Every finding on record at Stonebridge Lake Ozark

Based on interview and record review, facility staff failed to ensure three Nurse Aides (NA)'s (NA A, NA B and NA C) out of four sampled NAs completed the required nurse aide training program within four months of employment in the facility. The facility census was 48.1. Review of the facility's Nurse Aide Hiring and Competency policy, dated October 2017, showed it is the policy of the facility to comply with State and Federal regulations and requirements as they pertain to the training, certification, and continuing education They may be employed as full-time and permanent nursing aides but must provide documentation of certification within four months of their hire date. Facility will verify certification through the appropriate state's nurse aide registry. Those who are verified to be enrolled in a State approved nurse aide training and competency evaluation program. They will be allowed to be employed as a nursing aide no greater than four months without documented successful completion of the program and receipt of certification with verification through the state's nurse aide registry. Individuals who do not complete the required training and competency evaluation program(s) and successfully pass the certification exams (both written and skills) within the four-month period of time will not be allowed to perform the duties of a nurse aide until verification of such successful completion and certification is presented and verified with the state nurse aide registry. 2. Review of NA B's personnel file showed a hire date of 12/17/25. The file did not contain documentation the NA completed the required nurse aide training program.3. Review of NA C's personnel file showed a hire date of 12/17/25. The file did not contain documentation the NA completed the required nurse aide training program.4. Review of NA A's personnel file showed a hire date of 01/02/26. The file did not contain documentation the NA completed the required nurse aide training program.5.During an interview on 06/17/26 at 8:30 A.M., the administrator said there are four NA's going through classes and three of them are out of their 120 days. He/She said they were moved to a different department for 30 days and are now back working as nurses' aides.During an interview on 06/17/26 at 9:37 A.M., the Director of Nursing (DON) said he/she is responsible for nurse aide training. He/She said the NA's were out of their 120 window and were moved to different departments for 30 days and now are back on the floor as nurses aides.During an interview on 06/17/26 at 10:43 A.M., the Administrator said he/she did not realize that the nurses' aides timeframe did not start over if they were moved to a different department and then back to NA's after 30 days.During an interview on 06/17/26 at 10:44 A.M., the DON said he/she thought the NA's 120 days started over if they were in a different department like laundry for at least 30 days. He/She said the nurses' aides will be removed from the floor today and will not be allowed to work until their test is complete.During an interview on 06/30/26 at 1:12 P.M., the Administrator said NA A did not complete his/her training in time because he/she was also in nursing school and was time crunched and NA B and C both had childcare issues to be able to complete the classes and still get a paycheck. Complaint # 3006691

Based on interview and record review, facility staff failed to maintain professional standards of care, when staff failed to document the administration of wound treatments as ordered by the physician for one resident (Resident #2), failed to complete wound assessments for two residents (Resident #2 and #4), and failed to complete weekly skin assessments for two residents (Resident #3, and #4) out of three sampled residents with wounds. The facility census was 59. 1. Review of the facility's Pressure Ulcers/Skin Breakdown-Clinical Protocol policy, revised 03/2020, showed: -Assessment and recognition: the nursing staff and attending physician will assess and document an individual's significant risk factors for developing pressure sores; for example, immobility, recent weight loss, and a history of pressure ulcer(s). In addition, the nurse shall describe and document/report the following: -Full assessment of pressure sore (pressure ulcer/wound) including location, stage, length, width and depth, presence of exudate (drainage from a wound) or necrotic tissue, pain assessment, resident's mobility status, current treatments, including support services, and all active diagnoses;-Monitoring: weekly skin evaluations should evaluate the skin integrity of residents. Any skin integrity issues shall be reported to licensed nursing staff. 2. Review of Resident #2's admission Minimum Data Set (MDS), a federally mandated assessment, dated 05/20/25, showed staff assessed the resident as: -Cognitively intact;-At risk of developing pressure ulcers;-Moisture associated skin damage;-Did not receive pressure ulcer care;-Received surgical wound care;-Received application of ointments/medications other than to feet. Review of the resident's progress note, dated 05/17/25, showed staff documented skin irritation to buttocks and small open area to right buttock with treatment orders in place. Review of the resident's Physician's Order Sheet (POS), dated 05/16/25 through 05/31/25, showed: -05/16/25: Apply sure prep (a fast-drying skin protectant) to left heel three times a day and offload with heel protectors at all times for wound; -05/16/25: Paint left lateral ankle with betadine (to treat or prevent skin infection) and leave open to air once daily for wound therapy;-05/16/25: Cleanse bilateral buttocks with barrier wipes and apply a dime thick layer of triad (used to promote wound healing) to open ulcers every shift, three times a day for wound therapy;-Saline wet to dry dressing to Right below knee amputation wound and cover with island dressing (gauze dressing) two times a day for wound treatment. Review of the resident's Treatment Administration Record (TAR), dated 05/16/25 through 05/31/25, showed the record did not contain documentation staff provided wound treatments as directed to the resident's right leg below knee amputation on 05/19/25, or the resident's buttock and left heel on 05/30/25. Review of the resident's weekly skin assessments dated 05/16/25 through 05/31/25, showed the record did not contain documentation of a skin concern or full assessment of the wounds to the resident's buttock and left heel/ankle on 05/23/25 and 05/30/25. Review of the resident's POS, dated 06/01/25 through 06/30/25, showed: -05/16/25: Apply sure prep to left heel three times a day and offload with heel protectors at all times, for wound therapy;-05/16/25: Paint left lateral ankle with betadine and leave open to air daily for wound therapy;-05/16/25: Cleanse bilateral buttocks with barrier wipes and apply a dime thick layer of triad to open ulcers every shift, three times a day for wound therapy. Review of the resident's TAR, dated 06/01/25 through 06/30/25, showed the record did not contain documentation staff provided wound treatments as directed to the resident's buttock on 06/09/25, 06/14/25, 06/16/25 and 06/26/25, or the left heel on 06/09/25, 06/14/25, and 06/16/25. Review of the resident's weekly skin assessments, dated 06/01/25 through 06/30/25, showed the record did not contain documentation of a skin concern or full assessment of the wound to the resident's buttock and left heel/ankle on 06/06/25, 06/13/25, 06/20/25, and 06/27/25. Review of the resident's POS, dated 07/01/25 through 07/31/25, showed the physician ordered: -05/16/25: Sure prep to left heel three times daily and offload with heel protectors at all times, for wound therapy;-05/16/25: Paint left lateral ankle with betadine and leave open to air once daily for wound therapy;-05/16/25: Cleanse bilateral buttocks with barrier wipes and apply a dime thick layer of triad to open ulcers every shift, three times a day for wound therapy. Review of the resident's weekly skin assessment, dated 07/04/25, showed the record did not contain documentation of a skin concern or full assessment of the wounds to the resident's buttock and left heel/ankle. Review of the resident's weekly skin assessments, dated 07/05/25 through 07/31/25, showed the staff assessed the resident on 07/11/25, 07/18/25, and 07/25/25 with open ulcers to bilateral buttocks and upper thighs that were present on admission. The records did not contain documentation of a full assessment of the identified wounds to the resident's buttocks or upper thighs. Review of the resident's POS, dated 08/01/25 through 08/31/25, showed wound treatment orders: -05/16/25: Apply sure prep to left heel three times a day and offload with heel protectors at all times, for wound therapy;-05/16/25: Paint left lateral ankle with betadine and leave open to air once daily for wound therapy;-05/16/25: Cleanse bilateral buttocks with barrier wipes and apply a dime thick layer of triad to open ulcers every shift, three times a day for wound therapy, discontinued 08/03/25;-08/03/25: Clean buttocks with wound cleanser, pat dry using gauze, apply calcium alginate (to absorb moisture and minimize infection) to wound bed, cover with boarder foam. Change daily and as needed if dressing becomes soiled or dislodged, for wound management, discontinued 08/05/25;-08/05/25: Betadine wet to dry dressings to medial, left and right buttock wounds two times a day for wound care. Review of the resident's weekly skin assessments, dated 08/01/25 through 08/13/25, showed staff assessed the resident on 08/01/25 and 08/07/25 with open ulcers to bilateral buttocks and upper thighs present on admission. The records did not contain documentation of a full assessment of the identified wounds to the resident's buttocks or upper thighs, or an assessment of the wounds to the resident's left heel/ankle. During an interview on 11/21/25 at 3:27 P.M. Registered Nurse (RN) A said the facility had a wound nurse that was primarily responsible to complete the resident's treatments and document on the TAR once completed, but that staff is no longer employed by the facility. 2. Review of Resident #3's Significant Change MDS, dated [DATE], showed staff assessed the resident with severe cognitive impairment, received hospice care, and received pressure ulcer care. Review of the resident's Electronic Medical Record (EMR), dated 09/01/25 through 09/30/25, showed the record did not contain documentation staff completed a skin assessment from 09/01/25 to 09/15/25. Review of the resident's EMR, dated 10/01/25 through 10/31/25, showed the record did not contain documentation staff completed a skin assessment from 10/17/25 to 10/30/25. Review of the resident's EMR, dated 11/01/25 through 11/21/25, showed the record did not contain documentation staff completed a skin assessment from 11/01/25 to 11/10/25. During an interview on 11/21/25 at 3:27 P.M., RN A said the resident's wounds are assessed by the wound physician and hospice nurse weekly, but the nurses are still expected to complete a weekly skin assessment. 3. Review of Resident #4's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment;-At risk of developing pressure ulcers;-Received application of ointments/medications other than to feet;-Used pressure reducing device for bed and chair. Review of the resident's weekly skin assessment, dated 10/17/25, showed staff assessed the resident with a stage two pressure ulcer (partial thickness loss of skin presenting as a shallow open ulcer with a red or pink wound bed) to his/her right buttock. Documentation showed a treatment order received from the physician. The record did not contain documentation of a full wound assessment to include measurements or presence of exudate. Review of the resident's EMR, dated 10/18/25 through 10/30/25, showed the record did not contain documentation staff completed a skin assessment. Review of the resident's EMR, dated 11/01/25 through 11/21/25, showed the record did not contain documentation staff completed a skin assessment from 11/01/25 to 11/10/25 and from 11/12/25 to 11/21/25. During an interview on 11/21/25 at 3:27 P.M., RN A said the nurse should have documented a full assessment of the wound on 10/17/25, and the charge nurses should have completed a weekly skin assessment to monitor the wound and any other new skin concerns. 4. During an interview on 11/21/25 at 2:58 P.M., the administrator said the nurses are responsible to complete treatments as ordered by the physician and document on the TAR once completed, so if there are missing signatures on the TAR, the treatment probably wasn't done. He/She said the nurses are expected to complete a skin assessment on each resident weekly as prompted by the facility's EMR system and document a full assessment of any skin concern/wound. The administrator said he/she is aware skin assessments are not being completed as expected and will work with the newly hired Director of Nursing (DON) to address. During an interview on 11/21/25 at 3:27 P.M., RN A said he/she is the acting DON since the DON left about a month ago. RN A said the nurses are responsible to complete skin assessments weekly for each resident as prompted by the facility's EMR system. RN A said if the nurse assessed a resident with a new skin concern/open area, the nurse is expected to document the location, measurements, stage the wound (if comfortable staging), or ask the DON/assistant DON for help. RN A said he/she had been trying to audit for skin assessments and wound documentation, but it has been difficult to keep up with the increased workload. During an interview on 11/21/25 at 3:59 P.M., RN B said the nurses are responsible to complete a skin assessment for each resident on admission, and then weekly as prompted by the facility's EMR system. RN B said the skin assessment should include the location of any identified skin concern/wound, measurements, stage and drainage (if applicable), or a general description of the area. He/She said the nurses are also responsible to complete treatments as directed by the physician and document on the TAR after administered. He/She said if there is missing documentation/signature on the TAR, the treatment likely was not administered, and the nurse is expected to document a progress note with a reason for not administering a scheduled treatment. Complaint# 2657875

Based on interview and record review, facility staff failed to ensure one resident (Resident #1) remained free from sexual abuse when Resident #2 touched Resident #1's chest inappropriately. The facility census was 57. 1. Review of the Facility's Abuse, Neglect, and Exploitation Program Responsibilities policy, dated September 2022, showed: -Each resident has the right to remain free from abuse, neglect, misappropriation of resident property and exploitation. Residents must not be subject to abuse by anyone, including, but not limited to; facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies; -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish; -Sexual abuse is defined as non-consensual contact of any type with a resident. 2. Review of the facility incident note, dated 03/26/25, showed staff documented the nurse found Resident #2's hand down Resident #1's shirt touching his/her chest. 3. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment tool, dated 03/10/25, showed staff assessed the resident as: -Severe cognitive impairment; -Used [NAME] and wheelchair; -Takes antipsychotic medications; -Diagnosis of dementia. Review of the resident's care plan, dated 03/21/25, showed it did not contain interventions related to the sexual altercation by Resident #2. Review of the resident's progress notes, dated 03/26/25, showed staff documented the resident was touched inappropriately by Resident #2. During an interview on 03/27/25 at 12:05 P.M., Licensed Practical Nurse (LPN) C said he/she was told the resident was on 15-minute checks for the resident to resident sexual altercation. He/She said the resident is on the 15 minute checks because he/she wanders the facility and he/she wandered over to Resident #2 and Resident #2 to touch him/her inappropriately in the chest. During an interview on 03/27/25 at 12:07 P.M., the Director of Nursing (DON) said Resident #1 wandered over to Resident #2, and Resident #2 touched Resident #1 inappropriately. He/She said after the incident the residents were placed on 15 minute checks. 4. Review of Resident #2's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Verbal behavioral symptoms of yelling out; -No physical or sexual behaviors; -Diagnosis of stroke and anxiety. Review of care plan, dated 12/24/24, showed it did not contain documentation or interventions related to the inappropriate touching. During an interview on 03/27/25 at 12:05 P.M., LPN C said he/she was told the resident was on 15-minute checks for the resident to resident sexual altercation. Resident #2 inappropriately touched Resident #1's chest. During an interview on 03/27/25 at 12:07 P.M., the DON said was made aware of the incident by the Assistant Director of Nursing. He/She said Resident #2 touched Resident #1's chest inappropriately. He/She said Resident #2 is immobile. He/She said after the incident they were placed on 15 minute checks. MO00251734

Based on observation, interview, and record review, facility staff failed to revise a comprehensive person-centered care plan for two residents (Resident #1 and #2) out of two sampled residents who had behaviors. The facility census was 57. 1. Review of the facility's policy titled, Comprehensive Care Plans, dated February 2025, showed: -It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality; -The comprehensive care plan will describe, at a minimum, the services that are to be furnished to attain or maintain the resident's highest practicable physician, mental, and psychosocial well-being. 2. Review of the Facility's Resident to Resident Altercations policy, revised October 2022, showed staff should make any necessary changes in the care plan approaches to any or all of the involved individuals. 3. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 03/10/25, showed staff assessed the resident as: -Severe cognitive impairment; -Wanderer behavior occurred one to three days; -Behavioral symptoms of physical, verbal, and other did not occur; -Diagnosis of Dementia. Review of resident's elopement evaluation, dated 03/10/25, showed: -Moderate Risk to wander; -Wanderer behavior with a pattern; -Wanders aimlessly; -Wanderer behavior likely to affect others. Review of resident's behavioral chart showed staff documented: -On 09/12/24 wandered/paced hallways during shift; -On 10/08/24 wandered facility the whole shift, restless and anxious; -On 10/10/24 exhibited exit seeking behaviors; -On 10/15/24 attempted to get into bed with/another female resident; -On 10/26/24 wandered facility and other resident rooms confused and agitated; -On 02/14/25 wore shirt and a skirt and refused assistance and pants; -On 03/04/15 ambulated without assistance in hallway with just a shirt and brief on. He/She yelled pinched, and kicked at staff when they attempted to intervene. Review of resident's care plan, dated 03/21/25, showed the care plan did not contain documentation or interventions to direct staff for the resident's behaviors of wandering, elopement, physical behaviors towards others, verbal behaviors towards others, or after a resident to resident sexual altercation. Observation on 03/27/25 at 10:35 A.M., showed the resident propelled his/her self around the nurse station. Observation on 03/27/25 at 10:42 A.M., showed the resident propelled down the 200 hall. Observation on 03/27/25 at 10:50 A.M., showed the resident propelled down 200 hall and was looking in other resident rooms. During an interview on 03/27/25 at 10:30 A.M., Certified Nurse Aide (CNA) A said the resident wanders frequently and exit seeks. CNA A said he/she was made aware that the resident was touched inappropriately by another resident. He/She said the resident is now on 15 minute checks because he/she is mobile and wanders the halls frequently. He/She said he/she was unaware of interventions for the resident before the 15 minute checks. During an interview on 03/27/25 at 10:38 A.M., Certified Medication Technician (CMT) B said he/she was not made aware of any new interventions for the resident. CMT B said he/she knows the resident wanders but is not aware of any other behaviors. During an interview on 03/27/25 at 11:57 A.M., the MDS nurse said the resident does wander/exit seek. He/She said he/she was made aware of the resident being touched by another resident in appropriately that morning but did not update the care plan because he/she was not told it was witnessed and he/she thought it was just an allegation. He/she said residents who wander or are an elopement risk should have it care planed. He/She said he/she was not aware the resident was missing the wandering and elopement from his/her care plan and said it must have been an oversight. During an interview on 03/31/25 at 10:45 A.M., the resident's family member said the resident is known to exit seek and wander the facility. He/She said the resident uses a wander guard bracelet to prevent him/her from exiting the building. He/She said the resident is known to refuse care and be non-cooperative. During an interview on 03/27/25 at 12:05 P.M., Licensed Practical Nurse (LPN) C said he/she was told the resident was on 15-minute checks for a resident-to-resident altercation. He/She said the resident likes to wander and exit seek but has a wander guard on. He/She said he/she was not made aware of any other behaviors and had not witnessed any that day. He/She said wandering, elopement and any behaviors should be care planned. He/She would expect the incident to be care planed with interventions. During an interview on 03/27/25 at 12:07 P.M., Director of Nursing (DON) said the resident likes to exit seek and wander but does wear a wander guard. He/She said the resident can be verbally aggressive but not physically. He/She said he/she would expect the resident's behaviors, wandering/elopement risk, and the incident to be care planned. He/She said he/she is not sure why it wasn't. 4. Review of Resident #2's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Verbal behavioral symptoms; -No physical or sexual behaviors; -Diagnosis of stroke and anxiety. Review of care plan, dated 12/24/24, showed it did not contain documentation to direct staff for sexually inappropriate behaviors. During an interview on 03/27/25 at 11:57 A.M., the MDS nurse said residents with behaviors that are sexually inappropriate should be care planned. He/She said he/she was made aware of the incident regarding the resident inappropriately touching another resident, but he/she thought it was just an allegation and did not know it was witnessed. He/she said he/she did not update the care plan to include the new behavior or interventions. During an interview on 03/27/25 at 12:05 P.M., LPN C said he/she was made aware of the incident regarding the resident inappropriately touching another resident, during shift report. He/She said he/she would expect there to be an updated care plan regarding the situation and detailed interventions. He/She said he/she was told in report that they are to keep eyes on the residents and keep them separated. During an interview on 03/27/25 at 12:07 P.M., DON said he/she was in the facility when staff witnessed the resident touching another resident inappropriately. He/She said staff were made aware of the incident and he/she said he/she would expect the acre plan to have been updated with the new behavior. MO00251734

