an open bathroom door in the commons area. Further observation revealed a yellow housekeeping mop bucket filled with water and disinfectant. On 8/11/16 at 8:55 AM, Administrative Nurse E verified the whirlpool door and cabinet door open and stated the whirlpool door should not be left open and unattended. Administrative Nurse E further verified the mop bucket should not be left in the commons bathroom. The 3/19/07 facility Safety Regulations Policy stated hazardous substances are not to be left unattended at any time or stored in areas accessible to residents. The facility failed to provide a safe environment for the 6 cognitively impaired independently mobile residents, who reside in the facility, placing them at risk for injury.

The facility census totaled 29 residents with 12 residents included in the sample and 3 reviewed for nutrition. Based on observation,interview, and record review the facility failed to ensure 1 of 3 residents sampled for nutrition maintained acceptable parameters of nutritional status when resident #3 experienced a severe weight loss of 5.26% of body weight in one month and 12.2% of body of weight in 6 months. (#3) Findings included: - Review of resident #3's 4/8/14 electronic medical record included [DIAGNOSES REDACTED]. A 10/1/13 physician order [REDACTED].#3 returned to the facility after a hospital admission for [MEDICAL CONDITION] (an inflammation of the mucous membranes of the bronchi in the lungs) with orders for 4 oz (ounces) of supplement between meals, 1 scoop of protein powder with meals, and [MEDICATION NAME] (protein supplement) twice daily for wound healing. The orders also included [MEDICATION NAME] 20 mg (milligrams) twice daily and [MEDICATION NAME] 1 mg daily, both diuretics ordered for [MEDICAL CONDITION]. Resident #3's 11/2/13 Quarterly MDS (minimum data set) assessment revealed the resident had a BIMS (brief interview for mental status) score of 7 which indicated severe cognitive impairment and required supervision and set up help with eating. The MDS also revealed he/she weighed 112 pounds and had weight loss of 5% or more in one month or 10% in last 6 months with no physician prescribed weight loss regimen. Review of resident #3's Quarterly MDS dated [DATE] revealed a BIMS score of 6 which indicated severe cognitive impairment. The MDS revealed the resident exhibited hallucinations with behaviors and required supervision and set up help only for eating. The resident's height was 63 inches and weighed 117 pounds with no weight loss since the previous assessment. Review of resident #3's 5/3/13 ADL (activities of daily living) CAA (care area assessment)revealed the resident fed him/herself pretty well, but still required occasional cueing to stay on task. The nutritional CAA revealed the resident's average meal consumption was 26% with snack intake average of 81%. He/she received a regular diet with protein powder added to her/his hot chocolate which he/she drinks at all meals. He/she also received 2 Cal (nutritional supplement) 60 ml (milliliters) three times a day and 4 oz of supplement between meals due to a history of weight loss and poor meal intake. Review of resident #3's 11/7/13 nutrition nursing care plan revealed the resident had a history of [REDACTED]. The care plan directed staff that the resident required encouragement at meals and stated, "I usually don't eat much. Sometimes I sleep at the table and have to be roused frequently. Assist when needed." According to the care plan, the kitchen served the resident a regular diet with hot chocolate fortified with protein powder at all meals. The resident will sometimes drink 2 cups with each meal. The resident also received 4 ounces of supplement (ensure) between meals and added 2 ounces of 2 Cal with hot chocolate for between meal snacks. On 1/15/14, staff revised the care plan and discontinued the 2 Cal supplement. The resident continued to receive the 4 ounce supplement between meals. On 1/28/14 a care plan revision indicated discontinuation of the [MEDICATION NAME]. physician's orders [REDACTED]. * 11/22/13 4 ounces of 2 Cal with meals and between meals for weight loss. * 1/15/14 Discontinue 2 Cal and monitor intakes. * 2/19/14 Add 1 scoop protein powder to hot chocolate with every meal. * 4/7/14 May have 4 ounces of supplement between meals. Review of the weight record for resident #3 revealed the following: * 10/2/13 123 pounds * 11/1/13 112 pounds (Started 2 Cal supplement and 4 ounces of ensure between meals on 11/7/13) * 12/6/13 114 pounds * 1/10/14 115 pounds * 2/7/14 115 pounds (2 Cal supplement discontinued on 1/15/14 due to the resident gagging, The resident remained on the ensure between meals) * 3/4/14 114 pounds * 3/7/14 112 pounds * 3/13/14 109 pounds * 3/21/14 107 pounds * 3/28/14 107 pounds (6.14% loss of body weight from 3/4/14 - 3/28/14 a period of 24 days) * 4/4/14 108 pounds (5.26% loss of body weight from 3/4/14 to 4/4/14 in 1 month and 12.2% loss of body weight from 10/2/13 to 4/4/14 in 6 months) An 11/22/13 Nutritional Assessment