Based on interview and record review, facility staff failed to review the code status (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop) and failed to obtain physician orders for their preferred code status for two residents (Resident #42 and #159) out of 22 sampled residents. The facility census was 52. 1. Review of the facility's Advance Directives policy, dated [DATE], showed upon admission, the resident will be provided with written information in a manner easily understood by the resident or resident representative concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. Prior to or upon admission of a resident, the facility will inquire of the resident, his/her family members about the existence of any written advance directives. the resident's Advance Directives must be easily accessible by staff in order for staff to make appropriate clinical decisions during emergency and routine situations. Review of the facility's Do Not Resuscitate Order (DNR) policy, dated [DATE], showed a DNR form must be completed and signed by the attending physician and resident and placed in the front of the resident's medical record. 2. Review of Resident's 42's face sheet, undated, showed the resident admitted to the facility on [DATE]. The face sheet did not contain an Advance Directive for the resident. Review of the resident's medical record did not contain a completed Advance Directive form, dated and sign by the resident, or the resident's representative. Review of the the facility's Advance Directive Folder, kept at the nurse's station, showed it did not contain a completed Advance Directive form for the resident. Review of the resident's care plan, dated [DATE], showed the resident has an Advance Directive for a DNR code status. Review of the resident's Physician Order Sheet (POS), dated [DATE], showed it did not contain an order for Advance Directive. During an interview on [DATE] at 10:21 A.M., the resident's representative said he/she has not filled out any paperwork and has not been asked about the resident's Advance Directive, since his/her admission. During an interview on [DATE] at 1:46 P.M., Registered Nurse (RN) B said the resident is Hospice so he/she should have an advance directive/code status. The RN said he/she did not know the resident did not have an order for his/her code status. The RN said since the resident received hospice services and does not have a code status order it puts the resident at an increased risk of staff potentially performing Cardiopulmonary resuscitation (CPR), an emergency treatment that's done when someone's breathing or heartbeat has stopped. The RN said the Social Services Director (SSD) or charge nurse who is in the facility when the resident is admitted , should get a code status order. The RN said the resident admitted on [DATE], and should have a code status order by now. During an interview on [DATE] at 4:07 P.M., the SSD said he/she doesn't know why the resident doesn't have an order for his/her code status, the nurse should get the order. The SSD said he/she does not have access to the POS. The SSD said without an order, staff will code the resident and the resident is not a full code. The SSD said staff would have to perform CPR if there is not a DNR order. The SSD said he/she didn't ask the resident's family, the nurse should have asked his/her family, Advance Directives is in the nurse's admission paperwork. During an interview on [DATE] at 11:00 A.M., RN C said he/she admitted the resident and he/she had no paperwork to fill out with the resident when he/she admitted . The RN said he/she could not fill out the code status, because he/she did not have access to the paperwork he/she needed, to have the resident or family sign. During an interview on [DATE] at 1:51 P.M., RN C said he/she forgot to put the code status in when he/she admitted the resident. The RN said he/she got busy and did not get it done. 3. Review of Resident 159's face sheet, undated, showed the resident admitted to the facility on [DATE]. Review showed the face sheet did not contain an Advance Directive for the resident. Review of the resident's care plan, dated [DATE], showed the resident Advance Directive as a DNR code status. Review of the resident's Physician Order Sheet (POS), dated [DATE],did not contain an order for an Advance Directive. Review of the the facility's Advance Directive Folder, kept at the nurse's station, did not contain a completed Advance Directive Form for the resident. During an interview on [DATE] at 4:43 P.M., RN B said the SSD does not get orders, the SSD fills out the paperwork and gives it to the nursing staff and the nursing staff clarify the paperwork with the doctor and add the order to the POS. The RN said the nurses never received any paper work for the resident. During an interview on [DATE] at 4:01 P.M., the SSD said he/she doesn't know why the resident's POS doesn't have a code status order, typically the nurses call the doctor. The SSD said there should be a doctors order for the code status on the POS. 4. During an interview on [DATE] at 4:53 P.M., the Director of Nursing (DON) said typically the nurse who admits the resident should put admission orders in, if the nurse is overwhelmed, the assisting DON and DON can help. The DON said a code status should be added to the POS by the admitting nurse. The DON said code status and consent to treat is a part of the admission paperwork, but should be completed by the charge nurse when admitted . The DON said every resident should have a code status on their POS, when they are admitted to the facility. The DON said he/she does not know why the two residents don't have one. The DON said if staff don't have a code status for the resident, staff would perform CPR. The DON said paramedics would have to do the same without a DNR, they would have to provide life saving measures. The DON said the facility has a code status book at the nurse's station. The DON doesn't know why the two resident's code status is not in the code status book. The DON said it should be put in the book by the admitting nurse. The DON said he/she is sure somebody is supposed to review the code status book, he/she just doesn't know who. The DON said he/she does not think there is admission packets at the nurse's station. During an interview on [DATE] at 2:06 P.M., the administrator said the nurse who admits the resident, should fill out the code status paperwork and get a telephone order from the physician. The administrator said the DON is responsible to ensure the nurses get the code status orders.

Based on observation, interview and record review, facility staff failed to develop and implement a comprehensive person-centered care plan addressing code status (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop) for three residents (Resident #11, #20, and #25) out of a sample of 22 residents. The facility census was 52. 1. Review of the facility's policy titled, Comprehensive Care Plans, dated [DATE], showed it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will be developed within seven days after the completion of the comprehensive Minimum Data Set (MDS), a federally mandated assessment tool; all care area assessments (CAAs) triggered by the MDS will be considered in developing the plan of care. The comprehensive care plan will describe, at a minimum, the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, the resident's goals for admission, desired outcomes, and preferences for future discharge. 2. Review of Resident #11's Admission MDS, dated [DATE], showed staff the resident admitted to the facility on [DATE]. Review of the resident's Physician Order Sheet (POS), dated [DATE], showed an order for Full Code (a medical order that indicates a patient's medical team should take all possible measures to maintain and resuscitate their life if they experience cardiac or respiratory arrest) status with a start date of [DATE]. Review of the resident's comprehensive care plan, dated [DATE], showed it did not contain the resident's code status or preferences. 3. Review of Resident #20's Admission MDS, dated [DATE], showed staff assessed the resident admitted to the facility on [DATE]. Review of the resident's medical record showed staff documented the resident's code status as Do Not Resuscitate ((DNR), an order than informs medical staff that cardiopulmonary resuscitation (CPR) should not be attempted). Review of resident's care plan, dated [DATE], showed it did not contain the resident's code status or preferences. 4. Review of Resident #25's Admission MDS, dated [DATE], showed staff assessed the resident admitted to the facility on [DATE]. Review of the resident's medical record showed staff documented the resident's code status as DNR. Review of the resident's care plan, dated [DATE], showed it did not contain the resident's code status or preferences. 5. During an interview on [DATE] at 9:37 A.M., Certified Nurse Aide (CNA) K said the residents' code status can be found on the care plans. If the code status is not on the care plan the CNA would go to the nurse and ask. The CNA said if a resident is unresponsive, and he/she is unable to find the code status it would delay the residents care. The CNA said if he/she did not know a residents' code status, he/she would initiate CPR and this could be against the residents' wishes. During an interview on [DATE] at 9:39 A.M., Licensed practical nurse (LPN) J said a residents' code status should be on their care plan. The LPN said if the code status is not on the care plan a resident who wishes to be a DNR could receive CPR in an emergency situation. During an interview on [DATE] at 9:46 A.M., the Director of nursing (DON) said a residents' code status should be on their care plan. The DON said if a code status is not on a residents care plan there is potential staff would not follow the resident's wishes in an emergency. The DON said when a resident is admitted the nurse is responsible for obtaining the orders for code status preference. Once the nurse has the order it should be entered into the electronic Medication Administration Record (eMAR) system and the MDS coordinator is responsible for putting the code status on the care plan. During an interview on [DATE] at 10:50 A.M., the MDS coordinator said a residents' code status should be on the care plan. The MDS coordinator said he/she believes all residents have a code status on their care plan. The MDS coordinator said there could be a detrimental outcome if staff are needing to look for a code status and it is not there. During an interview on [DATE] at 11:25 A.M., the MDS Coordinator said code status should go on the care plan on admission, and the care plans should be reviewed quarterly or if there are any changes, including daily changes. He/she said he/she was responsible for making those changes and it was missed. During an interview on [DATE] at 1:00 P.M., the administrator said code status should be on the care plan and the MDS Coordinator is responsible to update, and he/she did not know some of the resident's did not have a code status on their care plan. 50361

Based on observation, interview, and record review, facility staff failed to review and revise the care plan for one resident (Resident #20) who started dialysis and for a change in code status for one resident (Resident #33) out of a sample of 22 residents. The facility census was 52. 1. Review of the facility's policy titled, Comprehensive Care Plans, dated [DATE], showed it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will be developed within seven days after the completion of the comprehensive Minimum Data Set (MDS), a federally mandated assessment tool) assessment. All care area assessments (CAAs) triggered by the MDS will be considered in developing the plan of care. The comprehensive care plan will describe, at a minimum, the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, and the resident's goals for admission, desired outcomes, and preferences for future discharge. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 2. Review of Resident #20's Admission MDS, dated [DATE], showed the resident admitted to the facility on [DATE] with diagnoses of anemia and End Stage Renal Disease (ESRD). Review of the resident's medical record showed staff documented the resident went to the hospital on [DATE] and returned to the facility on [DATE]. The resident returned with new orders to begin dialysis treatment three times a week. Review of the resident's care plan, dated [DATE], showed the care plan did not contain direction for staff in regard to the resident's dialysis treatments. During an interview on [DATE] at 9:40 A.M., Licensed Practical Nurse (LPN) J said a care plan should be updated right away when resident returns from the hospital because there was clearly a change in condition. LPN said if a resident has a new order for dialysis it should be updated on the care plan immediately to prevent lapse in care. During an interview on [DATE] at 9:48 A.M., the Director of nursing (DON) said care plans should be updated as soon as there is a change in condition with a resident. The DON said if a resident has returned from the hospital with a new order for dialysis, he/she would expect the care plan to be updated immediately. He/she said the MDS coordinator is responsible for updating the care plan. During an interview on [DATE] at 10:51 A.M., The MDS coordinator said care plans should be updated with any resident changes, which could be daily. The MDS coordinator said care plans are reviewed quarterly with the whole care team. The MDS coordinator said new orders for dialysis should be translated to the care plan in real time. He/she said he/she thought the resident's care plan was updated. During an interview on [DATE] at 1:49 P.M., the administrator said he/she would expect staff to complete a care plan review when a resident returns from the hospital. The administrator said they would expect to see new orders for dialysis on the resident's care plan. The MDS coordinator is responsible for ensuring care plans are completed and updated. 3. Review of Resident #33's Annual MDS, dated [DATE], showed staff assessed the resident admitted to the facility on [DATE]. Review of the resident's Physician Order Set (POS), dated [DATE], showed an order for Do Not Resuscitate ((DNR), an order that informs medical staff that cardiopulmonary resuscitation (CPR) should not be attempted). Review showed a previous order for Full Code status changed to DNR on [DATE]. Review of the resident's care plan, dated [DATE], showed it did not contain the resident's code status or change in code status or preferences. During an interview on [DATE] at 9:37 A.M., Certified nurse aide (CNA) K said he/she would look for a residents' code status on their care plan. If the code status is not on the care plan the CNA would go to the nurse and ask. The CNA said if a resident is unresponsive, and he/she is unable to find the code status this could delay care. The CNA also said if he/she did not know a residents' code status, he/she would initiate CPR and this could be against the resident's wishes. During an interview on [DATE] at 9:39 A.M., Licensed Practical Nurse (LPN) J said a residents' code status should be on their care plan. The LPN said if the code status is not on the care plan a resident who wishes to be DNR could receive CPR in an emergency situation. During an interview on [DATE] at 9:46 A.M., the Director of Nursing (DON) said a residents' code status should be on their care plan. The DON said if a code status is not on the resident's care plan there is a potential staff would not follow the resident's wishes in an emergency. He/she said when a resident is admitted the nurse is responsible for obtaining the orders for code status preference. Once the nurse enters the orders into the electronic Medication Administration Record (eMAR) system the MDS coordinator is responsible for putting the code status on the care plan. During an interview on [DATE] at 11:25 A.M., the MDS Coordinator said code status should go on the care plan on admission, and the care plans should be reviewed quarterly or if there are any changes, including daily changes. He/she said he/she is responsible for making those changes and it was just missed, it was a lapse. During an interview on [DATE] at 1:00 P.M., the Administrator said code status should be on the care plan and the MDS Coordinator is responsible to update, and he/she did not know they were missing. 50361

Based on observation, interview, and record review, staff failed to ensure medications were monitored and stored in a safe and effective manner. Licensed staff failed to maintain the control logs for three controlled medications in the facility's destruction cabinet. The facility census was 52. 1. Review of the facility's Controlled Substances policy, dated December 2016, showed nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing (DON). Review of the facility's Discarding and Destroying Medications policy, dated October 2016, showed disposal of controlled substances must take place immediately (no longer than three days) after discontinuation of use by resident. 2. Review of Resident #98's Control Log, undated, showed staff documented a count of 20 tablets of Hydrocodone/APAP(Tylenol) (a narcotic medication used to treat pain) 5-325 milligrams (mg) on 07/27/24. Review of the resident control log showed staff did not document a count of the residents Hydrocodone/APAP 5-325 mg on 07/28/24, 07/29/24, 07/30/24, 07/31/24 and 08/01/24, with the off going and on going nurses. Observation on 08/01/24 at 2:54 P.M., showed the destruction cabinet in the medication room contained a bubble pack of Hydrocodone/APAP 5-325 mg with 20 tablets left in the bubble pack. 3. Review of Resident #99's Control Log, undated, showed staff documented on 07/26/24 a count 19 tablets of Lorazepam (a narcotic medication used to treat anxiety) 0.5 mg and 30 milliliters (ml) of Morphine Solution (a narcotic medication used to treat pain) 100 mg/5 ml. Review of the resident control log showed staff did not document a count of the residents Lorazepam 0.5mg and Morphine Solution 100 mg/5 ml on 07/27/24, 07/28/24, 07/29/24, 07/30/24, 07/31/24 and 08/01/24, with the off going and on going nurses. Observation on 08/01/24 at 02:54 PM, showed the destruction cabinet in the medication room contained an open bottle of Morphine Solution with 30 ml left in the bottle. 4. During and interview on 08/01/24 at 2:54 P.M., the Assistant Director of Nursing (ADON) said the nurses who pull the controlled medication for destruction, put the medications in the destruction cabinet. The ADON said the nurse's usually bring the medications for destruction to him/her, but he/she should have checked the destruction cabinet. The ADON said he/she had not checked the destruction cabinet, because the DON had just quit and he/she had been trying to run everything and work the floor. The ADON said staff should always sign, when they have access to the controlled medications. The ADON said he/she does not know why the nursing staff had not been signing the controlled logs. During an interview on 08/01/24 at 3:12 P.M., Licensed Practical Nurse (LPN) J said the nurse who signs off on controlled narcotics should be the only staff with access to the controlled medications. The LPN said staff should sign the controlled log at the beginning and end of their shift. The LPN said the nurse coming on shift should count the controlled medications with the nurse who is leaving. The LPN said to be honest, he/she did not realize the medications were in the cabinet. During an interview on 08/01/24 at 3:18 P.M., Registered Nurse (RN) B said nurses should count controlled medications every time they take the keys. The RN said he/she did not sign for the controlled medications, because he/she did not know there was any controlled medications in the cabinet. The RN said he/she should have signed for the medications. During an interview on 08/01/24 at 5:22 P.M., the DON said staff have to sign the controlled log when they have access to controlled medications. The DON said staff should count and sign controlled logs at shift change. The DON said if controlled medications are in the destruction cabinet, they still have to count and document the count on a controlled log. The DON said the controlled medications should have never came out of the the medication cart, unless they were being destroyed. The DON said he/she does not know why staff weren't signing the control sheets. The DON said the ADON is responsible for monitoring for medications that need to be destroyed. During an interview on 08/02/24 at 2:06 P.M., the administrator said on-coming and off-going staff should count all controlled medications every shift. The administrator said controlled medications scheduled for destruction should be counted at shift change by staff. The administrator said he/she does not know why staff did not count the controlled medications in the destruction cabinet. The administrator said he/she does not know who is responsible to check the destruction cabinet. The administrator said he/she did not know there was a destruction cabinet.

Based on observation, interviews, and record reviews, the facility staff failed to properly store open food to prevent cross contamination and outdated usage. The census was 45. 1. Review of the facility's Food Receiving and Storage policy, dated July 2014, showed: - Dry foods that are stored in bins will be removed from original packaging, labeled, and dated; - All foods stored in the refrigerator or freezer will be covered, labeled, and dated. Observation on 7/12/23 at 10:50 A.M., showed two bulk bins of white substance unlabeled. Observation of the pantry on 7/12/23 at 3:42 P.M., showed: - Three pound container of kosher salt open, unprotected, and undated; - Container of pepper open, unprotected, and undated; - One pound container cornstarch open and unprotected; - Ziploc bag of bran flakes undated; - Four open loaves of bread undated; - One open hamburger bun undated; - Ziploc bag of bread crumbs undated; - Ziploc bag of tricolored pasta undated; - Ziploc bag of elbow noodles undated. Observation on 7/12/23 at 3:52 P.M., showed: - Open bag of brown sticks not labeled and undated; - Ziploc bag of sliced yellow cheese undated; - Open block white substance not labeled and undated; - Open block of white sliced substance not labeled and undated. Observation on 7/12/23 at 3:57 P.M., of the walk-in freezer, showed: - Two Ziploc bags bread rolls not labeled; - Ziploc bag of breaded strips not labeled and undated; - Ziploc bag of breaded food not labeled and undated; - Bag of orange strips not labeled. During an interview on 7/14/23 at 11:46 A.M., the dietary manager said he was responsible to ensure food was stored in a safe and sanitary manner. The facility had a policy regarding food storage, and he was trained on the policy. The dietary manager said all food should be labeled, dated, and protected. The dietary staff who put away the food have been trained on proper storage of food. The dietary manager said he and the cooks go through the pantry, refrigerator, and freezer every day, and they would discard any food items stored incorrectly. During an interview on 7/14/23 at 12:52 P.M., the administrator and the director of nursing said the dietary manager was responsible to ensure food was stored according to regulations. The facility had a policy regarding food storage, and the dietary manager was trained on the policy. The administrator and the director of nursing said it was expected the food was checked regularly, and staff reconcile or discard any food stored incorrectly.

Based on observation, interview, and record review, facility staff failed to provide a comfortable and homelike environment for all residents when they did not properly maintain the wallpaper on walls of the 100 and 200 halls. The facility census was 45. 1. Review of the facility's policy titled, Resident Environmental Quality, dated 2016, showed staff are directed to do the following: -It is the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public; -Preventative maintenance schedules, for the maintenance of the building and equipment, should be followed to maintain a safe environment; -All facility personnel are responsible for reporting broken, defective or malfunctioning equipment or furnishings immediately upon identification of the issue. Review of the Maintenance Book at the Nurse's station, undated, showed no documentation in regard to the disrepair of the wallpaper. 2. Observation on 07/12/23 at 1:21 P.M., showed two areas of torn wallpaper outside of room [ROOM NUMBER] to the right of the door. Observation on 07/12/23 at 1:22 P.M., showed torn and missing wallpaper outside of room [ROOM NUMBER] to the left of the door. Observation on 07/12/23 at 1:24 P.M., showed a missing piece of wallpaper on the right side of room [ROOM NUMBER]. Further observation showed a large piece of wallpaper missing from the wall between room [ROOM NUMBER] and room [ROOM NUMBER] and torn and missing wallpaper to the left of room [ROOM NUMBER] door. Observation on 07/12/23 at 1:26 P.M., showed two spots of torn and missing wallpaper on the right side of room [ROOM NUMBER]'s doorframe. Observation on 07/12/23 at 1:27 P.M., showed three areas of torn and missing wallpaper on the left side of room [ROOM NUMBER]'s doorframe. Observation on 07/12/23 at 1:29 P.M., showed two large areas of torn and missing wall paper below the staff kiosk on the 100 hall Observation on 07/12/23 at 1:30 P.M., showed three large areas of torn and missing wallpaper to the left and right of room [ROOM NUMBER]'s doorframe. Observation on 07/12/23 at 1:31 P.M., showed one area of torn and missing wallpaper to the left of room [ROOM NUMBER]'s doorframe. Observation on 07/12/23 at 1:32 P.M., showed two torn and missing areas of wallpaper to the left of room [ROOM NUMBER]'s doorframe. Observation on 07/12/23 at 1:33 P.M., showed four torn and missing areas of wallpaper on the right side of room [ROOM NUMBER]'s doorframe. Observation on 07/12/23 at 1:34 P.M., showed one torn and missing area of wallpaper on right side of room [ROOM NUMBER]'s doorframe. Observation on 07/12/23 at 1:35 P.M., showed two torn and missing areas of wallpaper on left side of room [ROOM NUMBER]'s doorframe. Observation on 07/13/23 at 8:54 A.M., showed torn wallpaper and a large missing piece of wallpaper to the side of room [ROOM NUMBER]'s doorframe. Observation on 07/13/23 at 8:56 A.M., showed five areas of torn and missing wallpaper between room [ROOM NUMBER] and room [ROOM NUMBER]. Observation on 07/13/23 at 8:58 A.M., showed four areas of torn and missing wallpaper between rooms [ROOM NUMBERS]. Observation on 07/13/23 at 9:00 A.M., showed one area of torn wallpaper on the left side of room [ROOM NUMBER]. Observation on 07/13/23 at 9:02 A.M., showed a large torn and missing area of wallpaper by the telephone on the right side of room [ROOM NUMBER]'s doorframe. During an interview on 07/13/23 at 9:12 A.M., Certified Nurse Aide (CNA) A said if he/she finds something that needs repaired he/she notifies the Maintenance Director. The CNA said he/she works on th 200 and 300 halls and is aware of the missing and torn wallpaper, but has not reported it to the Maintenance Director. The CNA said the facility has a maintenance book at the nurse's station but he/she has never used it. The CNA said the torn and missing wallpaper is not homelike. During an interview on 07/13/23 at 9:20 A.M., the Infection Preventionist (IP) said if something needs repaired a work order should be filled out in the Maintenance Work Orders book at the nurses' station. The IP said the Maintenance Director checks the book several times a day, and he/she expects staff to report maintenance concerns to him/her and he/she can pass it along. The IP said staff has not reported any concerns in regard to the wallpaper to him/her, but he/she has noticed the wall paper is peeling. The IP said he/she not filled out a work order for it, but he/she should have. The IP said the missing and torn wallpaper is not homelike. During an interview on 07/14/23 at 8:56 A.M., the Maintenance Director said staff should fill out a work order on the tablet if something needs repaired. The Maintenance Director said staff has not notified him/her the wallpaper needs repaired but he/she has seen it and knows it needs repaired. He/She said he/she did not know why the wallpaper has not been repaired, as it is not homelike. During an interview on 07/14/23 at 9:13 A.M., the Administrator said staff should report maintenance concerns to the maintenance department using the TELS system (web-based facility maintenance tracking system) on the computer, but the facility is transitioning away from that system and he/she is going to put a binder at the nurse's station. The Administrator said he/she has seen the torn wallpaper, but does not have access to the matching wallpaper. The tears in the wallpaper is not to his/her satisfaction.

42815 Based on observation, interview and record review, facility staff failed to develop a comprehensive person-centered care plan for each resident to meet the residents medical, and nursing needs when they failed to address facial hair preferences for five residents (Resident #1, #7, #19, #28, and #31), failed to address activities for ten residents (Resident #1, #3, #12, #13, #7, #19, #27, #28, #31 and #35) and failed to address behaviors for two residents (Resident #1 and #28). The facility census was 45. 1. Review of the facility's policy titled, Comprehensive Care Plans, dated September 2022, showed staff were directed to do the following: -Develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment; -The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care; -All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team (IDT), or in, accordance with the resident's preferences, will also be addressed in the plan of care; -Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. 2. Review of Resident #1's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 06/08/23, showed staff assessed the resident as follows: -Severe cognitive impairment; -Required extensive assistance from one staff member for personal hygiene; -Did not exhibit physical or verbal behaviors towards others; -Did not reject care; -Wandered daily; -Did not address preference for customary routine and activities; Review of the resident's care plan, dated 06/13/23, staff documented the resident required assistance from one staff member with grooming and bathing. Further review showed no direction for staff in regard to the resident's activity or facial hair preferences, wandering, rejection of care, or aggressive behavior. Review of the medical record, dated 04/16/23, showed staff documented: -04/16/23: Resident found laying in another resident's bed on two occasions and the resident became angry and raised the brush as if to hit someone with it and used profanity towards the staff member; -05/27/23: Resident found in another resident's room, refused to leave the room, and grabbed the staff members arm and dug his/her nails into his/her arm; -06/19/23: Resident found in another resident's room yelling at the resident and bit and scratched a staff member. Observation on 07/11/23 at 11:15 A.M., showed the resident had hair on his/her chin. Observation on 07/12/23 at 1:33 P.M., showed the resident had hair on his/her chin. Observation on 07/13/23 at 8:26 A.M., showed the resident had hair on his/her chin. During an interview on 07/14/23 at 9:13 A.M., Certified Nurse Aide (CNA) G said the resident occasionally rejects care. The CNA said refusals are documented in the behavioral log. During an interview on 07/14/23 at 9:46 A.M., Licensed Practical Nurse (LPN) H said the resident occasionally rejects care like nail trimmings and shaving. During an interview on 07/14/23 at 10:07 A.M., the MDS Coordinator said at one time the care plan addressed wandering, but it was removed because the resident doesn't wear a wander alert anymore. During an interview on 07/14/23 at 10:20 A.M., CNA A said the resident refuses care at times. 3. Review of Resident #3's Annual MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Not very important to do things with groups of people; -Not important at all to be around animals, keep up with the news or participate in religious services or practices; -Somewhat important to have books, newspapers, and magazines to read, to listen to music, do his/her favorite activities. Review of the resident's care plan, dated 06/13/23, showed no direction for staff in regard to activity preferences for the resident. During an interview on 07/13/23 at 3:27 P.M., the resident said he/she participates in all the activities. 4. Review of Resident #7's Significant Change in Status (SCSA) MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Required extensive assistance from one staff member for personal hygiene; -Not very important to have books, newspapers, and magazines to read, listen to music, to do things with groups of people or go outside to get fresh air; -Not important at all to be around animals, keep up with the news or participate in religious services or practices; -Somewhat important to do his/her favorite activities. Review of the resident's care plan, dated 06/21/23, showed no direction for staff in regard to facial hair or activity preferences. Observation on 07/11/23 at 10:44 A.M., showed the resident had hair on his/her chin. Observation on 07/12/23 at 11:09 A.M., showed the resident had hair on his/her chin. Observation on 07/14/23 at 9:53 A.M., showed the resident had a few long hairs on his/her chin. During an interview on 07/12/23 at 10:59 A.M., the resident said he/she does participate in some activities. Further, the resident said he/she plucked his/her own facial hair because he/she did not want to use a razor and risk growing more facial hair. 5. Review of Resident #12's SCSA MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Not very important to listen to music, to have books, newspapers, and magazines to read, go outside to get fresh air; -Not important at all to be around animals, keep up with the news or participate in religious services or practices; -Somewhat important to do things with groups of people, do his/her favorite activities. Review of the resident's care plan, dated 06/07/23, showed no direction for staff in regard to activities. During an interview on 07/13/23 at 3:38 P.M., the resident said he/she did not participate in activities. 6. Review of Resident #13's SCSA MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Not very important to listen to music; -Not important at all to be around animals, keep up with the news or participate in religious services or practices; -Somewhat important to have books, newspapers, and magazines to read, to do things with groups of people, do his/her favorite activities. Review of the resident's care plan, dated 04/07/23, showed no direction for staff in regard to activities. During an interview on 07/13/23 at 3:39 P.M., the resident said he/she did participate in some of the activities. 6. Review of Resident #19's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Required extensive assistance from two staff members for personal hygiene; -Did not reject care; -Did not address preference for customary routine and activities. Review of the resident's care plan, dated 04/26/23, showed staff documented the resident required assistance from two staff members with grooming. Further review showed no direction for staff in regard to facial hair and activity preferences. Observation on 07/11/23 at 11:16 A.M., showed the resident had hair on his/her upper lip and chin. Observation on 07/13/23 at 4:15 PM., showed the resident had hair on his/her upper lip and chin. 7. Review of Resident #27's Annual MDS, dated [DATE], showed staff assessed the resident as follows: -Brief Interview for Mental Status (BIMS) unable to be completed; -Staff assessment of daily and activity preferences showed listening to music as a resident preference; -Totally dependent on one staff member for locomotion on/off unit and eating; -Diagnoses of anemia (not having enough red blood cells), anoxic brain injury (caused by a complete lack of oxygen to the brain, which results in the death of brain cells), heart failure, diabetes, pneumonia, seizure disorder, anxiety, stiff man syndrome (a rare autoimmune neurological disorder that most commonly causes muscle stiffness and painful spasms), and depression; -The Care Area Assessment showed activities should be addressed on the care plan. Review of the Life Enrichment Assessment, dated 4/19/23, showed staff documented the resident does not wish to participate in any group activities or independent activities and he/she prefers to rest in his/her room. Review of the resident's care plan, reviewed 06/07/23, showed no direction for staff in regard to the resident's activity preferences. 8. Review of Resident #28's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Independent with personal hygiene; -Did not reject care; -Did not exhibit behaviors; -Did not address preference for customary routine and activities. Review of the resident's care plan, dated 07/12/23, showed staff documented the resident as independent with grooming and requires assistance from one staff member with bathing. Further review showed no direction for staff in regard to rejection of care, or facial hair and activity preferences. Observation on 07/12/23 at 1:16 P.M., showed the resident with unkempt facial hair. Observation on 07/13/23 at 3:30 P.M., showed the resident with unkempt facial hair. Observation on 07/14/23 at 9:44 A.M., showed the resident with unkempt facial hair. Further observation showed the resident worked on a word search puzzle. During an interview on 07/14/23 at 9:13 A.M., CNA G said the resident requires supervision for showering and personal hygiene. During an interview on 07/14/23 at 9:46 A.M., LPN H said the resident sometimes refuses nails trims and shaves. During an interview on 07/14/23 at 10:20 A.M., CNA A said the resident often refuses care. The CNA said the resident will shave him/herself with encouragement. During an interview on 07/14/23 at 10:07 AM., MDS Coordinator said the resident occasionally rejects care. 9. Review of Resident #31's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Required extensive assistance from one staff member for personal hygiene; -Did not reject care; -Not very important to have books, newspaper and magazines, listen to music, to go outside to get fresh air or participate in religious services or practices; -Not important at all to be around animals or keep up with the news; -Somewhat important to do things with groups of people and go outside to get fresh air. Review of the resident's care plan, dated 04/24/23, showed staff documented the resident requires assistance from two staff members for personal hygiene. Further reviewed showed no direction for staff in regard to the resident's facial hair and activity preference. Observation on 07/11/23 at 12:04 P.M., showed the resident with long hair on his/her chin. Observation on 07/13/23 at 8:29 A.M., showed the resident with long hair on his/her chin. Observation on 07/13/23 at 3:53 P.M., showed the resident with long hair on his/her chin. Observation on 07/14/23 at 9:46 A.M., showed the resident with long hairs on his/her chin. During an interview on 07/14/23 at 9:46 A.M., LPN H said he/she noticed the resident with facial hair, asked the resident if he/she wanted to be shaved and the resident said yes. 10. Review of Resident #35's Annual MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Not very important to listen to music, to do things with groups of people; -Not important at all to be around animals, keep up with the news or participate in religious services or practices; -Somewhat important to have books, newspapers, and magazines to read, go outside to get fresh air, do his/her favorite activities. Review of the resident's care plan, dated 05/17/23, showed no direction for staff in regard to activities. During an interview on 07/13/23 at 3:34 P.M., the resident said he/she did not participate in activities. During an interview on 07/14/23 at 9:13 A.M., CNA G said the care plan should guide the staff in the type of care each resident needs and prefers. The CNA said facial hair and civility preferences should be addressed in the care plan. During an interview on 07/14/23 at 9:46 A.M., LPN H said the care plan should provide staff with direction for the type of care the residents need and prefer. During an interview on 07/14/23 at 10:07 A.M., the MDS Coordinator said the care plan should inform staff of the residents' likes, dislikes, behaviors, and any other care needs. He/She said the care plans are updated every three months, and if the resident has a significant change. The MDS Coordinator said it would be beneficial to include facial hair preference on the care plans, but not every residents activity preferences should be listed, unless it's special. During an interview on 07/14/23 at 10:57 AM., the Administrator and Director of Nursing (DON) said the care plan should provide staff with direction to meet the total needs of each resident. They said the care plans are updated quarterly or with a change in condition by the MDS Coordinator. They said refusal of care, behaviors, activity preferences and wandering should be listed on the care plan, but not facial hair preference. 45489