completed by the dietary consultant G identified a nutritional goal for resident #3 to increase his/her weight by 3 pounds in 90 days, meal intake of greater than 20%, and no signs of dehydration. The assessment also included estimated calorie needs of 1325 calories/day and 53 grams of protein/ day. Review of the Registered Dietician progress notes on 2/28/14 stated the resident's weight was stable for 30 days and 180 days. The BUN (blood urea nitrogen, lab test for kidney function) was up to 42 mg/dl (milligrams per deciliter, normal 10-20 mg/dl) with creatinine of 2.2 mg/dl (normal for woman 0.5 - 1.1 mg/dl, lab test for kidney function). The dietician noted that with these lab increases it may alter the resident's appetite. The dietician recommended the use 4 oz nutritional supplements between meals with 2 Cal discontinued. Review of the record revealed the resident received 4 ounces of supplement between meals since re-admission to the facility on [DATE]. A physician's orders [REDACTED].#3's diet order changed to receive 4 oz of supplements between meals three times a day either ensure or mighty shake, which ever the resident chooses. According to the clinical record, the resident received the ensure three times a day between meals since re-admission to the facility on [DATE] and after discontinuation of the 2 Cal on 1/15/14. Review of resident #3's ADL/nursing care sheet completed by the CNAs (certified nurse's aides) for March revealed the resident had supplements ordered for between meals (morning, afternoon, and at bedtime). The resident refused the bedtime supplement 19 out of 31 days and took less than 50 ml (milliliters) or less of the supplement on 12 of 31 days of March of 2014. The record also revealed no documentation of supplement intake for the morning supplement for 29 of 31 days and no documentation of the afternoon supplement for 13 of 31 days of March. In April 2014, the resident took 50 - 100 ml of the morning supplement with no documentation for 1 day from 4/1/14-4/10/14. The resident took 50-100 ml of the afternoon supplement with no documentation on 2 days from 4/1/14 - 4/10/14. The record also revealed the resident 50 ml or less on 4 days for bedtime supplements with no documentation on 5 days from 4/1/14-4/10/14. Review of the resident's MAR (medication administration records) from November 2013 through 4/10/14 revealed the resident received [MEDICATION NAME] 20 mg twice daily and [MEDICATION NAME] 1 mg daily without any changes in dosage. On 4/8/14 at 11:29 a.m., an observation of resident #3 revealed he/she sat in the dining room at the table drinking a cup of hot chocolate. The dietary staff served 6 ounce of hot chocolate, a 6 ounce glass of water, small tossed salad, small bowl of pudding, one serving of scalloped potatoes, two small Salisbury steak patties, and one small piece of white cake. The resident ate one bite of cake, one steak patty, and approximately 1/4 helping of the scalloped potatoes and tossed salad. The resident finished the hot chocolate but did not drink any water. The resident fell asleep at the table and staff awakened and cued the resident several times throughout the meal. The resident consumed approximately 25% of the meal. During an observation on 4/9/14 at 7:20 a.m., the resident sat in the dining room at the table where staff served one cup of hot chocolate, one 6 ounce glass of water and milk, and one bowl of oatmeal. The resident consumed 100% of the hot chocolate, 50% of milk, 25% of water, and 75% of the oatmeal. During an observation 4/10/14 at 2:00 p.m., resident #3 sat in the lobby eating a Nutrigrain bar and drinking a Pepsi with staff supervision. The resident had the ability to hold the bar and eat it independently. During an interview on 4/10/14 at 9:46 a.m., direct are staff M stated that staff offered morning, afternoon and evening snacks and ensure to resident #3. If the resident refused the ensure, they will offer peanut butter crackers or other choices. He/she further stated they logged the snacks and supplements in the ADL book, and the dietician reviewed the book and would advise staff if there was a problem. During an interview on 4/9/14 at 4:14 p.m., licensed staff N stated the bath aides take the residents' weights. If the nurses notice a three pound loss or gain they will note it and send the notice on to the dietary manager and also to the physician. During an interview on 4/10/14 at 12:50 p.m., dietary staff H stated that he/she tracked the weights monthly for gain or loss. Dietary staff H confirmed that on 11/7/13 resident #3 had a significant weight loss of 5% and the physician ordered 2 Cal supplement to be added to the resident's hot chocolate. Staff H stated the 2 Cal supplement caused the resident to gag, so the physician ordered to discontinue the 2 Cal on 1/15/14. Dietary staff H also confirmed the dietician recommended continuation of a 4 ounce supplement between meals after discontinuation of the 2 Cal. He/she stated that nursing staff would notify the physician of