Based on observation, interview, and record review, facility staff failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment when staff failed to use hand hygiene during incontinence care for one resident (Resident #3). The facility census was 45. 1. Review of the facility's policy titled, Hand Hygiene, undated, showed staff were directed to do the following: -All staff will perform proper hand hygiene procedures to prevent the spread of infections to other personnel, residents, and visitors; -Use either soap or water or an Alcohol Based Hand Rub (ABHR) before applying and after removing personal protective equipment (PPE), including gloves. Observation on 07/13/23 at 9:47 A.M., showed Certified Nurse Aide (CNA) A and CNA F entered Resident #3's room to provide perineal care. CNA F cleansed the resident's bottom, noticed his/her gloves were visibly soiled with feces, and changed gloves, without performing hand hygiene between glove changes. CNA F then removed soiled sheets from the bed and placed a clean incontinence pad under the resident, and touched the resident's exposed side with the same soiled gloves on. CNA A removed the soiled linens, touched the incontinence pad, and changed gloves, but did not use hand hygiene. CNA A provided perineal care, and repositioned the resident, with the same soiled gloves on. CNA A removed gloves, did not perform hand hygiene, and covered up the resident with a sheet. CNA F and CNA A applied barrier cream to the resident, removed their gloves, and applied clean gloves, without performing hand hygiene between glove changes. The CNA's then placed a clean brief under the resident, gathered the resident's clothing, dressed the resident and transferred the resident. During an interview on 07/13/23 at 10:15 A.M., CNA A and CNA F said staff is supposed to wash hands and apply gloves when entering a residents' room, and from dirty to clean tasks. They CNA's said they should have washed hands between glove changes. They said they did know feces and urine can seep through the gloves and the purpose of hand hygiene is to prevent cross contamination. During an interview on 07/13/23 at 11:23 A.M., the Infection Preventionist (IP) said staff should wash hands between glove changes. The IP said if staff does not wash their hands between glove changes there is a concern of cross contamination since gloves are not 100% effective in preventing bodily fluids from leaking through the gloves and onto the hands. During an interview on 07/14/23 at 10:57 A.M., the Administrator and Director of Nursing (DON) said staff should change gloves and wash hands when moving from a dirty to clean task. 42815

Based on interview and record review, the facility failed to follow their policy to ensure they completed the required Employee Disqualification List (EDL) check and Criminal Background Check (CBC), prior to hire for three of ten sampled employees hired since the last survey. The facility census was 44. 1. Review of the facility's Abuse, Neglect, and Exploitation Policy, dated October 2017, showed the facility must not employ or otherwise engage individuals who: - Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; - Have had a finding entered in the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] - Background and credentials' checks will conducted on employees prior to employment, by facility administration, in accordance with applicable state and federal regulations. 2. Review of Business Office Manager (BOM) I's employee file showed: -Date of hire 10/20/20; - The file did not contain documentation the EDL had been checked prior to the date of hire; - The file did not contain documentation the CBC had been checked prior to the date of hire. 3. Review of Housekeeping K's employee file showed: -Date of hire 10/12/20; - The file did not contain documentation the EDL had been checked prior to the date of hire; - The file did not contain documentation the CBC had been checked prior to the date of hire. 4. Review of Cook L's employee file showed: -Date of hire 11/23/20; - The file did not contain documentation the EDL had been checked prior to the date of hire; - The file did not contain documentation the CBC had been checked prior to the date of hire. 5. During an interview on 05/05/22, at 08:48 A.M., the Director of Nursing (DON) said the Business office manager (BOM) does all the background checks. During an interview on 05/05/22, at 08:55 A.M., the administrator said his/her expectation is all checks are ran before the staff is hired and the staff should should have knowledge of who is in the building. The BOM is responsible for these checks. During an interview on 05/05/22, at 09:22 A.M., BOM said he/she is responsible for doing the CBC, EDL, NA registry, and the FCSR once the staff is hired, but prior to their start date. He/She does not know why the checks were not run correctly before his/her employment as the BOM. The EDL checks are to be done quarterly.

Based on observation, interview, and record review, the facility staff failed to follow policies and procedures for immunizations of residents against pneumococcal disease and influenza in accordance with national standards of practice and/or failed to provide education regarding vaccines, offer vaccines, and vaccinate four (Resident's #13, #18, #30, and #194) of ten sampled residents with doses of the pneumococcal and/or influenza vaccine, as recommended by the Center for Disease Control and prevention. The facility census was 44. 1. Review of the facility's pneumococcal vaccine policy, revised August 2016, showed the following: - All resident will be offered pneumoncoccal vaccines to aid in preventing pneumonia/pneumococcal infections; - Prior to or upon admission, resident will be assessed for eligibility to receive the pneumoncoccal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated; - Assessments of pneumococcal vaccination status will be conducted within five (5) working days of the resident's admission if not conducted prior to admission; - Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. (See current vaccine information statements at http:www.cdc.gov/vaccines/hcp/vis/index.html for educational materials.) Provision of such education shall be documented in the resident's medical record; - Pneumococcal vaccines will be administered to resident (unless medically contraindicated, already given, or refused) per our facility's physician-approved pneumococcal vaccination protocol; - Resident/representatives have the right to refuse vaccination. If refused, appropriate entries will be documented in each resident's medical record indicating the date of the refusal of the pneumococcal vaccination; - For residents who receive the vaccines, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's medical record; - Administration of the pneumococcal vaccines or revaccination's will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of vaccination. 2. Review of the facility's Influenza vaccine policy, revised August 2016, showed the following: - Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated or the resident or employee has already been immunized; - Residents admitted between October 1st and March 31st shall be offered the vaccine within five (5) working days of the resident's admission to the facility; - Prior to the vaccination, the resident (or resident's legal representative) or will be provided information and education regarding the benefits and potential side effects of the influenza vaccine. (See current vaccine information statements at http:www.cdc.gov/vaccines/hcp/vis/index.html for educational materials.) Provision of such education shall be documented in the resident's/employee's medical record; - For those who receive the vaccines, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's medical record; - A resident's refusal of the vaccine shall be documented on the Informed Consent for Influenza Vaccine and placed in the resident's medical record; - The infection preventionist will maintain surveillance data on influenza vaccine coverage and reported rates of influenza among resident and staff. Surveillance data will be made available to staff as part of educational efforts to improve vaccination rate among employees; - Residents may obtain their influenza vaccines from their personal physicians. Documentation of previous vaccination should be provided to the facility; - Administration of the influenza vaccine will be made in accordance with the current CDC recommendations at the time of the vaccination. 3. Review of Resident #13's medical record showed: -admitted [DATE]; -Age: 74; -The record did not contain documentation staff provided education regarding vaccines, the resident was offered vaccines, or the resident refused the pneumococcal or the influenza vaccine since admission by the facility. 4. Review of Resident #18's medical record showed: -admitted [DATE]; -Age: 92; -The record did not contain documentation staff provided education regarding vaccines, the resident was offered vaccines, or the resident refused the pneumococcal vaccine since admission by the facility. 5. Review of Resident #30's medical record showed: -admitted [DATE]; -Age: 73; -The record did not contain documentation staff provided education regarding vaccines, the resident was offered vaccines, or the resident refused the pneumococcal vaccine since admission by the facility. 6. Review of Resident #194's medical record showed: -admitted [DATE]; -Age: 91; -The record did not contain documentation staff provide education regarding vaccines, the resident was offered vaccines, or the resident refused the pneumococcal or the influenza vaccine since admission by the facility. 7. During an interview on 05/05/22, at 09:05 A.M., LPN A said resident vaccinations are done by the Director of Nursing (DON) or the Assistant DON (ADON). He/She said if he/she is told to vaccinate a resident, he/she will. The DON and ADON keep track of the residents due for vaccines and document in the electronic medical record. During an interview on 05/05/22, at 09:19 A.M., the ADON said the DON does the influenza and pneumonia vaccinations for the residents. He/She said the resident's vaccine status is in the electronic medical record and is documented when it's administered or refused by the resident. During an interview on 05/05/22, at 10:19 A.M., the DON said he/she administers the influenza and pneumococcal vaccines to the residents. He/She knows who is due by running a report in the electronic medical record. He/She said it should be documented in the electronic medical record when it was given, where it was given, the vaccine and lot number, and the staff who gave it. During an interview on 05/05/22, at 11:11 A.M., the Administrator said the DON is responsible for giving the resident's their influenza and pneumococcal vaccines. He/She said the DON and Infection Preventionist are responsible for keeping track of when the residents are due. He/She said he/she would refer someone to the DON on how and where it's documented if they've received the vaccines or refused.

Based on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of their bed hold policy at the time of transfer to the hospital for three residents (Residents #40, #200 and #202 ). The facility's census was 44. 1. Review of the facility's Bed Hold Policy, undated, showed staff were directed as follows: - Before and at the time the resident transfers out of the facility for hospitalization or therapeutic leave, we will provide the resident or the resident's representative with written notice explaining the duration of the bed-hold policy; - If a resident's care is not covered by Medicaid or Medicare, the facility will reserve the resident's bed only if a a bed reservation agreement has been negotiated and the resident has agreed to be personally responsible for the charges to reserve the bed. 2. Review of Resident #40's medical record showed the following: -Resident was assessed as cognitively intact; -Resident discharged from the facility on 04/18/22; -The medical record did not contain written documentation staff notified the resident or the resident's responsible party of the facility bed-hold policy. 3. Review of Resident #200's medical record showed the following: -Resident was assessed as cognitively intact; -Resident discharged from the facility on 11/08/21; -The medical record did not contain written documentation staff notified the resident or the resident's responsible party of the facility's bed-hold policy. 4. Review of Resident #202's medical record showed the following: -Resident was assessed as cognitively intact; -Resident discharged from the facility on 11/08/21; -The medical record not contain written documentation staff notified the resident or the resident's responsible party of the facility's bed-hold policy. During an interview on 05/05/22, at 08:39 A.M., the Assistant Director of Nursing (ADON)said when a resident goes out to the hospital a bed hold is sent with them, but if family is not present, it is put in with the paperwork to ER. If the resident is not their own guardian they call and let them know they are being sent to the hospital. It depends on the situation if they let the family know that there is a bedhold. It is his/her expectation every resident gets a bedhold when discharged to the hospital. The charge nurse on duty is responsible, but it depends on the situation. During an interview on 05/05/22, at 08:48 A.M., the Director of Nursing (DON) said it was his/her expectation every time a resident goes out, staff print and give the bedhold to the resident and leave a copy on Point Click Care (PCC). He/She said the guardian is called and informed the bedhold is being sent with the resident. He/She said the bed holds are sent with Emergency Medical Services (EMS) and he/she thinks the staff may have mailed bed holds to the guardian before, but is not sure who does it. During an interview on 05/05/22, at 08:55 A.M., the administrator said the facility meets the state and federal requirements for bed holds. He/She said social services is in charges of tracking bed holds for the census. He/She said he/she cannot answer what the standard of practice is here at this home, but the person doing the discharge would be responsible.

Based on observation and interview, facility staff failed to post the required nurse staffing information which included the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift, and on a daily basis. The facility census was 44. 1. Review of the facility's Department duty hours, nursing services policy, revised August 2006, showed: - Staffing ratios will be posted daily in a place that is easily visible to staff, resident, and visitors. Observation on 05/04/22 at 08:16 A.M., showed the nurse staffing posting by nurses station, dated 05/02/22. Observation on 05/04/22 at 09:24 A.M., showed the nurse staff posting by nurses station, dated 05/02/22. Observation on 05/04/22 at 10:08 A.M., showed the nurse staff posting by the nurses station, dated 05/02/22. Observation on 05/04/22 at 02:00 P.M., showed two nurse staff postings by nurses station, with one dated 05/02/22 and the second dated 05/04/22. Observation on 05/05/22 at 08:09 A.M., showed the nurse staff posting posted by the nurses station, dated 05/04/22. During an interview on 05/05/22, at 08:53 A.M., the Certified Nurses Aide (CNA) said the nurse staff posting is kept up by nurses station. He/She said the Director of Nursing (DON) or Assistant Director of Nursing (ADON) were responsible for at least every other day and may post a couple days at a time to cover the weekends. During an interview on 05/05/22, at 09:05 A.M., Licensed Practical Nurse (LPN) said the nurse staff posting is on the wall close to the nurses station. He/She said the posting is determined by their census and is updated daily by the DON or the night nurse for the next day. During an interview on 05/05/22, at 09:19 A.M., the ADON said the staff posting is kept by the nurses station and is supposed to be completed daily by the DON. He/She said the posting will be put up a couple days at a time for weekends. The DON is responsible for posting, changing, and tracking the nurse staff posting. During an interview on 05/05/22, at 10:19 A.M., the DON said the staff posting is kept on the wall by the nurses station, it is to be completed daily, and he/she is responsible for posting and tracking of the nurse staff posting. He/She said he/she tries to post it daily and will post a couple days at a time. During an interview on 05/05/22, at 11:11 A.M., the administrator said the nurse staff posting is located back by employee break area. He/She said the DON should do this daily and is responsible to keep track of the postings.

Based on interview and record review, the facility staff failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies as required. The facility census was 44. 1. Review of the facility's Facility Assessment Policy, dated October 2018, showed: -This facility conducts and documents a facility-wide assessment to determine what resources are necessary to care for our residents competently during both day-to-day operation emergencies. The purpose of this policy is to establish responsibilities and procedures for the facility assessment process; -The facility assessment will be reviewed and updated whenever there is, or the facility plans for, any change that would require a substantial modification to any part of the assessment or at a minimum annually. Any changed to the assessment will be documented, along with a revision history. Review of the facility's Resident Census and Condition of Residents form, dated 5/2/22, showed a census of 44 and the following resident characteristics: -Indwelling or external catheter: 3; -Occasionally or frequently incontinent of bladder: 36; -Occasionally or frequently incontinent of bowel: 5; -Bedfast all or most of the time: 1; -Documented signs and symptoms of depression: 29; -Documented psychiatric Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] -Dementia: 22; -Behavioral healthcare needs: 3; -Pressure Ulcers: 1; -Hospice care: 2; -[CONDITION(S)]: 1; -[CONDITION(S)] care: 0; -Ostomy care: 0; -Tube Feeding: 1; -Suctioning: 0; -Injections: 8; -Mechanically altered diets: 7; -Rehabilitative services: 9; -Receiving psychoactive medication: 24; -Antibiotics: 2; -Pain management program: 16. Review of the facility's Facility Assessment, dated 12/31/19, showed the facility did not have a current facility assessment completed for 2021 or 2022. During an interview on 05/05/22 at 08:39 A.M., the assistant director of nursing (ADON) said he/she is not aware of what a facility assessment is and to his/her knowledge has not been a part of the facility assessment for the last two years in his/her current position. During an interview on 05/05/22 at 08:48 A.M., the director of nursing (DON) said he/she is not sure if the facility assessment has been done or how often it should be done. He/She said he/she watches the census to determine staffing. During an interview on 05/05/22 at 08:55 A.M., the administrator said it is his/her responsibility to make sure the facility assessment is reviewed annually for accuracy. He/she said he/she doesn't know why it has not been because he/she was not the administrator until recently.

Based on interview and record review, facility staff failed to employ a qualified director of food and nutrition services with accredited education in food service management. The facility census was 52. 1. Review of the Dietary Manager's (DM) personnel records showed the facility hired the DM for the position of dietary manager on 03/28/17. Review showed the records did not contain documentation of a degree, accreditation or certification in food service management and safety. During an interview on 03/28/19 at 9:40 A.M., the DM said he/she had been the dietary manager for two years. The DM said he/she did not have a degree, accreditation or certification in food service management and safety and he/she was not currently enrolled or attending any courses for certification. The DM said the registered dietician comes to the facility on ce a month to provide consultation. During an interview on 03/28/19 at 2:00 P.M., the administrator said the DM did not have a degree, accreditation, or certification in food service management. The administrator said the DM is not enrolled in any courses to obtain certification. The administrator said he/she contacted the corporate office about getting the DM enrolled in certification courses through the corporation's contracted company, but there were not any classes available. The administrator said he/she did not seek out any other programs for the DM to attend for certification and the facility did not have any other person on staff that is certified in food service management that works full time. The administrator said the facility's registered dietician works as a consultant on a part-time basis.

Based on interview and record review, facility staff failed to ensure as needed (PRN) [MEDICAL CONDITION] medication orders were limited to 14 days unless specific duration and clinical rationale were provided for one resident (Resident #3), failed to perform Gradual Dose Reductions (GDRs) on [MEDICAL CONDITION] medications required for one resident (Resident #7). Staff also failed to obtain an appropriate [DIAGNOSES REDACTED].#25, and #34). The facility census was 52. 1. Review of the facility's [MEDICAL CONDITION] Medication Use, undated, shows the following: -A [MEDICAL CONDITION] drug is any drug that affects brain activity associated with mental processes and behaviors; -[MEDICAL CONDITION] medications can be used for [MEDICAL CONDITION] in the absence of dementia; -[DIAGNOSES REDACTED]. -PRN orders for [MEDICAL CONDITION] mediations beyond 14 days requires that the practitioner assess and document the rationale for the extended order. The duration of the PRN order will be indicated in the order; Review of the facility's Tapering Medications and Gradual Drug Dose Reduction policy, revised (MONTH) (YEAR), showed staff and practitioner shall attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated. 2. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 1/2/19, showed staff assessed the resident as follows: -Severe cognitive impairment; -No physical or verbal behaviors; -[DIAGNOSES REDACTED]. Review of the resident's care plan, dated 2/11/19, showed it directs staff to: -Monitor/document for side effects and effectiveness; -Monitor/document/report to nurse/doctor signs and symptoms of depression; -Staff are to apply lotion with increased anxiety as the resident becomes itchy. Review of the resident's Physician order [REDACTED]. Review of the resident's Medication Administration Record [REDACTED]. Review of the resident's record showed it did not contain a 14 day stop date or a rationale for continued use beyond 14 days. 3. Review of Resident #7's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -No physical or verbal behaviors; -[DIAGNOSES REDACTED]. Review of the resident's care plan, dated 5/17/18, showed it directs staff to: -Monitor/document for side effects and effectiveness; -Monitor/document/report to nurse/doctor risks for harm to self, risky actions, refusals of care and food, impaired judgement or safety awareness. Review of the resident's POS, dated (MONTH) 2019, showed staff obtained a physician's orders [REDACTED]. Review of the resident's medical record showed staff did not document they attempted a GDR of the resident's [MEDICAL CONDITION] medication. Staff did not document any interventions regarding behaviors or rationale to continue the medication without a GDR. 4. Review of Resident #25's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -No physical or verbal behaviors; -[DIAGNOSES REDACTED]. Review of the resident's care plan, dated 11/13/18, showed it directs staff to: -Monitor/document for side effects and effectiveness; -Monitor/document/report to nurse/doctor signs and symptoms of depression. Review of the resident's Physician order [REDACTED]. Review of the resident's Medication Administration Record [REDACTED]. Further review showed staff did not ensure the resident has an appropriate [DIAGNOSES REDACTED]. 5. Review of Resident #34's admission MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -No physical or verbal behaviors; -[DIAGNOSES REDACTED]. Review of the resident's care plan, dated 2/11/19, showed it directs staff to: -Monitor/document for side effects and effectiveness; -Monitor/document/report to nurse/doctor signs and symptoms of depression. Review of the resident's POS, dated (MONTH) 2019, showed staff obtained a physician's orders [REDACTED]. Further review showed staff did not ensure the resident has an appropriate [DIAGNOSES REDACTED]. 6. During an interview on 3/29/19 at 3:33 P.M., Registered Nurse (RN) C said at admission the MDS Coordinator puts the [DIAGNOSES REDACTED]. He/She said the MDS Coordinator also adds any new [DIAGNOSES REDACTED]. He/She said PRN [MEDICAL CONDITION] medication should have a stop date of a month but is not really sure. He/She said the GDR is entered when the doctor is here on rounds and the nurse that goes with the doctor makes sure they are entered. During an interview on 3/29/19 at 3:50 P.M., the Director of Nursing (DON) said anyone that enters an order is in charge of making sure it is a correct diagnosis. He/She said PRN [MEDICAL CONDITION] medications have a 14 day stop date. He/She said both doctors and nurses are responsible for making sure the PRN has a 14 day stop date. He/She said medical records or the nurse going on rounds with the doctor is responsible for making sure the pharmacy recommendations are entered.

Based on observation, interview and record review, facility staff failed to provide reasonable dining accommodations for individual needs and preferences by failing to ensure the dining room tables encouraged meal independence for six residents (Residents #6, #15, #18, #19, #32 and #43). The facility census was 52. 1. Review of the facility's policy Accommodation of Needs, date (MONTH) 2009, directs the staff: -Environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity and well-being; -Resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, shall be evaluated upon admission and reviewed on an ongoing basis. 2. Review of Resident #6's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -[DIAGNOSES REDACTED].>-Severe cognitive impairment; -Moderate depression; -Extensive assistance of one staff member for eating. Review of the resident's care plan, dated 11/9/18, showed the resident has a nutritional problem or potential nutritional problem and will maintain weight with no sign or symptoms of malnutrition. Observation on 3/26/19, at 12:10-12:39 P.M., showed the resident in the dining room in his/her wheelchair. Additional observation showed the resident's food on the table. Further observation showed the resident's wheel chair foot pedals against the table bases, and the resident's wheelchair could not fit under the table. The resident could not reach his/her food, the resident reached for his/her cup and his/her plate but could not reach it. 3. Review of Resident #15's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severely impaired cognition; -Required extensive assistance of two or more staff for transfers; -Required extensive assistance of one staff for locomotion; -Required set up assistance and supervision of one staff for eating; -Used a wheelchair for mobility. Observation on 3/26/19, at 12:10 P.M., showed the resident in the dining room in his/her wheelchair. Additional observation showed the resident's food on the table. Further observation showed the resident's wheel chair foot pedals against the table bases, and the resident's wheelchair could not fit under the table. The resident leaned forward to reach his/her food. Observation on 3/27/19, at 12:30 P.M., showed the resident in the dining room in his/her wheelchair. Additional observation showed the resident's food on the table. Further observation showed the resident's wheel chair foot pedals against the table bases, and the resident's wheelchair could not fit under the table. The resident leaned forward to reach his/her food, and dropped his/her food in his/her lap. 4. Review of Resident #18's significant change MDS, dated [DATE], showed staff assessed the resident as follows: -Severely impaired cognition; -Required extensive assistance of one staff for transfers and locomotion; -Required set up assistance and supervision of one staff for eating; -Used a walker and wheelchair for mobility. Observation on 3/26/19, at 12:16 P.M., showed the resident in the dining room in his/her wheelchair. Additional observation showed the resident's food on the table. Further observation showed the resident's wheel chair foot pedals against the table bases, and the resident's wheelchair could not fit under the table. The resident leaned forward to reach his/her food. Observation on 3/28/19, at 12:45 P.M., showed the resident in the dining room in his/her wheelchair. Additional observation showed the resident's food on the table. Further observation showed the resident's wheel chair foot pedals against the table bases, and the resident's wheelchair could not fit under the table. The resident leaned forward to reach his/her food. Observation on 3/29/19, at 8:43 A.M., showed the resident in the dining room in his/her wheelchair. Additional observation showed the resident's food on the table. Further observation showed the resident's wheel chair foot pedals against the table bases, and the resident's wheelchair could not fit under the table. The resident leaned forward to reach his/her food. 5. Review of Resident #19's significant change MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Requires extensive assistance with locomotion and eating; -Significant weight loss. Review of the resident's care plan, last updated 2/11/19, showed it directed staff the resident has a nutritional problem, and to provide cues and assist as needed. Observation on 3/27/19, at 12:26 P.M., showed resident #19 in the dining room in his/her wheelchair with his/her food on the table. Additional observation showed the resident's wheel chair foot pedals against the table bases, the resident's wheelchair could not fit under the table, and the resident's wheelchair in a reclined position at a 75 degree angle. Further observation showed the resident had food on his/her lap that would drop from his/her fork with each bite. Observation on 3/29/19, at 8:28-8:49 A.M., showed the resident in the dining room in his/her wheelchair. Additional observation showed the resident's food on the table. Further observation showed the resident's wheel chair foot pedals against the table bases, and the resident's wheelchair could not fit under the table. The resident leaned forward to reach his/her food. 6. Review of Resident #32's annual MDS, dated [DATE], showed staff assessed the resident as follows: -Severely impaired cognition; -Required extensive assistance of one staff for transfers, locomotion, and eating; -Used a wheelchair for mobility. Observation on 3/26/19, at 12:25 P.M., showed the resident in the dining room in his/her wheelchair with his/her eyes closed. Additional observation showed the resident's food on the table. Further observation showed the resident's wheel chair foot pedals against the table bases, and the resident's wheelchair could not fit under the table. The resident could not reach his/her food. Observation on 3/27/19, at 12:30 P.M., showed the resident in the dining room in his/her wheelchair. Additional observation showed the resident's food on the table. Further observation showed the resident's wheel chair foot pedals against the table bases, and the resident's wheelchair could not fit under the table. The resident leaned forward to reach his/her food. 7. Review of Resident #43's annual MDS, dated [DATE], showed the staff assessed the resident as: -Severe cognitive impairment; -Required limited assistance of one staff member for eating; -Required extensive physical assistance of a staff member for locomotion; -Dependent on two or more staff members for transfers, and bathing; -Weighed 150 pounds, significant weight loss, not on a physician prescribed plan. -Review of the resident's Care Plan, last revised 3/13/19, showed it directed the staff the resident has lost weight, remind the resident of his/her dietary restrictions, cue the resident as needed, and provide assistance as needed. Observation on 3/26/19, at 12:19 P.M., showed the resident in the dining room in his/her wheelchair. Additional observation showed the resident's food on the table. Further observation showed the resident's wheel chair foot pedals against the table bases, and the resident's wheelchair could not fit under the table. The resident could not reach his/her food. Observation on 3/29/19, at 8:25-8:49 A.M., showed the resident in the dining room in his/her wheelchair. Additional observation showed the resident's food on the table. Further observation showed the resident's wheel chair foot pedals against the table bases, and the resident's wheelchair could not fit under the table. The resident reached forward and he/she could only reach the edge of the table. At 8:33 A.M. the resident drank his/her shake and tried to sit it on the table, but could not reach it so he/she held it against his/her chest. Then at 8:37 A.M., the resident tried to sit the cup on the table, he/she could not reach past his/her plate and the cup caught the lip of the plate, and his shake spilled on the table. At 8:37 A.M., the resident had his/her coffee cup, he/she attempted to sit the coffee cup on the table and could not reach it so he/she held the cup in his/her lap and closed his/her eyes. At 8:44 A.M., the resident continued to hold his/her coffee cup on his/her lap, the resident's eyes were closed and the cup was on its side. An unidentified staff member approached the resident at 8:48 A.M., and removed his/her coffee cup and said, Thank goodness that wasn't hot you spilled it on your lap. Licensed practical nurse (LPN) A assisted the resident to eat at 8:50 A.M., and the resident said, oh thank you that is good. At 8:59 A.M., staff removed the resident from the table, and the resident had visible wetness on his/her shirt and pants. 8. During an interview on 3/29/19, at 12:57 P.M., certified nurse assistant (CNA) B said that residents with the foot rest, especially the ones that can't come off can not get close to the table because of the table bases. During an interview on 3/29/19, at 12:58 P.M., registered nurse (RN) C said the pedestal (base) of the table prevents resident's with foot pedals from getting close to the table. He/She said Resident #43's knees are too high and cannot get under the table. During an interview on 3/29/19, at 1:04 P.M., the administrator (ADM) said staff should position residents close to the table. He/she said staff are expected to take off the leg rests and place them in the bag on the back of the resident's wheelchair during meals, and position the residents close to the table.