any dietician recommendations. During an interview on 4/10/14 at 1:33 p.m., consultant staff G stated that dietary recommendations go directly to the DON (director of nursing), then the nurses will fax the recommendations on to the physician. The nurses should watch and make sure these orders come back and that they are implemented. During an interview on 4/10/14 at 1:45 p.m., physician assistant I stated the nurses will fax over the dietary recommendations or weight variances to the physician or provider. According to physician assistant I, no one from long term care called him/her and advised them of any dietician recommendations or variations in weight. Physician assistant I reviewed his/her documentation and could not find any information regarding dietary recommendations or weight variances for resident #3. During an interview on 4/14/14 at 10:08 a.m., administrative nurse A confirmed resident #3 should receive supplements at 10:00 a.m., around 2:30 p.m., and at bedtime. Nurse A further stated that documentation of resident #3's supplements during March of 2014 was inconsistent. Nurse A confirmed that at this time, no one monitored the ADL sheets to ensure that residents received their supplements or refused them. Nurse A also confirmed that staff weighed resident #3 weekly and was unaware of his/her weight loss during the month of March, after discontinuation of the 2 Cal supplement. An interview on 4/14/14 at 10:25 a.m. with dietary staff H revealed that he/she reviewed the ADL sheets quarterly with the resident's care plan meeting and was not aware that resident #3 refused supplements or that staff failed to document supplements given. Staff H further stated that he/she was not aware of the resident's weight loss in March as he/she only reviewed the resident's monthly weights. The facility's 3/5/14 revised Weight Change policy stated, "The certified dietary manager, under the supervision of the consulting RD (registered dietician) is notified by nursing of a resident/patient that has a potential for significant weight change, or has reached a significant change. Significant change is 5% in one month, 7.5% in three months, or 10% in six months." The facility failed to ensure resident #3 received nutritional supplements (ensure) between meals, failed to adequately monitor for supplement intake, failed to initiate new interventions to prevent weight loss, and failed to monitor for weight variances. Resident #3 experienced a severe weight loss of 5.26% of body weight from 3/4/14 to 4/4/14 in 1 month and 12.2% of body weight from 10/2/13 to 4/4/14 in 6 months).

The facility had a census of 29 residents. The facility identified 5 residents as cognitively impaired and independently mobile. Of those residents, the facility identified two residents currently at risk for elopement. The sampled included both residents at risk for elopement as well as one other resident. Based on observation, interview and record review, the facility failed to ensure one of two residents at risk for elopement received adequate supervision and assistive devices to prevent accidents (elopement). Facility failure to place a Wanderguard alarm on resident #1 after staff identified the resident as an elopement risk and failure to implement appropriate elopement prevention strategies placed resident #1 in immediate jeopardy of harm. Findings included: - Resident #1's clinical record included a face sheet which noted admission to the facility at 4:45 p.m. on 3/5/12 with [DIAGNOSES REDACTED]. A 3/18/12 Admission MDS (Minimum Data Set) completed 13 days after admission identified resident #1 with disorganized thinking, an acute change in mental status, delusions, behaviors which placed the resident at risk for physical illness/injury, wandering behaviors which placed the resident at significant risk of getting to a potentially dangerous place, worsened behavioral status, independence in mobility and transfers, use of a walker, and use of antipsychotic and anticoagulant medications. CAAS (Care Area Assessment Summaries) completed on 3/19/12 included a CAA for "Cognitive Loss/Dementia". According to that CAA, resident #1 had a recent admission to an area geropsychiatric center with, "worsening of Alzheimer's and increased cognitive loss with acute delirium and psychosis with paranoia, auditory and visual hallucinations and delusions..." The CAA also described an incident that occurred on 3/7/12, two days after admission, when resident #1 left the facility without staff knowledge and, "was found approximately 2 blocks from the facility." According to the CAA, staff placed a Wanderguard bracelet on resident #1 after the elopement. An elopement assessment completed on 3/8/12, the day after resident #1's elopement, included, "Is now voicing (he/she) will leave again..... has searching behaviors that might be indicative of wandering risk, increased confusion/anxiety/disorientation over the past 30 days, at risk for elopement, wears ankle bracelet, all staff are aware of potential for elopement." The