Based on observation, interview, and record review, the facility failed to implement new orders, develop and update a plan of care for pressure ulcer prevention/treatment to communicate interventions to facility staff , failed to properly use equipment to prevent new and/or worsening pressure ulcers, and protect a wound from maceration (white discoloration of the skin showing damage from moisture) for one (Resident #8) of fifteen sampled residents to promote wound healing. Additionally, facility staff failed to identify, report, and stage a new pressure wound, and develop new interventions and treatments timely for one resident (Resident #2) of fifteen sampled residents. Facility census was 60. 1. Review of the National Pressure Ulcer Advisory Panel (NPUAP) guidelines, dated September 2016, showed the following definitions: -Stage 1 pressure injury is intact skin with localized area of non-blanchable (when you press on the area of redness the redness does not go away) [DIAGNOSES REDACTED] (redness). Presence of blanchable [DIAGNOSES REDACTED] changes in sensation, temperature, or firmness may precede visual changes; -Stage 2 pressure injury is a partial-thickness loss of skin with exposed dermis (the thick layer of living tissue below the top layer of skin that forms the true skin). The wound bed is viable, visible and deeper tissue are not visible. Granulation tissue (new connective tissue), slough (dead tissue in the process of separating from the body which is usually light colored, soft, moist, or stringy), and eschar (dead tissue that sheds or falls off from health skin) are not present; -Stage 3 pressure injury is a full thickness loss of skin, where adipose (fat) is visible in the ulcer and granulation tissue and rolled wound edges are often present. Slough and eschar may be visible, but do not obscure the extent of tissue loss. The depth of tissue damage varies by the location on the body. Undermining and tunneling may occur. Fascia (a thin sheath of fibrous tissue), muscle, tendon, ligament, cartilage or bone are not exposed; -Stage 4 pressure injury is a full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and or eschar may be visible, but do not obscure the extent of tissue loss. Rolled edges, undermining and or tunneling often occur. Depth varies by location; -Unstageable pressure injury is a full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar; -Deep Tissue Pressure Injury is an intact or non-intact skin with localized area of persistent non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure injury (unstageable, stage 3 or stage 4 pressure injury). 2. Review of the facility's Pressure Ulcer Treatment policy, dated March 2016, showed staff are directed the pressure ulcer treatment program should focus on the following strategies: -Assessing the resident and the pressure ulcer(s) on a weekly basis; -Managing tissue loads; Pressure ulcer care; -Managing bacterial colonization and infections; -Operative repair of the pressure ulcer(s); -Documentation; Education and quality improvement. Pressure Ulcer Interventions/Care Strategies: Pressure: -Determine cause of pressure and relieve; -Redistribute pressure; -Implement pressure-relieving device(s) in accordance with resident's assessed needs; -Notify physician, family, and appropriate facility personnel; and -Initiate a skin grid and care plan. Incontinence: -Cleanse with incontinence cleanser; -Pat dry and evaluate need for protective barrier cream; and -Consider scheduled toileting program. Friction or Shearing: -Reduce cause by using transfer techniques and devices as needed. Immobility: -Turn schedule; and -Restorative Nursing (range of motion, walking, bed mobility). 3. Review of the air filled wheelchair cushion manufacturer recommendations dated 2013 showed: -Check inflation frequently, at least once a day; -If using a wheelchair with a seat that does not provide a firm foundation, the manufacturer recommends the use of a solid seat insert, or a solid seat platform, in conjunction with your wheelchair cushion for best positioning results; -The cushion is most effective when there is 1/2 inch to 1 inch of air between the individual's lowest bony prominence and the seating surface; -To adjust the inflation: Slide your hand between the cushion and the individual. Slightly lift the individual's leg and feel for their lowest bony prominence. Lower their leg to a sitting position; While keeping your hand under the individuals lowest bony prominence, open the inflation valve (turn counterclockwise). Release air until you can barely move your fingertips; -Do not use an under-inflated product because the product benefits will be reduced or eliminated, resulting in an increased risk to skin and other soft tissue; -Not Holding Air: Inflate the cushion. Confirm that the inflation valve is completely closed (turn clockwise). Look for holes. If large holes or leaks are found replace, call for warranty information. If very small holes or no holes are visible, follow the instructions in the repair kit provided with your product. 4. Review of Resident #8's five day (an assessment done for billing the first week of admission) minimum data set (MDS), a federally mandated assessment tool, dated 9/3/16 , showed staff assessed the resident as follows: -Severe impairment of cognition; -Required extensive assistance with transfers, bed mobility, and hygiene; -Frequently incontinent of bladder, and occasionally incontinent of bowel and; -At risk for developing pressure ulcers; -No unhealed pressure ulcer; -Pressure reducing device for chair; -Pressure reducing device for bed; -Turning/Repositioning program. Review of the residents quarterly MDS, dated [DATE] , showed staff assessed the resident as follows: -Severe impairment of cognition; -Required extensive assistance with transfers, bed mobility, and hygiene; -Frequently incontinent of bowel and bladder; -At risk for developing pressure ulcers; -Unhealed pressure ulcers; -Two unstageable pressure ulcers due to wound bed covered by slough and/or eschar; -Dimensions of Unhealed Stage 3 or 4 Pressure Ulcers or Eschar: length 1.6 centimeters (cm), width 1.0 cm, and depth 1.5 cm; -Most severe tissue type for any pressure ulcer- slough-yellow or white tissue that adheres to the ulcer bed in strings or thick clumps; -Pressure reducing device for chair; -Pressure reducing device for bed; -Turning/Repositioning program; -Nutrition or hydration intervention to manage skin problems. Review of the resident's plan of care, dated 9/6/16, showed staff updated the plan of care on 2/9/17,with interventions related to pressure or potential for pressure ulcer development related to immobility, current area on left medial gluteus (tailbone). Additional review of the plan of care showed the following: -Administer treatments as ordered and monitor for effectiveness; -Follow facility policies/protocols for the prevention/treatment of [REDACTED].>-Turn/reposition at least every 2 hours, more often as needed or requested; -Pressure relieving/reducing device on bed/chair; -Resident requires supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing; -Position the bed as flat as possible to reduce shear. Reposition with two people, lifter, slider; -Monitor dressing shiftly to ensure it is intact and adhering. Report lose dressing to treatment nurse; -Notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration noted during bath or daily care; -Big black boot to right foot at all times. Additional review showed the care plan did not contain pressure ulcer interventions prior to 2/9/17. Review of the facility weekly wound report dated 12/9/16-12/16/16, showed staff documented a facility acquired Stage II pressure to the resident's left medial gluteus ulcer with measurements 1.6 cm length, 1.5 cm width, and 0.2 cm depth with moderate amount of serous exudate (drainage), 1-33% necrotic tissue/adherent slough, 67-100% granulation. Review of the wound clinic History and Physical, dated 12/19/16, showed wound clinic staff documented the resident's coccyx (tailbone) midline pressure injury classification as Stage IV, measures 1.3 centimeters (cm) length, 2 cm width, 0.6 cm depth. There is exposed tendon. There is a large amount of necrotic tissue including adherent slough. There is no maceration. Review of the wound clinic physician's orders [REDACTED]. -Wound #3 midline coccyx, cleanse with normal saline, apply Santyl (an ointment used to remove dead tissue from the wound), cover with foam, change daily. Keep weight off area of wound at all times. Continue using cushion in wheelchair. Review of the wound clinic progress note, dated 12/28/16, showed wound clinic staff documented, He/She states probably sits on his/her wound too much, he/she stated probably 50% of the time. Staff also documented the resident's, coccyx midline pressure injury classification as Stage IV, measured 2 cm length, 2.2 cm width, 0.6 cm depth. There is exposed tendon. There is a large amount of necrotic tissue including adherent slough. There is no maceration. Review of the wound clinic physician's orders [REDACTED]. -Wound #3 midline coccyx, cleanse with normal saline, apply Santyl, cover with foam, change daily. Keep weight off area of wound at all times. Continue using cushion in wheelchair. Resident to only sit on backside for one hour at a time, do not sit on wound more than one hour. Review of the wound clinic progress note, dated 1/4/17, showed the following order: -Wound #3 midline coccyx, cleanse with normal saline, apply Stimulen (collagen dressing to promote healing) cover with bordered foam, change daily. Wound clinic staff documented the resident's, coccyx midline pressure injury classification as Stage IV. The wound measured 2 cm length, 2.2 cm width, 0.7 cm depth. There is exposed tendon. There is a large amount of necrotic tissue including adherent slough. There is no maceration. Keep weight off area of wound at all times. Continue using cushion in wheelchair. Resident to only sit on backside for one hour at a time, do not sit on wound more than one hour. Review of the wound clinic progress note, dated 1/25/17, showed wound clinic staff documented the resident's coccyx midline pressure injury classification as Stage IV. The wound measured 2 cm length, 1.8 cm width, 1.4 cm depth. There is exposed tendon. There is a large amount of necrotic tissue including adherent slough. There is no maceration. Keep weight off area of wound at all times. Continue using cushion in wheelchair. Consultation ordered with plastic surgery for [REDACTED]. Review of the wound clinic progress note, dated 2/1/17, showed a new order for wound #3 midline coccyx, cleanse with normal saline, apply no-sting barrier wipe to periwound (to protect skin around wound from maceration), apply Calcium Alginate, Silver, and Stimulen cover with bordered foam, change daily. Staff documented the resident's coccyx midline pressure injury classification as Stage IV. Staff documented the wound measured 2 cm length, 1.8 cm width, 1.3 cm depth. There is exposed tendon. There is a large amount of necrotic tissue including adherent slough. The periwound is moist. Keep weight off area of wound at all times. Continue using cushion in wheelchair. Resident to only sit on backside for one hour at a time, do not sit on wound more than one hour. Review of the resident's Order Summary Report, dated 10/1/16-3/31/17, showed the report did not contain a change in the treatment order to coccyx to include apply no-sting barrier wipe to periwound 2/1/17-2/16/17, as recommended by the wound clinic. Review of the wound clinic progress note, dated 2/8/17, showed staff documented the resident's coccyx midline pressure injury classification as Stage IV. The wound measured 1.6 cm length, 1 cm width, 1.2 cm depth. There is exposed tendon. There is a large amount of necrotic tissue including adherent slough. There is no maceration. Keep weight off area of wound at all times. Continue using cushion in wheelchair. Resident had evaluation by plastics. High risk operation, recommend continued non surgical management at this time. Wound measures smaller. Review of the wound clinic progress note, dated 2/16/17, showed a new order for wound #3 midline coccyx, cleanse with normal saline, apply Santyl cover with 4 x 4 gauze and secure with tape, change daily. Staff documented the resident's, coccyx midline pressure injury classification as Stage IV. The wound measured 1.6 cm length, 1 cm width, 1.5 cm depth. There is exposed tendon and fat. There is a large amount of necrotic tissue including adherent slough. The periwound is moist. Keep weight of area of wound at all times. Continue using cushion in wheelchair. Resident to only sit on backside for one hour at a time, do not sit on wound more than one hour. Review of the resident's Order Summary Report, dated 10/1/16-3/31/17, showed the report did not contain a change in the treatment order to the coccyx from 2/16/17-2/22/17, as recommended by the wound clinic. Review of the wound clinic progress note, dated 2/22/17, showed a new order for wound #3 midline coccyx, cleanse with normal saline, apply Santyl cover with bordered foam, change daily. The resident's, coccyx midline pressure injury classification as Stage IV. The wound measured 2 cm length, 1.3 cm width, 1.5 cm depth. There is exposed tendon and fat. There is a large amount of necrotic tissue including adherent slough. The periwound is moist. Keep weight off area of wound at all times. Continue using cushion in wheelchair. Resident to only sit on backside for one hour at a time, do not sit on wound more than one hour. New wound on left trochanter (hip) classified as a Stage II wound with etiology as pressure wound. The wound measured 1.4 centimeters (cm) length, 1.4 cm width, 0.2 cm depth. Review of the resident's Order Summary Report, dated 10/1/16-3/31/17, showed the report did not contain a change in the treatment order to the coccyx from 2/22/17-3/2/17, as recommended by the wound clinic. Review of the resident's physician's orders [REDACTED].>-Order date 2/27/17-Santyl Ointment 250 unit/gram(gm), apply to left hip every day for treatment: cleanse with normal saline; apply Santyl, back with 2 x 2 gauze; secure with foam with boarders; change daily. Review of the wound clinic progress note, dated 3/1/17, showed wound clinic staff documented the resident's coccyx midline pressure injury classification as Stage IV. The wound measured 2.4 cm length, 1 cm width, 1.7 cm depth, small undermining of deeper portion inferiorly. There is exposed tendon and fat. The periwound is moist. Keep weight of area of wound at all times. Continue using cushion in wheelchair. Resident to only sit on backside for one hour at a time, do not sit on wound more than one hour. Wound on left trochanter (hip) classified as a Stage II wound, measured 1.4 centimeters (cm) length, 1.4 cm width, 0.3 cm depth. Review of the resident's physician's orders [REDACTED].>-Order date 3/2/17-Santyl Ointment 250 unit/gram(gm), apply to left medial gluteus topically every day for treatment: cleanse with normal saline; apply Santyl, back with 2 x 2 gauze; secure with foam with boarders; change daily. -Order date 3/8/17-Apply skin prep to right hip and cover with foam with boarders for protection every day shift for protection. Review of the wound clinic progress note, dated 3/8/17, showed a new order for wound #3 midline coccyx, cleanse with normal saline, skin prep barrier to periwound, apply Santyl cover with bordered foam, change daily. Please have Dietician consult with resident about low [MEDICATION NAME]/[MEDICATION NAME] levels and dietary supplements; check for incontinence often. Staff documented the resident's coccyx midline pressure injury classification as Stage IV. The wound measured 2.3 cm length, 1 cm width, 1.8 cm depth. There is exposed tendon and fat. There is a large amount of necrotic tissue including adherent slough. The periwound is moist. Keep weight off area of wound at all times. Continue using cushion in wheelchair. Resident to only sit on backside for one hour at a time, do not sit on wound more than one hour, left side for no more than 30-45 minutes. Left trochanter (hip) classified as a Stage II wound with etiology as pressure wound. The wound measured 0.5 centimeters (cm) length, 0.3 cm width, 0.1 cm depth. Review of the resident's physician's orders [REDACTED].M., showed the orders did not contain a change in the order to the coccyx treatment to include skin prep barrier to periwound, as recommended by the wound clinic. Review of the resident's medical record dated 3/8/17, and 3/9/17 showed it did not contain documentation about the wound including maceration, a nurse's note, new care plan interventions, notification of the facility wound nurse or resident's physician, and did not contain new orders. Observation on 3/8/17 at 1:20 P.M., showed Licensed Practical Nurse (LPN) E provided wound care to the resident. LPN E said the wound to the left medial gluteus measured 2.4 cm length, 1.0 cm width, and 1.6 cm depth, and said he/she thought the wound is a stage III with maceration (white appearance of skin or tissue as a result of too much moisture from wound drainage, incontinence, or a dressing/treatment that is too wet) on the wound edges. Observation showed the resident's coccyx wound (left medial gluteus) tissue deep red, with striated (band of parallel fibers) white tissue close to the wound base, with white maceration around the wound. He/She said the wound to the left hip measured 1.4 cm length, 1.4 cm width, and 0.2 cm depth. Additional observation showed a deflated air cushion on the resident's wheelchair and not on a solid seat, as per manufacturer recommendations. During an interview on 3/8/17 at 1:20 P.M., LPN E said the cushion should be fully inflated. He/She said there is a pump at the nurses' station, and you open the valve, air it up with the pump, and close the valve. He/She said there is not a way to check the pressure. Observation on 3/9/17 at 2:50 P.M., showed LPN F provide wound care to the resident. Observation showed the coccyx wound with increased maceration. LPN F said, the wound is way too wet with that dressing, I will take care of that. Additional observation showed the wheelchair cushion partially deflated and not on a solid seat, as per manufacturer recommendations. Observation on 3/10/17 at 6:35 A.M., showed the resident in bed. Additional observation showed the air cushion in the resident's wheelchair seat, partially deflated, and not inflated to manufacturer recommendations. Observation on 3/10/17 at 10:25 A.M., showed the resident in bed. Observation showed the air cushion in the resident's wheelchair seat, partially deflated, and not inflated to manufacturer recommendations. During an interview on 3/10/17 at 10:25 A.M., certified nursing assistant (CNA) N said the cushion is not inflated all the way, with some air in front and a little air in the back. The CNA said he/she thinks therapy airs them up. He/She would ask the charge nurse for a new cushion if therapy staff is not available. The CNA said he/she does not know how to inflate the cushion properly. During an interview on 3/10/17 at 10:35 A.M., LPN E said it is the CNA's responsibility to notify charge nurses if a cushion is deflated. The facility does not have a system to check the air cushions. The LPN said the cushion may not be sealing, and said if an air cushion failed to hold air he/she would get a new one. During an interview on 3/10/17 at 12:12 P.M., LPN E said he/she received in report the wound remains really moist, and is calling the physician today after he/she assesses the wound to see if the physician wants to change the dressing. The LPN said I am the wound nurse so staff leave me a note or text me if there is a problem with a wound and I call the wound clinic or physician. Maceration can make a wound worse within 24 hours. The LPN also said on 10/3/16, staff discovered a facility acquired stage IV on the resident's right heel, which healed the last week of January. Staff discovered the facility acquired coccyx (left medial gluteus) wound on 12/5/16 and the facility acquired left hip wound, on 2/3/17 and treatment for [REDACTED]. During an interview on 3/10/17 at 1:00 P.M., the Director of Nursing (DON) said if there is a new wound, a change, or deterioration in a wound he/she expects staff to inform the wound nurse, the DON, the physician, or the wound clinic to receive new orders, and/or new interventions the same shift. He/She said if maceration is worse, staff need to request a new treatment the same shift. He/She expects staff who wash wheelchairs or the wound nurse to check pressure relief cushions, but there is not a system in place to check them. The DON said he/she needs to make a schedule to check the air cushions. He/She said maceration, and a deflated air cushion could cause Resident #8's wound to worsen. During an interview on 3/13/17 at 11:16 A.M., LPN F said if staff assess a wound is worse, staff are expected to notify the wound nurse the same day, they normally leave a note for the wound nurse. The LPN said he/she did not call because he/she wasn't sure if the wound worsened. He/She did not review the wound clinic note from 3/8/17 for comparison. During an interview on 3/13/17 at 3:03 P.M., the wound physician said a deflated air cushion could be detrimental to the resident's wound. The staff should call if there is a drastic change in the wound between visits. 5. Review of Resident #2's annual MDS, dated [DATE], showed staff assessed the resident as follows: -[DIAGNOSES REDACTED]. -Moderate impairment of cognition; -Dependent with transfers, extensive assistance of 2 staff for bed mobility, and extensive assistance of 2 staff for hygiene; -Frequently incontinent of bowel and bladder; -At risk for developing pressure ulcers; -One venous/arterial ulcer present; -Application of non surgical dressings (with or without topical medications) other than to feet; -Pressure reducing device for chair; -Pressure reducing device for bed; -Turning/Repositioning program; -Nutrition or hydration intervention to manage skin problems. Review of the resident's plan of care, last updated 1/30/17, showed staff assessed the resident at risk for pressure ulcer development related to immobility, and directed staff as follows: -[MEDICATION NAME] supplement for skin care daily; -Follow facility policies/protocols for the prevention/treatment of [REDACTED].>-Weekly appointments at the wound care clinic; -Resident prefers to be positioned on his/her back, encourage resident to lay side to side frequently in bed to relieve pressure; -Keep bed as flat as possible; -Reposition with assist of 2 staff; -Large black boots on at all times; -Wedge under legs while in bed. Review of the nurses' progress notes, dated 3/1/17-3/7/17, showed the notes did not contain identification of a new pressure wound, or area of concern. Review of the resident's weekly wound assessment, dated 3/3/17, showed LPN E documented an arterial wound to right-malleous lateral (right outer ankle), measured 13.2 cm length, 1.9 cm width, 0.3 cm depth. The wound assessment did not contain any information related to other wounds or open areas. Review of the resident's weekly skin evaluation, dated 3/5/17, showed LPN G documented continue with daily dressing change to right lower extremity and every other day dressing change to coccyx. No new issues noted. No new open areas. Review of the Medication Administration Record [REDACTED] -Clean the area to the coccyx and the left buttock with normal saline and cover with xeroform (medicated gauze) and then [MEDICATION NAME] dressing (wound dressing to promote moist healing) change every other day; -Apply skin prep to coccyx. Cover with [MEDICATION NAME] dressing for protection. Change every other day. Additional review of the MAR indicated [REDACTED]. Review of the resident's Treatment Administration Record (TAR) dated 3/1/17-3/10/17 showed staff are directed as follows: -Cleanse left buttock shearing with normal saline. Apply xeroform to area secure with transparent film. Change daily and as needed. Review showed an order date of 3/8/17. Additional review of the TAR showed it did not contain documentation to show staff provided the treatment on 3/9/17. Observation on 3/8/17 at 10:15 A.M., showed LPN E removed a [MEDICATION NAME] dressing from the resident's coccyx. Observation showed a large deep maroon open area to the resident's left buttocks, with non-blanchable tissue around the edges of the wound. LPN E measured the wound's dimensions as 3.5 cm length, 4 cm width, depth <0.1 cm. Additional observation showed a discoloration, purple in color, closer to the coccyx. The area did not blanch in the center of the wound when LPN E applied fingertip pressure. During an interview on 3/10/17 at 8:59 A.M., the MDS coordinator said he/she is responsible to complete all the sections in the MDS assessment and develop care plans, including pressure ulcer interventions. He/She said he/she is new to the MDS job, but also works the floor too so it is hard to get to all of it. During an interview on 3/10/17 at 12:45 P.M., LPN G said staff applied a [MEDICATION NAME] dressing for protection because staff noted the resident with redness of the coccyx area. He/She said on 3/3/17 he/she received a report the resident's coccyx worsened with a deep maroon area. The LPN said he/she did not contact the wound nurse, physician, or the director of nursing because he/she assumed staff reported it, and he/she did not know who reported it to him/her. The LPN said the nurse who finds it is expected to report wound changes. The LPN said charge nurses do not call the physicians about wounds. During an interview on 3/10/17 at 1:00 P.M., the DON said if there is a new wound, a change, or deterioration in a wound he/she expects staff to inform the wound nurse, the DON, the physician, or the wound clinic to receive new orders, and/or new interventions the same shift.

Based on observation, interview and record review, facility staff failed to ensure functioning alarms and adequately supervise one resident (Resident #10) with a history of falls that fell at the facility 18 times, resulting in a hip fracture after one fall and a subdural hematoma after another fall. Additionally, facility staff failed to provide a safe environment for the confused residents by leaving multiple medications unlocked and accessible. The resident census was 63. Review of the facility's Fall and Fall Risk Policy, dated December 2007, showed staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident form falling and try to minimize complications from falling. Review showed staff were directed to do the following: - If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant; - If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable; - The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling; - If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. 1. Review of Resident #10's initial Minimum Data Set (MDS), a federally mandated assessment instrument, dated 4/11/12, showed the resident was admitted to the facility on [DATE]. Review of the resident's care plan, dated 4/24/12, showed staff identified the resident required assistance with Activities of Daily Living (ADLs), had limited independent mobility, and a cognitive deficit. Review showed staff identified the resident had a potential for falls related to generalized weakliness compounded by a decreased safety awareness and that the resident had a history of [REDACTED]. The resident's care plan directed staff to do the following for the resident: - Assist to get in and out of bed, stand, and ambulate; - Take the resident to the toilet every two hours, upon rising, after meals, and at bedtime because the resident is occasionally incontinent. Check on the resident routinely through the night. Toilet routinely to prevent the resident from attempting to toilet him/herself; - Physical Therapy (PT)/Occupational Therapy (OT) to increase strength, endurance, and independence with ADLs; - Bed alarm attached at all times when in bed to alert staff of needed assistance; - Chair alarm to alert staff of needed assistance; - Call light in reach at all times when in room; - Check resident frequently, especially while in bed; - High/low bed with foam mat at bedside. Mattress with perimeters (high foam wedge shaped mattress to help prevent falls from bed); - Resident is ambulatory with a walker and staff assistance of one. Encourage the resident to sit and rest when she appears tired or has an unsteady gait. Review of the resident's nurse's notes, dated 4/5/12, showed staff documented the following about the resident's first fall at the facility: - 8:45 P.M. - The resident fell in his/her room and hit head on the floor. Left side of head injured and bleeding. Physician notified and directed staff to send the resident to the emergency room (ER). Staff notified the resident's family and DON; - 9:45 P.M. - ER nurse called and said the computed tomography (CT) scan of the head showed no internal injuries. The ER physician sutured the resident's head wound. Review of the resident's nurse's notes, dated 5/17/12, showed staff documented the following about the resident's sixth fall at the facility: - 7:00 P.M. to 7:00 A.M. - Staff found the resident on the floor face down on a mat at 2:00 A.M.. The resident hit his/her head on the night stand and received a bump on the back of the head. The resident said he/she was trying to go to the bathroom. The resident's personal alarm did not sound because he/she took it off. Review of the resident's nurse's notes, dated 6/15/12, showed staff documented the following about the resident's eight fall at the facility: - 1:00 A.M. - Staff heard the resident yelling but no alarm sounded. Staff found the resident on the floor in his/her room on the his/her left side. The floor mat was kicked away from the bedside. The alarm box was disconnected and under the bed. The resident complained of hip pain. Staff transferred the resident to the ER; - 4:00 A.M. - Staff called the hospital and was told the resident was admitted due to a hip fracture. Review of the resident's History and Physical from the hospital, dated 6/15/12, showed a physician documented the following: - "The resident states he/she cannot recall how he/she got on the floor. It is not clear as to whether or not he/she actually passed out, but he/she states he/she screamed until someone came to assist him/her"; - The resident complained of right hip pain; - The resident had a right hip fracture and underwent a surgical repair. Review of the resident's care plan showed on 6/22/12 staff documented the following updates: - The resident returned to the facility from the hospital after suffering a fall with a hip fracture that was surgically repaired; - The resident's mattress with perimeters was discontinued; - One side of the resident's bed against wall with the open side with Bolster (foam padded wedge to prevent rolling out of bed); - PT/OT to increase strength, balance, and safety. Review of the resident's care plan showed on 7/19/12 staff documented the following updates: - Personal alarm on at all times; - Self release alarming seat belt on wheel chair. Review of the resident's nurse's notes, dated 8/4/12, showed staff documented the following about the resident's 11th fall at the facility: - Staff heard the resident screaming and found the resident on the floor in the bathroom with head up against the wall; - No alarms sounded; - The resident complained of right wrist and right hip pain; - The resident's right wrist had a "large hematoma" (collection of blood outside a blood vessel that occurs because the blood vessel wall was damaged ; can cause significant swelling); - The resident's right side of head had a "small hematoma"; - The residents right foot leaned to the right side; - Staff sent the resident to the ER after notifying the physician; - The resident's chair alarm was in two pieces; - The resident's seat belt alarm was not alarming. Review of the resident's care plan showed on 8/4/12 staff documented a new intervention for staff to place an alarm on bathroom door to alert staff if the resident attempted to toilet his/herself without assistance. Review of the resident's nurse's notes, dated 8/30/12, showed staff documented the following about the resident's 12th fall at the facility: - Staff found the resident in a room on his/her knees at the side of the bed. The resident's upper body was across the bed. The resident's bed alarm did not have batteries in it. During an interview on 1/18/13 at 3:10 P.M., the Director of Nursing (DON) said she did not know why the resident's bed alarm did not have batteries in it after the resident's 12th fall. Review of the resident's nurse's notes, dated 9/23/12, showed staff documented the following about the resident's 13 th fall at the facility: - Staff heard the resident call out for help and found the resident on his/her left side; - The resident's floor mat was pushed away; - The resident's bed alarm was in place but did not sound. Review of the resident's physician's orders [REDACTED]. level as "up with wheeled walker and assist on one". Review of the resident's nurse's notes, dated 11/4/12, showed staff documented the following about the resident's 16th fall at the facility: - Staff heard the resident calling out for help; - The resident's "alarm was not sounding"; - Staff found the resident on his/her bottom on the bathroom floor; - The resident had a large abrasion on the right side of his/her back and complained of pain to this area; - "Alarms in place but not sounding". Review of the resident's nurse's notes, dated 11/25/12, showed staff documented the following about the resident's 18th fall at the facility: - At 11:25 A.M. two staff witnessed the resident ambulate through the double doors between the skilled side of the facility and the residential care side of the facility; - Before staff could reach the resident the resident fell forward and struck his/her right side; - The walker was beneath the resident; - The resident's glasses broke and the lens lacerated the right side of the residents face near the right eye. The laceration "bled profusely"; - The resident received a skin tear to the right hand; - Staff called an ambulance and the resident was taken to the ER. Review of the resident's History and Physical from the hospital, dated 11/25/12, showed a physician documented the following: - The resident had a witnessed fall after he/she apparently lost balance and fell ; - The resident "hurt his/her hip, arm, and sustained a head contusion; - CT scan of the resident's head showed a small subdural hematoma (a collection of blood on the surface of the brain that usually results from a head injury; can result in brain injury and lead to death); - The physician talked to a family member of the resident and notified him/her that the resident did have "a potentially serious condition with a small subdural hematoma, but currently it is stable condition"; - The resident was admitted to the hospital. Review of the resident's most recent MDS, dated [DATE], showed staff assessed the resident as follows: - Severely impaired cognitive skills for daily decision making; - Did not reject care; - Required extensive assistance from two staff for bed mobility, transfers, dressing, toilet use, and personal hygiene; - Totally dependent on staff for locomotion; - Extensive assistance required for one person for eating; - Always incontinent of bladder; - Frequently incontinent of bowel; - diagnosed with [REDACTED]. - Took a diuretic seven days out of the last seven days. During an interview on 1/22/13 at 1:20 P.M., Registered Nurse (RN) A said the following: - He/she was on duty when the resident fell on [DATE] and he/she was the one that charted the nurse's note on that fall; - He/she does not remember where the resident was walking from, where the resident was, prior to the fall; - He/she was unsure if there was an alarm sounding but he/she doesn't think there was because that is something that he/she would include in the nurse's note about the incident. During a family interview on 1/18/13 at 10:33 A.M., a family member of the resident said the following: - The resident's fall that resulted in a subdural hematoma "really set him/her back"; - The resident was put on hospice after this fall because he/she "wasn't eating and was sleeping all the time". During an interview on 1/18/13 at 2:40 P.M., Certified Nurses Aide (CNA) D said the following: - Most of the resident's falls were at night and occurred because the resident would not stay in bed and often got out of the bed to urinate. During an interview on 1/18/13 at 3:10 P.M., the DON said the following: - The resident falls because he/she has poor balance and most of the falls occurred when the resident was trying to go to the bathroom; - Cognitively, the resident does not realize that he/she can not get up without assistance; - All of the resident's alarms should be checked weekly; - She thinks the Restorative Aides (RAs) check all of the resident's alarms weekly on Saturday; - The resident is supposed to be on a toileting schedule during the day, but she is not sure if the resident is supposed to be on a toileting schedule at night; - She is unsure of why the resident had multiple falls where his/her alarms did not alarm. During an interview on 1/18/13 at 3:40 P.M., RA H said the following: - RAs check all of the resident's alarms every Saturday; - If a resident's alarm is not working, staff are supposed to let the RAs know; - Staff never notified him/her that the resident's alarms did not alarm. During an interview on 1/22/13 at 11:10 A.M., RN A said he/she knows the RAs check the resident's alarms weekly because the RA that checks the alarms has to sign off that they were checked on the "Alarms Checked" sheet. Review of "Alarms Checked" record, undated, showed a staff signature and date for alarm checks. Review showed the sheet did not contain resident names or specific alarms that were checked. During an interview on 1/22/13 at 11:15 A.M., RN A said the following: - He/she knows the aides check all of the residents alarms, even though they do not document each resident's alarm that they check on the "Alarms Checked" record, because "if they say they're checked they're checked". During an interview on 1/22/13 at 1:20 P.M., RN A said the following: - Anytime a staff member notices an alarm not working, that staff member should replace the alarm; - When a resident sits down on a bed alarm or chair alarm, those alarms are supposed to beep once to indicate to the staff that they are functioning properly. 2. Observation on 1/16/13 at 3:45 P.M. showed the door to the DON's office was open. In the office, a sharps container sat under the DON's desk that was approximately three quarters full of unidentified medication, with the lid closed. An open cardboard box sat in the corner of the office and contained various items including a pill bottle with a label that indicated the pills inside contained hydrocodone (a narcotic pain medication). During an interview conducted at the time of the observation, the DON said: - The medication in the sharps container was to be destroyed, and did not contain any controlled medications; - The procedure for destroying non-controlled medications, is for the Certified Medicine Technician (CMT) to pop the medications from the medication cards into a sharps container, fill it with water, and keep it with the medical waste in the locked dirty utility room until the containers can be picked up by the proper personal; - Nurses are the only staff that handle the controlled medications, and they dispose of them in a separate sharps container in the same way; - The sharps container holding the medication under the desk was delivered by a CMT from the Residential Care Facility side of the building, who brought it to the DON because he/she did not know what to do with it; - She put the container under her desk and intended to destroy the medication properly; - A resident's family member brought in the cardboard box holding the hydrocodone medication approximately one month ago.