Admission care plan completed on 3/5/12, the date of admission, for resident #1 did not mention the resident's wandering behaviors or interventions to prevent elopement. After the elopement from the facility on 3/7/12, staff made a notation on the care plan advising staff of the resident's elopement risk and use of a Wanderguard alarm. The 3/22/12 care plan identified resident #1 as an elopement risk. According to that care plan, resident #1 experienced confusion and "wants to go home" and "will look for any opportunity to get outside." Elopement prevention strategies identified on the care plan include use of a Wanderguard alarm, visual checks every 30 minutes, monitoring for behaviors, and methods to redirect the resident when he/she becomes anxious and expresses a desire to leave the facility. Nurses Notes included the following entries: o 3/5/12 admission note at 4:45 p.m.: "Pleasantly confused [AGE] year old white (male/female) arrives from (name of hospital) via private vehicle with son and (spouse).....resident states is only here to get hair done. Son requests we play along for awhile until (resident) is more comfortable with surroundings." o 3/8/12 note written at 4:03 a.m.: "At 1950 (7:50 p.m.) res. was found by front door to LTC (long term care). This nurse went and assisted resident back to lobby. This nurse assisted resident to room to help get ready for bed. Res. stated I need to call my dad and tell him where I am. This nurse then asked the resident to get ready for bed and then we could take care of that........AT 1957 (7:57 p.m.) res. was seen by this nurse in the LTC lobby talking with another resident that was sitting in the lobby......." This nurses note goes on to describe staff inability to locate resident #1 in either the LTCU (long term care unit) or the attached hospital at approximately 8:00 p.m. Staff then notified appropriate administrative staff and initiated a search of the facility grounds. According to the note, staff located resident #1 at approximately 8:25 p.m., walking with an off duty police officer approximately 1/2 block from the facility. Staff returned the resident to the facility and assessment revealed no injury to the resident. Upon return to the facility, resident #1 told staff he/she had been at a brother's house and "got lost in the woods". According to Wunderground.com (Weatherunderground), temperatures in the area on 3/7/12 ranged from a low of 24 degrees Fahrenheit to a high of 52 degrees Fahrenheit. Hourly temperatures were not available. During an interview on 4/12/12 at 3:00 p.m., Administrative Nurse A confirmed resident #1 left the faciity on [DATE] at approximately 8 p.m. without staff knowledge. According to Nurse A, facility surveillance tapes showed the resident exited the building via the unalarmed/unlocked exit door at the end of the Assisted Living hallway. After leaving the building, the resident went down the stairs to ground level, walked along the back side of the building, through a hedge row of tall pine/evergreen trees, crossed a residential street and then walked in the adjacent neighborhood until the off duty police officer found him/her. Nurse A also reported it was dark and cool outside at 8 p.m. on 3/7/12. During an interview on 4/12/12 at 3:15 p.m., Administrative Nurse A reported he/she identified resident #1 as an elopement risk at the time of admission due to the resident's confusion and ability to ambulate without staff assistance. According to Nurse A, he/she advised Licensed Nurse D, the charge nurse at the time of admission, to place a Wanderguard bracelet on resident #1. Nurse A also reported he/she reminded Nurse D again to place the Wanderguard and Nurse D confirmed he/she planned to do it. Nurse A confirmed he/she failed to follow up with Nurse D to ensure placement of the Wanderguard. During an interview on 4/13/12 at 11:55 a.m., Social Services Staff B reported he/she advised Administrative Nurse A of resident #1's need for a Wanderguard bracelet after completing the preadmission assessment. According to Social Services Staff B, the family of resident #1 reported increased confusion and wandering prior to admission. Even though the family denied the resident wandering outside, Staff B determined resident #1 had an elopement risk and therefore recommended placement of the Wanderguard. Social Services Staff B reported staff did not place the Wanderguard bracelet at the time of admission. According to Staff B, staff placed the Wanderguard after the 3/7/12 elopement. During an interview on 4//12/12 at 7:15 p.m., Licensed Nurse C confirmed he/she was on duty the evening of 3/7/12 when resident #1 left the facility without staff knowledge. According to Nurse C's account, resident #1 expressed a desire to leave prior to the elopement and staff redirected him/her. Within a half hour of redirection, staff could not locate resident #1 and them implemented a search of the facility as well as the adjacent neighborhood. Staff eventually found resident #1 walking with an off duty police