Based on observation, interview and record review, the facility failed to provide interventions for three residents (Resident #2, #7 and #14) at risk for falls who fell and resulted in a fracture. Additionally, the facility staff failed to ensure that residents at risk for falls, with pressure alarms, had equipment that was maintained in good working condition for three residents (Resident #6, #8 and #14). Staff also failed to ensure the personal body alarms were appropriately attached to alert staff of residents attempts to rise unassisted for three residents (Resident #3, #17 and #18) out of 19 sampled residents. The facility's census was 58. Review of the facility's Fall Policy, dated 10/14/2008, showed the following: - At the time of the fall the charge nurse will initiate an incident report. The charge nurse will evaluate the fall and initiate any preventative measures to ensure the resident does not fall again. Fall and any new interventions will be placed on the care plan. -The Director of Nursing will review the incident reports and document on the resident's fall tracking log. Evaluation of preventative measures will be done after each incident. Further interventions will be placed accordingly to prevent reoccurrence and care plan undated accordingly. -If the fall or incident results in a fracture or death, a self report will be made to the State Hotline. -Each month the Director of Nursing collects data statistics for number of high fall risk residents being monitored and reports to monthly QI (Quality Indicator) committee where discussions are conducted on improvements and declines. -The Director of Nursing/Falling Leaf Supervisor will track all falls. Weekly interdisciplinary meeting are conducted to discuss individual cases to assist in individual interventions and preventative techniques. -If a resident has three or more falls/incidents within one month period, the resident is place on the "Catch a Falling Leaf" program. The care plan is updated accordingly. 1. Review of Resident #8's Minimum Data Set (MDS), a federally mandated assessment tool, dated 8/14/11, showed the staff assessed the resident as follows: -Short and long term memory loss; -Poor cognitive impairment for daily decisions; -Disorganized thinking; -Requires extensive assistance from staff with bed mobility, transfers, dressing, toileting and personal hygiene; -Frequently incontinent of bowel and bladder -Two or more falls since admission or since previous assessment. Review of the resident's Fall Assessment, dated 3/2/11, showed the staff assessed the resident at high risk for falls. Review of the resident's comprehensive care plan, dated 2/25/11, showed staff are directed to provide the following interventions: -Take the resident to the toilet every two hours, upon rising, after meals and at bedtime. Check routinely throughout the night; -Call light within reach all all times, answer light promptly; -Bed alarm attached at all times when in bed to alert staff of needed assistance; -Check resident frequently while in bed; -Gather and assess information on past falls; -If resident appears restless then bring up to the nurses' station, provide toileting or offer a snack; -Attempt to keep in a well monitored area when up; -Personal alarm on at all times implemented on 10/2/11; -Falling leaf program implemented on 1/5/12 (the resident had three falls in 11/2011) Further review of the resident's comprehensive care plan showed updated information on the following falls: -6/26/11-fell on the floor in bathroom doorway-continue plan of care; -11/12/11-fall-continue plan of care; -11/19/11-fall-continue plan of care; -11/27/11-fall-continue plan of care; -1/9/12-fall-continue plan of care; -1/14/12-fall-continue plan of care; -1/20/12-fall-continue plan of care. Staff did not plan any new interventions to prevent continued falls and possible injury. Review of the resident's physician's orders [REDACTED]. Review of the resident's nurses' notes, dated 1/9/12 at 9:00 P.M. (evening shift), showed staff documented the resident was found "seated on the floor in his/her bedroom," "Bed alarm and personal alarm both in place for safety but did not sound." Further review showed staff did not follow up with documentation after the fall, the next entry was dated 1/13/12. Review of the resident's nurses' notes, dated 1/14/12 at 6:00 A.M. (night shift), showed staff documented the resident was found on the floor "six feet away from his/her chair." Review showed staff documented the alarm did not sound when the resident got up from his/her chair. Staff did not plan any new interventions after repeated identified falls to prevent additional falls and possible subsequent injury. 2. Review of Resident #6 MDS, dated [DATE], showed staff assessed the resident as follows: - Severe cognitive impairment; - Falls within the last two to six months prior to admission; - Required extensive assistance from staff with transfers, walking in room and corridor, dressing, toilet use and personal hygiene; - Balance not steady with walking, moving on and off toilet, moving from seated to standing position; - Uses walker. Review of the resident's comprehensive care plan, dated 9/20/11, directed staff on the following interventions for falls: -Call light within reach at all times; -Check frequently while in bed; -Keep bed in low position; -Bed alarm attached at all times when in bed to alert staff of needed assistance; -Check on resident more frequently during the night; -Place chair alarm under pillow at bedtime; -High-low bed with foam mat at side; -Place the resident near the nursing station for close monitoring. Further, review of the resident's comprehensive care plan showed updated information on the following falls: -11/6/11-Fall with no injury; -11/7/11-Fall with no injury; -12/8/11-Fall with no injury-continue plan of care; -12/9/11-Fall with injury-continue plan of care; -1/3/12-Fall with no injury-continue plan of care. Staff did not plan any new interventions to prevent continued falls and possible injury. Review of the resident's Braden Scale (skin breakdown assessment), dated 12/8/11, showed the staff assessed the resident at high risk for falls. Review of the resident's nurses' notes, dated 11/7/11 at 11:30 P.M., (evening shift) showed the staff documented the resident was found seated in the doorway to his/her room. Further, review showed staff documented the resident said, " I guess I fell out of bed." Review of the resident's nurses' notes, dated 12/8/11 at 2:20 A.M. (night shift), showed the staff documented the resident was found on the floor bedside the bed with the alarm sounding. Further review showed staff documented the resident was "soiled." Review of the resident's nurses' notes, dated 12/9/11 at 2:15 A.M. (night shift), showed staff documented the resident fell in his/her room and struck her/his head on the bed frame causing a hematoma on the left side of the head and a skin tear to the left elbow. Further review showed the resident was sent to the hospital for an evaluation. Review of the resident's nurses' notes, dated 1/3/12 at 10:40 P.M. (evening shift), showed the staff documented the resident "found on the floor of the bathroom by staff. The resident had transferred self out of the bed into the bathroom without assist. The bed alarm was not sounding related to improper functioning." Staff did not monitor the resident's bed alram for proper functioning to prevent continued falls and possible injury. 3. During an interview on 01/24/12 at 8:50 A.M., the Director of Nursing (DON) said the facility is trying to reduce the noise level in the common area. The DON said the facility had a meeting a couple of weeks ago, which consisted of a charge nurse, restorative aide and two CNA's to discuss eliminating chair and personal alarms while the residents are in the common area, where staff can monitor them closely. The DON said the entire staff had not yet been in-serviced regarding this attempt at eliminating alarms in the common area. The DON said the residents are still to have alarms in place when not in the common area. The DON said the nurses check the alarms for correct placement and functioning each shift (12 hour shifts) and record it on the resident's treatment administration record. 4. Record review of Resident #14's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 01/04/12, showed staff assessed the resident as the following: - Confused; - Extensive assistance of one staff for Activities of Daily Living including transfers and ambulation; - Unsteady balance; - No impairment in range of motion in his/her extremities; - Incontinent of bladder; - Dementia; - One fall since prior assessment with major injury (bone fractures). Review of the resident's plan of care, updated 01/03/12, showed staff assessed the resident as a potential for falls related to his/her occasional unsteady gait compounded by cognitive deficit. Resident receives antipsychotics, antidepressants and antianxiety. Further review showed the care plan directed staff to provide the following interventions for the resident: - Chair alarm at all times; - Bed alarm on at all times while resident in bed; - Keep bed in lowest position; - Call light in reach at all times; - Keep environment clutter free; - Falling leaf program; - Keep everything he/she needs in easy reach. Review of the facility's Daily High Fall Risk Monitoring form, dated December 24, 2011 through January 02, 2012, showed staff recorded the resident as being a high fall risk. Review of the resident's fall risk assessment, dated 9/29/11, showed the staff assessed the resident as a 14 (10 and above is high risk for falls). Additional, review of the resident's fall risk assessment dated [DATE] showed the staff assessed the resident as a 19. Review of the resident's nurse's notes showed staff documented the following: - 12/24/11 at 9:00 P.M., Resident found on the floor in hallway in upright position. No injury notes. Resident was given a bed alarm and chair alarm to try to prevent reoccurrence's. - 12/25/11 at 8:00 P.M., Resident stood up out of wheelchair and took two steps and fell on second step and bumped head on the nurse's station. Physician notified. Xanax (antianxiety) and Seroquel (antipsychotic) on hold tonight. - 01/04/12 at 4:00 A.M., Resident found on floor and complained of left hip and back pain. Had two skin tears. Physician notified, family notified. Left leg rotated to left with pain upon palpitation. Order to send to local hospital for evaluation and treat. Review of a facsimile received from the facility showed staff documented the following: - "The administrator spoke with Licensed Practical Nurse (LPN) I this morning. LPN I said the day of the resident's fall on 01/04/12 he/she was alerted that the resident had fallen. LPN I found the resident on the floor. The bed alarm did not go off. LPN I checked the alarm. It was on, batteries in place. When LPN I put pressure on the alarm pad which was on the bed and when he/she let off pressure, the alarm sounded. LPN is confident that the alarm did not sound with the resident got out of bed because of the pillow top mattress that he/she had on his/her bed." Review of the resident's hospital records showed hospital staff recorded the following: - Patient was originally admitted on [DATE] following complaints of left hip pain after sustaining a fall at the nursing home. He/she was seen and evaluated by the Emergency Department to have a left intertrochanteric (part of the femur connecting to the hip bone) hip fracture. He/she went to surgery on 01/05/12 and underwent an Open Reduction with Internal Fixation (surgically repairing a fractured bone) of the left hip. 5. During an interview on 01/11/12 at 1:40 P.M., the MDS Coordinator said if a resident has three falls in 30 days, the resident is placed on the falling leaf program and is also listed on the High Fall Risk Monitoring form, which is kept at the nurse's station. 6. During an interview on 01/18/12 at 3:00 P.M., the administrator said the resident's family brought in the resident's own pillow top mattress from home. The administrator said the facility knew the bed alarm would not be "as sensitive" to the resident's movements because of the "poofey" mattress, and ran the "risk" of the alarm not functioning correctly. The administrator said a bed alarm on top of a pillow top mattress has to be pressed down on "hard" to set off the alarm. 7. During an interview on 01/24/12 at 8:50 A.M., the Director of Nursing (DON) said the facility is trying to reduce the noise level in the common area. The DON said the facility had a meeting a couple of weeks ago, which consisted of a charge nurse, restorative aide and two CNA's to discuss eliminating chair and personal alarms while the residents are in the common area, where staff can monitor them closely. The DON said the entire staff had not yet been in-serviced regarding this attempt at eliminating alarms in the common area. The DON said the residents are still to have alarms in place when not in the common area. The DON said the nurses check the alarms for correct placement and functioning each shift (12 hour shifts) and record it on the resident's treatment administration record. The DON said the facility was aware that the bed alarm on top of Resident #14's pillow top mattresses wasn't as sensitive to the resident's movements because the mattress was too soft. The DON said other alternatives to add in conjunction with the bed alarm and pillow top mattress would be to use a personal alarm or maybe place the bed alarm under the resident's pillow; However, Resident #14 did not return to the facility. 8. Review of Resident #2's MDS, dated [DATE], showed staff assessed the resident as: - Moderately cognitively impaired; - Requires extensive assistance for bed mobility, transfers, dressing, toileting, and personal hygiene; - Uses a wheelchair; - Two falls with no injury and one fall with a minor injury since the last MDS assessment. Review of the resident's comprehensive care plan, dated 1/20/11, showed staff identified the resident as at risk for falls related to generalized weakness, decreased safety awareness and the routine use of antianxiety/antipsychotic medications. Further review showed the care plan directed nursing staff to provide the following interventions for the resident: - Bed alarm; - Chair alarm; - Toilet the resident routinely to prevent him/her from toileting unassisted; - Call light in reach at all times. Answer call light promptly. - Check the resident frequently, especially while the resident is in bed; - Keep the resident's bed at the lowest level; - Keep environment clutter free; - Keep the resident in a well monitored area when he/she is up; - Maintain a pleasant quiet environment; - Make sure the resident has everything he/she needs within easy reach, especially when he/she is in the bed; - Self release alarming seatbelt on the resident's wheelchair; - Target with the physician to use the least dose of psychotropic/narcotic medication for optimal effect; - Monitor for common side effects of psychotropic/narcotic medications such as dizziness and lightheadedness; - Review the record to assess the effectiveness of the drug and document any positive/negative effects. Review of the resident's comprehensive plan of care, dated 1/20/12, shows staff made the following nursing intervention updates to the care plan for falls: - On 2/14/11, make sure dining room is supervised at all times when the resident is eating in it; - On 4/13/11, decrease dosage of narcotic medications; - On 6/10/11, perimeters on mattress. Review of the resident's nurses notes, dated 2/3/11 at 6:10 P.M., showed staff documented: - The resident was found on the dinning room floor on his/her right side with wheelchair alarm sounding. - The resident fell while attempting to ambulate; - The resident had no apparent injury but had a low oxygen saturation (measures how much oxygen is carried in the blood) of 76% (95-100% is normal, less than 90% is considered low). and to increase the resident's oxygen saturation to a normal level, the staff had to administer oxygen to the resident. Review of the resident's MDS, dated [DATE], showed staff assessed the resident as: - No falls since the last MDS assessment. Review of the resident's nurses notes, dated 6/10/11 at 1:34 A.M., showed staff documented: - The resident fell in his/her room while attempting to get up into a chair. - The resident sustained [REDACTED]. Review of the resident's MDS, dated [DATE], showed staff assessed the resident as: - One fall since the last MDS assessment resulting in a minor injury. Review of the resident's nurses notes, dated 9/18/11 at 7:05 P.M., showed staff documented: - The resident was found in the 100 hallway on the floor on his/her right side outside of another resident's room; - A fell ow resident reported the resident's fall to facility staff; - The resident's wheelchair was found in another resident's room alarming; - The resident took off his/her self release alarming seatbelt and walked a few feet before he/she fell ; - The resident sustained [REDACTED]. Review of the resident's MDS, dated [DATE], showed staff assessed the resident as: - No falls since the last MDS assessment. Review of the resident's nurses notes, dated 12/1/11 at 6:45 A.M., showed staff documented: - Staff found the resident sitting on the floor beside his/her bed. - The resident attempted to get out of bed unassisted to get dressed. - The bed alarm was sounding. Further review showed staff failed to accurately assess the resident's history of falls on their corresponding MDS. 9. Record review of Resident #7's Quarterly MDS, dated [DATE], showed staff assessed the resident as the following: - Moderately impaired; - Extensive assistance of two staff for transfers; - Did not walk in room or corridor; - Frequently incontinent of bladder; - [DIAGNOSES REDACTED]. - History of falls. Review of the resident's POS, dated January 2012, showed the physician ordered staff to: -Apply and chair and bed alarm at all times for safety. Further review of the POS showed the resident has a [DIAGNOSES REDACTED]. -Dizziness; -Ataxia (lack of muscle coordination); -Leg cramps. Review of the resident's plan of care, dated 1/04/11, showed staff assessed the resident as at risk for falls. Further, review showed the care plan directed staff to provide the following interventions for the resident: - Personal alarm (monitor, alerting the staff if the resident attempts to rise from his/her chair) at all times; - Call light in reach at all times; - (1/12/12) Foam mat at bedside; - (1/13/12) Avoid narcotic pain medications if possible - causes increased confusion; - (1/18/12) Move resident's room closer to nurses station; - (1/25/12) High/low bed in the low position with mat at side. Additional review of the resident's current care plan showed staff documented the resident fell on : -11/3/11- with no injury; -11/20/11- with no injury; -12/1/11- with injury, continue with plan of care (injury unknown); -12/14, 12/15, 1/7, 1/12, and 1/19/12 - with no injury and continue with plan of care. - 1/8/12 - resident has fractured ribs, as needed pain medications, use extra care with transfers, gait belt used for all transfers. Review of the resident's active medical record showed staff documented in the nurses notes the resident fell on : -10/29/11- (unknown time) Resident found on floor between wheelchair and bed, no injury; -11/3/11- (3:10 A.M.) Resident found on floor beside the bed, no injury; -11/20/11- (9:15 P.M.) Staff responded to alarm sounding in dayroom, found resident on right side on floor, resident complained of right shoulder and right hip; -12/14/11- (3:00 P.M.) Resident found sitting on floor in front of the recliner, no injury; -12/15/11- (9:15 P.M.) Resident found on floor, no injury; -1/12/12 - (11:15 P.M.) Found resident sitting on floor beside the bed, no injury; - 1/8/12 - Resident received and skin tear and complained of rib pain to right rib area. The doctor was notified and and new order was obtained for x-rays. The x-ray results showed a fracture of the 6 th, 7 th and 8 th ribs, non-displaced. Resident slid to the end of the recliner chair and was found leaning over the right arm of the chair. -1/19/12 - (12:00 P.M.) Resident attempted to transfer self with out assistance and ended up sitting on floor, no complaints of pain; -1/24/12 -(3:00 A.M.) Resident calling out for help. Found on floor next to bed. Resident reported pain localized to the right hip. Pain medication was administered. The resident's son was notified by phone. A fall report was faxed to the resident's doctor. -1/24/12 - (6:00 A.M.) "Resident formerly complained of right hip pain, now complains of left hip pain all the way into the foot. Resident can stand if supported by two persons. No abnormal rotation of the either hip". Review of the nurses notes showed staff did not document that the resident's doctor was notified at this time. -1/24/12 - (1:00 P.M.) "Resident complained of bilateral hip pain, has been vomiting since right after breakfast, has not eaten anything today, is diaphoretic and a bump was noticed on the right side of the back of the head upon assessment. Sent to hospital via ambulance for evaluation and treatment at 12:30 P.M. per resident's doctor family notified". Review of the resident's facility transfer sheet to the hospital, dated 1/24/12, showed staff documented the resident has a "goose egg" on the back of the head and complained of hip pain. Review of the resident's medical report from the hospital, dated 1/25/12, showed the resident received and fractured right hip from the fall. Further, review of the resident's care plan and medical records show the staff documented seven out of nine falls occurred during the evening and night shifts. Additionally staff failed to assess and implement fall interventions in a timely manner. Review of the resident's care plan showed the resident fell seven times before an additional intervention was put into place. 10. Record review of Resident #17's quarterly MDS, dated [DATE], showed staff assessed the resident as the following: - Confused; - Extensive assistance of two staff for transfers; - Did not walk in room or corridor; - Incontinent of bladder; - Cerebrovascular Accident (stroke). Review of the resident's plan of care, dated 10/04/11, showed staff assessed the resident as at risk for falls related to generalized weakness compounded by some decreased safety awareness. Further, review showed the care plan directed staff to provide the following interventions for the resident: - Personal alarm (monitor, alerting the staff if the resident attempts to rise from his/her chair) at all times; - Call light in reach at all times; - Keep environment clutter free; - keep bed at lowest level; - Keep everything he/she needs in easy reach. Review of the resident's nursing cardex (a reference showing the resident's care requirements) (undated) at the nurse's station showed the resident was to have a personal alarm at all times. Review of the resident's fall risk assessment, dated 12/23/11, showed the staff assessed the resident as a 15 (10 and above is high risk for falls). Observation on 01/11/12 at 10:00 A.M., showed the resident sat in his/her wheelchair in his/her room. Further, observation showed Certified Nurse Assistant (CNA) J and CNA K transferred the resident from his/her wheelchair to his/her recliner. CNA K placed the resident's personal alarm on the resident's table next to his/her recliner. Neither CNA attached the resident's personal alarm to him/her before leaving the resident's room. Observation on 01/11/12 at 11:15 A.M., continued to show the resident sat in his/her room. Further, observation showed the resident did not have a personal alarm attached to the resident. During an interview at this time CNA M said he/she did not know if the resident needed an alarm, but would find out. Observation on 01/11/12 at 12:05 P.M., showed the resident sat in his/her recliner. Further, observation showed a personal alarm attached to the resident. Further, observation showed the monitor was not attached to the resident's chair and was hanging freely. During an interview, at this time, Licensed Practical Nurse (LPN) N said yes, the resident is to have a personal alarm in his/her chair. LPN N said the monitor needs to be attached to something, so if the resident should stand up, the string clipped to the resident's clothing will pull out of the monitor and set off the alarm. 11. Record review of Resident #3's quarterly MDS, dated [DATE], showed staff assessed the resident as the following: - Confused; - Extensive assistance of two staff for transfers; - Did not walk in room or corridor; - Incontinent of bowel and bladder; - Dementia; - Two or more non-injury related falls since the previous assessment; - Two or more injury (except major) related falls since previous assessment. Review of the resident's plan of care, updated 06/13/11, showed staff assessed the resident as at risk for falls related to generalized weakness compounded by decreased safety awareness. Further review showed the care plan directed staff to provide the following interventions for the resident: - Personal alarm at all times; - Bed alarm on at all times while resident in bed; - Floor mat next to bed; - Call light in reach at all times; - Keep environment clutter free; - keep bed at lowest level; - Bed in lowest position; - Keep everything he/she needs in easy reach. Review of the resident's nurse's notes showed staff documented the following: - 11/13/11: Resident found on floor on blue mattress beside bed. No injury. - 11/20/11: Resident slid from chair onto the foot pedals. Resident lowered self slowly to a sitting position on pedals. Staff witnessed. No injury. - 11/28/11: Resident found laying on pad beside bed. No injury. Review of the facility's Daily High Fall Risk Monitoring folder, dated December, 2011 through January, 2012, showed staff recorded the resident as a high fall risk. Review of the resident's nursing cardex (undated) at the nurse's station showed the resident was to have a personal alarm for safety, bed alarm, low bed with mat and bed bolsters. Review of the resident's fall risk assessment, dated 10/18/11, showed the staff assessed the resident as a 10 (10 and above is high risk for falls). Observation on 01/11/12 at 10:30 A.M., showed the resident sat in his/her wheelchair in his/her room. Further observation showed the resident did not have a chair alarm in his/her wheelchair or a personal alarm attached to him/her for safety. Observation on 01/11/12 at 10:50 A.M., showed the resident continued to sit in his/her wheelchair in his/her room. Further, observation showed the resident did not have a personal alarm attached for safety. Observation on 01/11/12 at 12:15 P.M., showed the resident sat in his/her wheelchair in the facility's common area (residents activity area by the nurses station). Further observation showed the resident did not have a chair alarm in his/her wheelchair or a personal alarm attached to the resident. During an interview, at this time, LPN N said the resident is to have chair and personal alarms at all times while in his/her wheelchair. CNA L said he/she was told the resident no longer needed his/her chair alarms. CNA L said therapy had removed all of the resident's chair alarms. CNA L said it's up to therapy to recommend or discontinue the alarms. CNA L said he/she it was a group decision to continue or discontinue a resident's chair alarm. 12. During an interview on 01/11/12 at 12:30 P.M., the MDS Coordinator said there is not just one person who decides if a resident should or should not have an alarm device. The MDS Coordinator said physical therapy, the Director of Nursing and herself meet to discuss the "pros and cons" of either continuing or discontinuing a resident's chair or personal alarm. The MDS Coordinator said the charge nurse also has input into the decision making. 13. During an interview on 01/11/12 at 12:40 P.M., Physical Therapist (PT) O said he/she hasn't been involved in the resident's care for a long time. PT O said in his/her opinion, the resident should have a chair alarm. PT O said because of the resident's confusion and movement while in his/her wheelchair showed the resident as a potential for falls. 14. Review of Resident # 18's quarterly MDS, dated [DATE], showed staff assessed the resident with the following: -Short and long term memory problems; -Moderately impaired decision-making skills; -Extensive assist of one person with transfer, ambulation, and dressing; -Ambulates with a walker; -No falls since last assessment. Review of the resident's care plan, dated 7/15/2011, showed staff is directed to: -Check resident frequently, especially while in bed; -Chair alarm to alert staff of needed assistance; -Bed alarm attached at all times when in bed to alert staff of needed assistance; -Updated 10/20/2011 to encourage gait belt with ambulation and to use a wheelchair for transfers. Review of the resident's nurses' notes, dated 10/10/2011 at 8:00 A.M., showed staff recorded the resident became weak in the knees and was lowered to the floor by the CNA with use of a gait belt. Review of the resident's Fall Assessment Sheet, dated 10/10/2011, showed staff assessed a score of 18 (above 10 considered high risks for falls). Review of the resident's nurses' notes, dated 10/20/2011 at 4:55 A.M., showed staff recorded the resident fell while staff ambulated him/her to the restroom. Resident obtained a skin tear, doctor and family notified. Neurological checks, (assessment for signs and symptoms of head injury) were started. Observation on 1/11/2011 at 9:45 A.M., showed the resident sat in a recliner in his/her room watching television. A chair alarm was not noted on the chair. Observation on 1/11/2011 at 10:55 A.M., showed the resident remained in his/her room in the recliner without a chair alarm attached. Observation on 1/11/2011 at 12:00 P.M., showed the resident remained in the recliner asleep without an alarm attached to the chair. Observation on 1/11/2011 at 12:35 P.M., showed CNA F assisted the resident to the dining room for the noon meal. During a interview on 1/11/2011 at 1:30 P.M., Registered Nurse (RN) H said the chair alarm should have gone to the dining room with the resident to be attached to the dining room chair. Observation on 1/11/12 at 1:32 P.M. showed the resident sat in a regular chair at the table without a chair alarm. CNA F sat beside the resident. CNA F said the resident did not have a chair alarm on when he/she assisted him/her out of the chair. 15. During an interview on 01/24/12 at 8:50 A.M., the Director of Nursing (DON) said the facility is trying to reduce the noise level in the common area. The DON said the facility had a meeting a couple of weeks ago, which consisted of a charge nurse, restorative aide and two CNA's to discuss eliminating chair and personal alarms while the residents are in the common area, where staff can monitor them closely. The DON said the entire staff had not yet been in-serviced regarding this attempt at eliminating alarms in the common area. The DON said the residents are still to have alarms in place when not in the common area. The DON said the nurses check the alarms for correct placement and functioning each shift (12 hour shifts) and record it on the resident's treatment administration record. MO 011