officer approximately 1 1/2 blocks away from the facility. Nurse C confirmed the weather was cool at the time and it was dark outside. Nurse C also confirmed resident #1 did not have a Wanderguard bracelet in place prior to the elopement. According to Nurse C, resident #1 has the ability to ambulate independently and should use a walker due to his/her fall risk. During an interview on 4/12/12 at 7:25 p.m., Direct Care Staff F reported he/she worked the evening of 3/7/12 when resident #1 left the facility without staff knowledge. According to Staff F, the resident, "was very agitated" and wanted to leave the facility between the hours of 6 p.m. - 8 p.m. that evening. Staff redirected him/her and then went about their duties of providing care to other residents. At approximately 8 p.m. staff could not locate resident #1 and initiated a search of the facility and the grounds. According to Staff F, resident #1 did not wear a Wanderguard bracelet prior to the 3/7/11 elopement. Staff F reported resident #1 wore either a dress with long sleeves or a skirt and long sleeved blouse at the time of the elopement. During an interview on 4/13/12 at 10:15 a.m., Direct Care Staff E reported resident #1 "constantly tries to get out of the building." Staff E reported he/she did not work the evening of 3/7/12 when resident #1 left the building without staff knowledge, but confirmed the resident has the physical ability to ambulate without staff assistance. According to Staff E, the resident is a fall risk and should use a walker but frequently forgets to take it with him/her and walks independently without assistive devices at those times. On 4/12/12 at 2:50 p.m., Administrative Nurse B demonstrated the route resident #1 took to exit the building and facility grounds on 3/7/12. According to that demonstration, the resident left the lobby area of the facility and walked down a north/south hallway leading from the lobby area to the intersecting dining room hallway. At that intersection, resident #1 made a right turn and continued walking down the east/west dining room hallway. Resident #1 then made a sharp left turn into a short hallway and then another sharp right turn into the Assisted Living hallway. Resident # 1 walked the length of the Assisted Living hallway and went out the unalarmed/unlocked East exit door. Upon exiting that door, the resident stood on a concrete "landing", and proceed down five steps to ground level. Once at ground level, the resident walked along the backside of the facility which is uneven grass/gravel terrain, through a row of tall pine/evergreen trees, onto an east/west residential street, and then proceeded west along that street. When found by the off duty police officer, the resident was in the quiet residential neighborhood near the facility. During an observation on 4/12/12 at 2:45 p.m. and 4:10 p.m., resident #1 remained in the facility lobby/commons area. The resident wore a Wanderguard bracelet on the right ankle. At times, resident #1 stood from a chair independently and ambulated to other parts of the room without his/her walker. The resident was pleasant and alert but confused. On 4/13/12 at 8:30 a.m., a check of the functional status of resident #1's Wanderguard bracelet revealed a functioning alarm. The facility failed to protect resident #1 from potential harm when staff failed to place a Wanderguard alarm on the resident once staff identified the resident as an elopement risk. Resident #1 had significant cognitive impairment as well as a risk for falls. The resident left the facility without staff knowledge on a dark, cool evening at approximately 8 p..m..via an unlocked, unalarmed door, went down 5 concrete steps to ground level, walked along uneven terrain, through a row of pine/evergreen trees, crossed a residential street and continued walking in the residential neighborhood until spotted by an off duty police officer and returned to the facility. Facility failure to place a Wanderguard alarm on resident #1 and failure to implement appropriate elopement prevention strategies placed resident #1 in immediate jeopardy of harm. The facility abated the immediate jeopardy on 4/17/12 at 12 p.m. by implementing the following measures: - Placement of a Wanderguard alarm bracelet on resident #1 on 3/7/12 immediately after the elopement - Assessment of all cognitively impaired and independently mobile residents for elopement risk and then ensuring placement of Wanderguard alarm bracelets on both residents deemed at risk of elopement. - Completion of mandatory all-staff education related to exit seeking behaviors and appropriate interventions to keep residents safe. - Changing the facility policy to ensure completion of elopement risk assessments at the time of admission rather than within 14 days of admission as per the previous policy. - Locking of an unalarmed door leading from the LTCU commons area into a courtyard to ensure staff awareness of residents entering the courtyard. This deficient practice remains at a scope/severity of "D." .